Development and Validation of a s Standardized Video-Based Assessment of Movement Quality in Breast Cancer Survivors

Development and Validation of a s Standardized Video-Based Assessment of Movement Quality in Breast Cancer Survivors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development and Validation of a s Standardized Video-Based Assessment of Movement Quality in Breast Cancer Survivors Seung Hyun Chung, Heoung Su Kim, Ha Ra Jeon, Mi Ri Suh, So Young Ahn, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8725974/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Cancer survivors frequently experience persistent movement inefficiencies and coordination deficits following cancer treatment, which may not be fully captured by commonly used performance-based mobility tests. The purpose of this study was to develop and validate a clinically feasible, video-based assessment designed to characterize movement quality in cancer survivors. Methods This cross-sectional validation study included 70 breast cancer survivors recruited from outpatient rehabilitation clinics. The Rehabilitation Movement Assessment Protocol (ReMAP) consists of standardized, sequential, and unfamiliar functional tasks designed to elicit real-time sensorimotor control demands. Movement quality was quantified using kinematic metrics derived from markerless video-based pose estimation, reflecting postural stability, motor control, inter-limb coordination, and movement efficiency. Construct validity was examined using correlations with clinical reference measures, and within-session internal reliability and measurement error were evaluated. Results ReMAP-derived kinematic metrics demonstrated distinct associations with conventional mobility measures, supporting construct distinction between movement quality and task performance. Reliability varied across movement quality domains, with coordination and motor control metrics demonstrating higher reliability than postural sway measures. Measurement error indices were within acceptable ranges for clinical assessment. Conclusions The ReMAP Assessment provides a feasible approach for quantifying movement quality in cancer survivors and captures functional characteristics not readily identified by performance-based mobility tests. These findings support the use of ReMAP as a movement phenotyping tool in cancer survivorship research and rehabilitation practice. Implications for Cancer Survivors For cancer survivors, functional limitations often reflect inefficient coordination and altered movement control rather than reduced task completion speed alone. By characterizing how functional movements are executed, the ReMAP Assessment provides clinically relevant information that may help identify subtle movement inefficiencies associated with fatigue and reduced functional confidence. This approach has potential to support more individualized rehabilitation strategies and improve functional participation in cancer survivorship. Cancer survivors Movement quality Functional Mobility Postural Balance Motion Analysis Measurement properties Figures Figure 1 Introduction Advances in cancer treatment have resulted in a rapidly growing population of cancer survivors living with long-term functional consequences. Even after completion of primary treatment, many survivors report persistent difficulties with balance, coordination, and efficient movement that interfere with daily activities and participation [ 1 ]. Importantly, these functional impairments often occur in the absence of overt muscle weakness or cardiopulmonary limitation [ 2 , 3 ], suggesting that deficits in movement control and coordination play a central role in post-treatment functional decline [ 4 , 5 ]. Functional impairment in cancer survivorship differs in important ways from that observed in populations with central neurological disorders or age-related decline. Cancer treatments such as surgery, chemotherapy, and radiation therapy can disrupt sensorimotor integration, proprioception, and coordination, leading to inefficient and fatiguing movement strategies. These treatment-related alterations may reduce functional confidence and increase activity avoidance, even when overall task performance appears preserved. However, such qualitative movement deficits are not readily detected by commonly used performance-based mobility tests, which primarily summarize task completion time or distance rather than how movement is executed. Movement quality has therefore emerged as a clinically relevant construct in cancer rehabilitation [ 6 ], reflecting how individuals stabilize, coordinate, and adapt their movements during functional tasks [ 7 , 8 ]. Despite its importance, movement quality is rarely quantified using standardized and objective tools that are feasible for routine clinical use in oncology settings [ 9 ]. Accordingly, the purpose of this study was to develop and validate the Rehabilitation Movement Assessment Protocol (ReMAP), a video-based assessment designed to quantify postural stability, motor control, inter-limb coordination, and movement efficiency during functional task performance in cancer survivors [ 10 ]. Accordingly, the purpose of this study was to develop and validate a standardized, video-based movement quality assessment for breast cancer survivors. The assessment, termed the Rehabilitation Movement Assessment Protocol (ReMAP), was designed to evaluate postural stability, coordination, and movement efficiency using sequential, unfamiliar functional tasks that emphasize real-time sensorimotor processing. Using kinematic metrics derived from video-based pose estimation, we examined the construct validity and reliability of the assessment, with the goal of establishing a clinically feasible tool for quantifying movement quality in oncology rehabilitation. Methods Study Design This study employed a cross-sectional validation design to develop and evaluate a standardized movement quality assessment for breast cancer survivors, termed the Rehabilitation Movement Assessment Protocol (ReMAP). The assessment consists of sequential, unfamiliar functional movement tasks intended to emphasize real-time sensorimotor processing rather than learned or habitual movement patterns. Analyses were conducted using baseline data from a single assessment session to establish construct validity and within-session internal reliability. Accordingly, this study focused exclusively on evaluating the measurement properties of the ReMAP Assessment, without examining intervention effects or longitudinal change. Setting and Eligibility Criteria This study was conducted between January 2023 and June 2024 at cancer rehabilitation centers affiliated with seven university hospitals in Korea, with recruitment carried out at three hospital-based centers. Eligible participants were women aged 18–65 years with a diagnosis of breast cancer who had completed curative treatment at least 3 months and within 10 years prior to enrollment, and who were able to ambulate independently and follow verbal instructions. Participants with acute musculoskeletal injuries, non–cancer-related neurological disorders, or other conditions that could interfere with safe task performance were excluded. The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Boards of all participating institutions. Written informed consent was obtained from all participants. ReMAP Movement Quality Assessment The ReMAP Assessment was designed to evaluate qualitative aspects of movement using sequential, unfamiliar functional tasks that emphasize real-time sensorimotor processing rather than task familiarity. The protocol comprised three standardized paired task sequences, each including two distinct subtasks performed continuously without pauses. Tasks were selected to challenge key components of movement quality, including postural stability, single-leg balance, trunk rotation, bilateral coordination, and multi-directional stepping. Participants performed the assessment barefoot or in standard footwear, without assistive devices, under standardized verbal instruction and supervision by trained assessors. No physical guidance or feedback was provided during task execution. All tasks were functionally relevant, low risk, and feasible for outpatient cancer survivors, and were administered in a fixed order according to a predefined protocol (Supplementary Table 1). Movement performance was recorded using standard RGB cameras capturing frontal and lateral views. Video data were processed using MediaPipe Pose to extract 33 anatomical landmarks, with trajectories visually inspected and low-pass filtered prior to kinematic analysis. The conceptual framework of the ReMAP Assessment is illustrated in Figure 1. ReMAP is a standardized, video-based movement quality assessment consisting of sequential, unfamiliar functional tasks designed to emphasize real-time sensorimotor processing. RGB video is processed using pose estimation to derive kinematic metrics representing multiple domains of movement quality, including postural stability, coordination, movement efficiency, and motor control. Kinematic Outcome Metrics Kinematic metrics were derived a priori to reflect four predefined domains of movement quality: postural stability, motor control, inter-limb coordination, and movement efficiency (Supplementary Table 2). Postural stability was quantified as the variability of mediolateral center-of-mass (COM) displacement over time, with higher values indicating poorer stability. Motor control was assessed using trajectory variability, reflecting the consistency and precision of limb movement paths across repeated task executions, where higher values indicated poorer motor control. Inter-limb coordination was quantified using correlation-based indices derived from bilateral limb trajectories, with higher values indicating better coordination. Movement efficiency was assessed using an energy ratio comparing observed mechanical energy expenditure with a theoretical minimum-energy trajectory, with higher values indicating lower efficiency. For each participant, domain-specific metrics were calculated at the task level and averaged across tasks to generate summary measures. Construct Validity Construct validity was examined by evaluating associations between ReMAP-derived kinematic metrics and established clinical measures of balance and functional mobility. Clinical reference measure included the Timed Up and Go (TUG) test. Construct validity was examined using both Pearson and Spearman correlation coefficients to evaluate associations between ReMAP-derived kinematic metrics and clinical reference measures. Based on theoretical considerations, we hypothesized moderate associations between ReMAP metrics and balance-related measures and weaker associations with time-based functional performance. Reliability Reliability of the ReMAP Assessment was evaluated using within-session internal consistency based on intraclass correlation coefficients (ICC). ICC values were interpreted according to established guidelines, with higher values indicating greater reliability. Statistical Analysis Descriptive statistics were calculated for participant characteristics and all kinematic metrics. Continuous variables are reported as mean ± standard deviation or median with interquartile range, as appropriate. Construct validity was examined using Pearson and Spearman correlation coefficients to evaluate associations between ReMAP-derived kinematic metrics and clinical reference measures. Reliability of the ReMAP Assessment was evaluated using within-session internal consistency based on intraclass correlation coefficients (ICC) with corresponding 95% confidence intervals. All statistical analyses were performed using Stata version 19 (StataCorp, College Station, TX, USA). All statistical tests were two-sided, and a p-value < 0.05 was considered statistically significant. Results Participant Characteristics Baseline demographic and clinical characteristics of the participants are summarized in Table 1 . The study included 70 breast cancer survivors with a mean age of 49.7 ± 6.5 years. Approximately half of the participants had completed college education or higher (51.4%), and 48.6% were employed at the time of assessment. The cohort was recruited from outpatient rehabilitation clinics and represents a clinically relevant population of cancer survivors receiving follow-up or rehabilitative care. Most participants were diagnosed with stage II (48.6%) or stage III disease (38.6%), while a smaller proportion had stage I disease (12.9%). This distribution reflects a population with moderate to advanced disease severity, consistent with referral patterns to rehabilitation services following primary cancer treatment. All participants had a confirmed diagnosis of breast cancer and therefore constituted a single target-condition cohort. The ReMAP Assessment and clinical reference measures were administered during the same baseline evaluation session , and no clinical interventions occurred between the index test and the reference standard assessments. Accordingly, the time interval between assessments was negligible, minimizing the potential for temporal or treatment-related confounding. Table 1. Baseline Characteristics of Participants (n=70) N (% of sample) Demographic Age (mean ± SD) 49.7 ± 6.5 Education High school/some college 34 (48.6) College graduate or more 36 (51.4) Employment Employed 34 (48.6) Retired 24 (34.3) Other not employed 12 (17.1) Clinical Breast Cancer Stage at Diagnosis 1 9 (12.9) 2 34 (48.6) 3 27 (38.6) Primary Surgical Treatment Lumpectomy 37 (52.9) Unilateral mastectomy 30 (42.9) Bilateral mastectomy 3 (4.3) Axillary surgery ALND 32 (45.7) SLNB 38 (54.3) Received radiation No 24 (34.3) Yes 46 (65.7) Received chemotherapy No 14 (20.0) Yes 56 (80.0) On endocrine therapy No 4 (5.7) Yes 66 (94.3) Values are presented as mean ± standard deviation or number (%). ALND , axillary lymph node dissection; SLNB , sentinel lymph node biopsy. Descriptive Statistics of ReMAP Kinematic Metrics Summary statistics for the ReMAP-derived kinematic metrics are presented in Table 2. Across participants, mediolateral center-of-mass sway, inter-limb coordination indices, and energy ratio values exhibited broad distributions without evidence of floor or ceiling effects. Metrics derived from different movement quality domains demonstrated distinct distributions, supporting the conceptual separation of postural stability, coordination, and movement efficiency as related but nonredundant constructs. Measurement error indices derived from reliability estimates are presented in Table 2. Standard error of measurement (SEM) and minimal detectable change at the 95% confidence level (MDC₉₅) varied by metric, reflecting domain-specific differences in task sensitivity and measurement precision. Table 2. Descriptive statistics of ReMAP movement quality metrics Domain Metric Mean ± SD Median [Q1, Q3] SEM MDC 95 Postural stability COM sway (ML) 78.38 ± 22.66 74.24 [66.42, 89.37] 20.4 56.5 Motor control Trajectory variability 72.88 ± 38.90 84.17 [25.61, 98.28] 24.4 67.7 Coordination Lateral correction rate 1.82 ± 2.72 0.15 [0.13, 5.40] 0.65 1.80 Efficiency Energy ratio 61.26 ± 43.74 62.44 [20.17, 84.08] 31.8 88.0 Values are presented as mean ± SD and median [interquartile range]. Participant-level metrics were calculated by averaging task-level values across all task sequences. SEM indicates standard error of measurement. MDC₉₅ represents the minimal detectable change at the 95% confidence level, calculated as SEM × 1.96 × √2. Construct Validity Construct validity analyses demonstrated generally weak associations between ReMAP-derived kinematic metrics and clinical reference measures of functional mobility and balance (Table 3). Among coordination-related metrics, lateral correction rate showed a significant monotonic association with TUG performance (Spearman ρ = 0.295, p = 0.015), whereas Pearson correlation was not significant, consistent with a non-normal distribution and a rank-based relationship. Other metrics, including postural stability (COM sway), movement efficiency (energy ratio), and motor control (trajectory variability), demonstrated weak and non-significant associations with TUG. Overall, these findings support the construct validity of the ReMAP Assessment by demonstrating that its kinematic metrics capture qualitative dimensions of movement behavior that are not strongly reflected by commonly used performance-based mobility measures. Table 3. Construct validity of ReMAP movement quality metrics Metric Reference Pearson r (p) Spearman ρ (p) COM sway (mediolateral) TUG 0.018 (0.883) 0.016 (0.898) Trajectory variability TUG -0.018 (0.882) 0.010 (0.935) Lateral correction rate TUG 0.130 (0.293) 0.295 (0.015) Energy ratio TUG -0.049 (0.691) -0.042 (0.735) Pearson and Spearman correlation coefficients were calculated to examine associations between ReMAP-derived kinematic metrics and established clinical reference measures. Clinical reference measure included the Timed Up and Go test (best of two trials). Participant-level ReMAP metrics were calculated by averaging task-level values across all task sequences. Internal reliability Within-session internal reliability was assessed using intraclass correlation coefficients across repeated task segments. Reliability varied across movement quality domains. Coordination-related metrics demonstrated the highest reliability, with lateral correction rate exhibiting excellent internal reliability (ICC[3,1] = 0.94, 95% CI 0.92–0.96). Motor control, quantified by trajectory variability, showed good reliability (ICC[3,1] = 0.61, 95% CI 0.50–0.70). Movement efficiency (energy ratio) demonstrated moderate reliability (ICC[3,1] = 0.47, 95% CI 0.36–0.59). In contrast, COM sway (mediolateral) showed lower reliability (ICC[3,1] = 0.17, 95% CI 0.09–0.30). Intraclass correlation coefficients (ICCs) were calculated to evaluate within-session internal reliability of ReMAP-derived kinematic metrics across repeated task segments. ICCs were estimated using a two-way mixed-effects model for single measures and consistency (ICC[3,1]). Participant-level metrics were derived from task-level values obtained from sequential functional task segments. Discussion This study describes the development and initial validation of the Rehabilitation Movement Assessment Protocol (ReMAP), a video-based assessment designed to characterize movement quality in cancer survivors. The principal finding of this study is that ReMAP-derived kinematic metrics capture qualitative aspects of movement behavior that are distinct from conventional performance-based mobility measures. These findings support the concept that movement quality represents a complementary construct to task performance and may help explain functional difficulties experienced by cancer survivors despite preserved performance on standard mobility tests. Across the examined movement quality domains, ReMAP metrics demonstrated domain-specific reliability patterns. Measures reflecting inter-limb coordination and motor control showed moderate to high reliability, suggesting that these domains capture stable, individual-specific movement strategies consistently expressed across task execution. In contrast, postural sway exhibited lower reliability, which likely reflects sensitivity to immediate task demands rather than measurement instability. In the context of sequential and unfamiliar functional tasks, variability in postural sway may represent adaptive adjustments to changing balance requirements rather than random error. This interpretation aligns with contemporary motor control frameworks that conceptualize movement variability as a functional and informative component of motor behavior. From a cancer survivorship perspective, these findings are clinically meaningful. Functional impairment following cancer treatment often arises from disrupted sensorimotor integration, altered proprioception, and inefficient coordination rather than focal neurological deficits or generalized deconditioning [ 11 ]. Such treatment-related movement alterations may contribute to increased effort, fatigue, and reduced confidence during everyday activities, even when overall task completion remains intact [ 12 ]. By quantifying movement quality across multiple domains, the ReMAP Assessment provides a structured approach for identifying these subtle but impactful movement characteristics that are not readily captured by conventional mobility tests [ 13 , 14 ]. Taken together, the present findings support the use of ReMAP as a movement phenotyping tool in cancer survivorship research and rehabilitation practice. Rather than replacing existing performance-based assessments, ReMAP is intended to complement them by providing insight into how functional tasks are executed [ 15 ]. This information may be valuable for tailoring rehabilitation strategies, monitoring functional recovery, and advancing the understanding of movement-related sequelae of cancer treatment. A key strength of the ReMAP Assessment is its use of sequential, unfamiliar functional tasks performed without pauses. By minimizing reliance on task familiarity, the assessment challenges real-time sensorimotor processing and increases sensitivity to qualitative movement deficits. In addition, the use of standard RGB video and pose-estimation technology enables objective, quantitative analysis of movement quality without the need for laboratory-grade motion capture systems or wearable sensors. This approach enhances feasibility, scalability, and potential clinical adoption while maintaining methodological rigor. Prior studies in cancer survivorship have primarily relied on performance-based measures such as gait speed, balance duration, and the Timed Up and Go test to characterize functional mobility. While these measures are clinically useful, they predominantly capture task completion time or endurance and provide limited insight into how movements are executed [ 16 , 17 ]. Previous work has demonstrated that cancer survivors frequently exhibit balance impairments and altered movement strategies despite preserved muscle strength or aerobic capacity, suggesting a dissociation between physical capacity and movement control [ 18 , 19 ]. Consistent with this literature, the generally weak associations observed between ReMAP movement quality metrics and conventional clinical reference measures support the conceptual distinction between movement quality and performance-based outcomes. Rather than indicating poor validity, these findings suggest that ReMAP captures qualitative dimensions of movement behavior—such as coordination strategies, movement efficiency, and motor control—that are not reflected by time-based functional tests [ 20 ]. Similar dissociations have been reported in movement science research, in which kinematic measures of variability and coordination provide complementary information beyond traditional clinical scores [ 21 ]. The domain-specific reliability patterns observed in the present study further align with prior work on motor control and movement variability. Coordination-related metrics demonstrated high reliability, consistent with evidence that inter-limb coordination and corrective motor strategies represent relatively stable individual characteristics [ 22 ]. In contrast, postural sway exhibited lower reliability, likely reflecting its sensitivity to task-specific balance demands rather than measurement instability. This pattern parallels findings from postural control research, where variability is understood as an adaptive response to task constraints rather than random error [ 23 ]. Overall, internal reliability differed across movement quality domains, ranging from low reliability for postural sway to excellent reliability for coordination-related metrics. Movement efficiency and motor control measures demonstrated moderate to good reliability, indicating domain-specific variation in measurement stability. underlying control characteristics captured by the ReMAP Assessment. Coordination-related metrics demonstrated the highest reliability, suggesting that corrective coordination strategies represent stable, trait-like features of individual movement behavior that are consistently expressed across varying task demands. Measures of movement efficiency and motor control showed moderate to good reliability, reflecting their dependence on both individual movement strategies and task-specific constraints. In contrast, postural sway exhibited lower reliability, which likely reflects its sensitivity to immediate task demands rather than measurement instability. In the context of sequential and unfamiliar functional tasks, variability in postural sway may represent adaptive adjustments to changing balance requirements rather than random error [ 24 ]. This interpretation aligns with contemporary movement science perspectives, in which variability is understood as a functional component of motor control rather than an undesirable source of noise [ 15 , 25 ]. Together, these findings support the conceptual coherence of the ReMAP framework and underscore the importance of interpreting reliability within the context of domain-specific movement demands. Study Limitations Several limitations of this study should be acknowledged. First, this investigation represents an initial validation of the ReMAP Assessment using a cross-sectional design and baseline data only. As such, test–retest reliability and responsiveness to change were not evaluated and should be examined in future longitudinal studies. Second, the study sample consisted exclusively of breast cancer survivors recruited from outpatient rehabilitation clinics, which may limit generalizability to other cancer types or survivorship contexts. Third, kinematic metrics were derived from two-dimensional, markerless video-based pose estimation, which may not capture all aspects of three-dimensional movement. However, this approach was intentionally selected to enhance clinical feasibility and scalability. Finally, reference measures were limited to commonly used clinical mobility tests; future studies incorporating patient-reported outcomes and prospective functional endpoints may further elucidate the clinical relevance of movement quality phenotypes identified by ReMAP. Conclusion The Rehabilitation Movement Assessment Protocol (ReMAP) is a standardized, video-based assessment designed to characterize movement quality in cancer survivors. This initial validation study demonstrates that ReMAP captures qualitative aspects of movement behavior that are distinct from conventional performance-based mobility measures and are relevant to the functional challenges experienced during cancer survivorship. By providing a feasible approach to quantifying postural stability, motor control, coordination, and movement efficiency, ReMAP offers a novel framework for movement phenotyping in oncology rehabilitation. Further studies are warranted to evaluate its longitudinal properties and clinical utility across diverse cancer populations. Declarations Author contributions E.J Yang designed the study and acquired funding. H.S Kim, H.R.Jeon, M.R. Suh, S.Y. Ahn, J.A.Yoon, S.Y.Lee and Y.H.Won recruited the patients. J.Y.Lee and S.H.Chung performed data analysis. S.H.Chung wrote the first draft of the manuscript. All authors critically revised and approved the final version of the manuscript. Funding Information This study was funded by a grant from the National R&D Program for Cancer Control, Ministry of Health & Welfare, Republic of Korea (HA21C0216). Data availability The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest. Ethical approval All procedures performed involving human participants were in accordance with the ethical standards of the Institutional Review Boards of all participating institutions, including Daerim St. Mary’s Hospital (IRB No. DMC-22-047), Pusan National University Hospital (2305-025-126), CHA University Bundang Medical Center (CHAMC 2023-04-062-002), National Health Insurance Service Ilsan Hospital (NHIMC 2023-03-056-001), Jeju National University Hospital (JEJUNUH 2023-03-006), Chungnam National University Hospital (CNUH 2022-12-075-001), and Jeonbuk National University Hospital (CUH 2023-04-003-002). Written informed consent was obtained from all participants. Informed consent Informed consent was obtained from all individual participants included in the study. References Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. 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Key properties of expert movement systems in sport : an ecological dynamics perspective. Sports Med 2013;43(3):167-78. Latash ML. Understanding and Synergy: A Single Concept at Different Levels of Analysis? Front Syst Neurosci 2021;15:735406. van Wegen EE, van Emmerik RE, Riccio GE. Postural orientation: age-related changes in variability and time-to-boundary. Hum Mov Sci 2002;21(1):61-84. Harbourne RT, Stergiou N. Movement variability and the use of nonlinear tools: principles to guide physical therapist practice. Phys Ther 2009;89(3):267-82. Latash ML. The bliss (not the problem) of motor abundance (not redundancy). Exp Brain Res 2012;217(1):1-5. Additional Declarations No competing interests reported. Supplementary Files 1a.mp4 1b.mp4 2a.mp4 2b.mp4 3a.mp4 3b.mp4 Supplementary.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8725974","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":582109264,"identity":"b651b9e9-885c-4b69-b64b-95094ad5d114","order_by":0,"name":"Seung Hyun Chung","email":"","orcid":"","institution":"National Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Seung","middleName":"Hyun","lastName":"Chung","suffix":""},{"id":582109266,"identity":"55779f96-5259-4946-8ebf-ddc70d6e5a0c","order_by":1,"name":"Heoung Su Kim","email":"","orcid":"","institution":"Seoul National University Bundang Hospital","correspondingAuthor":false,"prefix":"","firstName":"Heoung","middleName":"Su","lastName":"Kim","suffix":""},{"id":582109267,"identity":"79ded9c2-8407-44d1-bcdf-475f2755112f","order_by":2,"name":"Ha Ra Jeon","email":"","orcid":"","institution":"National Health Insurance Service Ilsan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ha","middleName":"Ra","lastName":"Jeon","suffix":""},{"id":582109268,"identity":"6e268df5-f760-4e62-875b-850e0fa78d20","order_by":3,"name":"Mi Ri Suh","email":"","orcid":"","institution":"CHA University","correspondingAuthor":false,"prefix":"","firstName":"Mi","middleName":"Ri","lastName":"Suh","suffix":""},{"id":582109269,"identity":"56cec849-074a-4f71-8eca-1dd51ace1685","order_by":4,"name":"So Young Ahn","email":"","orcid":"","institution":"Chungnam National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"So","middleName":"Young","lastName":"Ahn","suffix":""},{"id":582109270,"identity":"3ce59347-1e54-49b8-b2b9-d8161dff5b9b","order_by":5,"name":"Jin Ah yoon","email":"","orcid":"","institution":"Pusan National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jin","middleName":"Ah","lastName":"yoon","suffix":""},{"id":582109271,"identity":"8220e014-432b-441b-81ca-321515018fc4","order_by":6,"name":"So Young Lee","email":"","orcid":"","institution":"Jeju National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"So","middleName":"Young","lastName":"Lee","suffix":""},{"id":582109272,"identity":"90d67d9f-62dd-42b0-b939-50e44f5cb133","order_by":7,"name":"Yu Hui Won","email":"","orcid":"","institution":"Jeonbuk National University","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"Hui","lastName":"Won","suffix":""},{"id":582109273,"identity":"92f868ce-9c5b-4640-979b-887145e59cb9","order_by":8,"name":"Eun Joo Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYNCCAhDBfABISMgQqcUARLAlgLTwkKKFB0ISVCwfffjhhw8GNon9/Gc+v7pRY8HDwH746AZ8WgzPpRlLzjBIS5w5I3ebdc4xoMN40tJu4NXSw2DGzGNw2NjgBu824xw2oBYJHjMCWti/Mf8BarE/f+aZcc4/IrTI8/CYMTMYHJYzYMhhfpzbRoQWAx6eYskegzQ5iRtpZsy5fRI8bIT8It/DvvHDjwobHv7+w48/53yrk+NnP3wMvy0HEGw2CTCJTznYlgYEm/kDIdWjYBSMglEwMgEAnJxA+cZaDS8AAAAASUVORK5CYII=","orcid":"","institution":"Seoul National University Bundang Hospital","correspondingAuthor":true,"prefix":"","firstName":"Eun","middleName":"Joo","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2026-01-29 01:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8725974/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8725974/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101486641,"identity":"dfec6c3e-0be4-448f-b0d9-3fe620884eb3","added_by":"auto","created_at":"2026-01-30 09:17:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":24301,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual framework of the Rehabilitation Movement Assessment Protocol (ReMAP).\u003c/p\u003e\n\u003cp\u003eReMAP is a standardized, video-based movement quality assessment consisting of sequential, unfamiliar functional tasks designed to emphasize real-time sensorimotor processing. RGB video is processed using pose estimation to derive kinematic metrics representing multiple domains of movement quality, including postural stability, coordination, movement efficiency, and motor control.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8725974/v1/2e68d557030c11d94cee6be9.png"},{"id":101755316,"identity":"1ae4a078-2282-4340-88ba-67563ef2819f","added_by":"auto","created_at":"2026-02-03 10:50:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":649673,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8725974/v1/d3c36bc7-1cc0-4e30-8f1b-8d1fc8323414.pdf"},{"id":101486647,"identity":"b68ee407-ad4d-4bea-b3f2-d204ac20b20c","added_by":"auto","created_at":"2026-01-30 09:17:28","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1638898,"visible":true,"origin":"","legend":"","description":"","filename":"1a.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8725974/v1/6cfb96c80258c4448d422ca0.mp4"},{"id":101486642,"identity":"b3d838bd-1903-4d44-947a-7fabc977e18e","added_by":"auto","created_at":"2026-01-30 09:17:28","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":1881890,"visible":true,"origin":"","legend":"","description":"","filename":"1b.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8725974/v1/4b394d584e0e5ff67e94a85b.mp4"},{"id":101486648,"identity":"062264a1-1dc1-4290-9772-6087ad8dc709","added_by":"auto","created_at":"2026-01-30 09:17:29","extension":"mp4","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":1783117,"visible":true,"origin":"","legend":"","description":"","filename":"2a.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8725974/v1/643534d70f7bb41acd8b6a60.mp4"},{"id":101751528,"identity":"d255a315-2b42-4da2-a4e9-8d90d0b4b22b","added_by":"auto","created_at":"2026-02-03 10:21:04","extension":"mp4","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":2249388,"visible":true,"origin":"","legend":"","description":"","filename":"2b.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8725974/v1/9a2900f12e961535ac3e1b21.mp4"},{"id":101752143,"identity":"b124c15d-a052-4c54-9106-ba8ebc9b7596","added_by":"auto","created_at":"2026-02-03 10:25:41","extension":"mp4","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":2269625,"visible":true,"origin":"","legend":"","description":"","filename":"3a.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8725974/v1/10174721be8345682b9267d3.mp4"},{"id":101486644,"identity":"35317f0a-3784-4bf8-aa74-7b8a204935c1","added_by":"auto","created_at":"2026-01-30 09:17:28","extension":"mp4","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":2123877,"visible":true,"origin":"","legend":"","description":"","filename":"3b.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8725974/v1/c73b12ec1b49a96aaa5aca5f.mp4"},{"id":101752250,"identity":"f0f9f0e4-0a60-4e8c-bc00-b1792114448d","added_by":"auto","created_at":"2026-02-03 10:26:18","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":16716,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary.docx","url":"https://assets-eu.researchsquare.com/files/rs-8725974/v1/cdc59d0396da7179563c1923.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development and Validation of a s Standardized Video-Based Assessment of Movement Quality in Breast Cancer Survivors","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdvances in cancer treatment have resulted in a rapidly growing population of cancer survivors living with long-term functional consequences. Even after completion of primary treatment, many survivors report persistent difficulties with balance, coordination, and efficient movement that interfere with daily activities and participation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Importantly, these functional impairments often occur in the absence of overt muscle weakness or cardiopulmonary limitation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], suggesting that deficits in movement control and coordination play a central role in post-treatment functional decline [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFunctional impairment in cancer survivorship differs in important ways from that observed in populations with central neurological disorders or age-related decline. Cancer treatments such as surgery, chemotherapy, and radiation therapy can disrupt sensorimotor integration, proprioception, and coordination, leading to inefficient and fatiguing movement strategies. These treatment-related alterations may reduce functional confidence and increase activity avoidance, even when overall task performance appears preserved. However, such qualitative movement deficits are not readily detected by commonly used performance-based mobility tests, which primarily summarize task completion time or distance rather than how movement is executed.\u003c/p\u003e \u003cp\u003eMovement quality has therefore emerged as a clinically relevant construct in cancer rehabilitation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], reflecting how individuals stabilize, coordinate, and adapt their movements during functional tasks [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Despite its importance, movement quality is rarely quantified using standardized and objective tools that are feasible for routine clinical use in oncology settings [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Accordingly, the purpose of this study was to develop and validate the Rehabilitation Movement Assessment Protocol (ReMAP), a video-based assessment designed to quantify postural stability, motor control, inter-limb coordination, and movement efficiency during functional task performance in cancer survivors [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccordingly, the purpose of this study was to develop and validate a standardized, video-based movement quality assessment for breast cancer survivors. The assessment, termed the Rehabilitation Movement Assessment Protocol (ReMAP), was designed to evaluate postural stability, coordination, and movement efficiency using sequential, unfamiliar functional tasks that emphasize real-time sensorimotor processing. Using kinematic metrics derived from video-based pose estimation, we examined the construct validity and reliability of the assessment, with the goal of establishing a clinically feasible tool for quantifying movement quality in oncology rehabilitation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed a cross-sectional validation design to develop and evaluate a standardized movement quality assessment for breast cancer survivors, termed the Rehabilitation Movement Assessment Protocol (ReMAP). The assessment consists of sequential, unfamiliar functional movement tasks intended to emphasize real-time sensorimotor processing rather than learned or habitual movement patterns. Analyses were conducted using baseline data from a single assessment session to establish construct validity and within-session internal reliability.\u0026nbsp;Accordingly, this study focused exclusively on evaluating the measurement properties of the ReMAP Assessment, without examining intervention effects or longitudinal change.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting and Eligibility Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted between January 2023 and June 2024 at cancer rehabilitation centers affiliated with seven university hospitals in Korea, with recruitment carried out at three hospital-based centers. Eligible participants were women aged 18\u0026ndash;65 years with a diagnosis of breast cancer who had completed curative treatment at least 3 months and within 10 years prior to enrollment, and who were able to ambulate independently and follow verbal instructions. Participants with acute musculoskeletal injuries, non\u0026ndash;cancer-related neurological disorders, or other conditions that could interfere with safe task performance were excluded.\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Boards of all participating institutions. Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReMAP Movement Quality Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ReMAP Assessment was designed to evaluate qualitative aspects of movement using sequential, unfamiliar functional tasks that emphasize real-time sensorimotor processing rather than task familiarity. The protocol comprised three standardized paired task sequences, each including two distinct subtasks performed continuously without pauses. Tasks were selected to challenge key components of movement quality, including postural stability, single-leg balance, trunk rotation, bilateral coordination, and multi-directional stepping.\u003c/p\u003e\n\u003cp\u003eParticipants performed the assessment barefoot or in standard footwear, without assistive devices, under standardized verbal instruction and supervision by trained assessors. No physical guidance or feedback was provided during task execution. All tasks were functionally relevant, low risk, and feasible for outpatient cancer survivors, and were administered in a fixed order according to a predefined protocol (Supplementary Table 1). Movement performance was recorded using standard RGB cameras capturing frontal and lateral views. Video data were processed using MediaPipe Pose to extract 33 anatomical landmarks, with trajectories visually inspected and low-pass filtered prior to kinematic analysis. The conceptual framework of the ReMAP Assessment is illustrated in Figure 1.\u003c/p\u003e\n\u003cp\u003eReMAP is a standardized, video-based movement quality assessment consisting of sequential, unfamiliar functional tasks designed to emphasize real-time sensorimotor processing. RGB video is processed using pose estimation to derive kinematic metrics representing multiple domains of movement quality, including postural stability, coordination, movement efficiency, and motor control.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKinematic Outcome Metrics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKinematic metrics were derived a priori to reflect four predefined domains of movement quality: postural stability, motor control, inter-limb coordination, and movement efficiency (Supplementary Table 2).\u0026nbsp;Postural stability was quantified as the variability of mediolateral center-of-mass (COM) displacement over time, with higher values indicating poorer stability. Motor control was assessed using trajectory variability, reflecting the consistency and precision of limb movement paths across repeated task executions, where higher values indicated poorer motor control. Inter-limb coordination was quantified using correlation-based indices derived from bilateral limb trajectories, with higher values indicating better coordination. Movement efficiency was assessed using an energy ratio comparing observed mechanical energy expenditure with a theoretical minimum-energy trajectory, with higher values indicating lower efficiency. For each participant, domain-specific metrics were calculated at the task level and averaged across tasks to generate summary measures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConstruct Validity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConstruct validity was examined by evaluating associations between ReMAP-derived kinematic metrics and established clinical measures of balance and functional mobility. Clinical reference measure included the Timed Up and Go (TUG) test. Construct validity was examined using both Pearson and Spearman correlation coefficients to evaluate associations between ReMAP-derived kinematic metrics and clinical reference measures. Based on theoretical considerations, we hypothesized moderate associations between ReMAP metrics and balance-related measures and weaker associations with time-based functional performance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReliability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReliability of the ReMAP Assessment was evaluated using within-session internal consistency based on intraclass correlation coefficients (ICC). ICC values were interpreted according to established guidelines, with higher values indicating greater reliability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were calculated for participant characteristics and all kinematic metrics. Continuous variables are reported as mean \u0026plusmn; standard deviation or median with interquartile range, as appropriate. Construct validity was examined using Pearson and Spearman correlation coefficients to evaluate associations between ReMAP-derived kinematic metrics and clinical reference measures. Reliability of the ReMAP Assessment was evaluated using within-session internal consistency based on intraclass correlation coefficients (ICC) with corresponding 95% confidence intervals. All statistical analyses were performed using Stata version 19 (StataCorp, College Station, TX, USA). All statistical tests were two-sided, and a p-value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBaseline demographic and clinical characteristics of the participants are summarized in \u003cstrong\u003eTable 1\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e The study included 70 breast cancer survivors with a mean age of 49.7 \u0026plusmn; 6.5 years. Approximately half of the participants had completed college education or higher (51.4%), and 48.6% were employed at the time of assessment. The cohort was recruited from outpatient rehabilitation clinics and represents a clinically relevant population of cancer survivors receiving follow-up or rehabilitative care. Most participants were diagnosed with stage II (48.6%) or stage III disease (38.6%), while a smaller proportion had stage I disease (12.9%). This distribution reflects a population with moderate to advanced disease severity, consistent with referral patterns to rehabilitation services following primary cancer treatment. All participants had a confirmed diagnosis of breast cancer and therefore constituted a single target-condition cohort. \u0026nbsp;The ReMAP Assessment and clinical reference measures were administered during the \u003cstrong\u003esame baseline evaluation session\u003c/strong\u003e\u003cstrong\u003e,\u003c/strong\u003e and no clinical interventions occurred between the index test and the reference standard assessments. Accordingly, the time interval between assessments was negligible, minimizing the potential for temporal or treatment-related confounding.\u003c/p\u003e\n\u003cp\u003eTable 1. Baseline Characteristics of Participants (n=70)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eN (% of sample)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003eDemographic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003eAge (mean\u0026nbsp;\u0026plusmn;\u0026nbsp;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e49.7\u0026nbsp;\u0026plusmn;\u0026nbsp;6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003eEducation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003e\u0026nbsp;High school/some college\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e34 (48.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003e\u0026nbsp;College graduate or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e36 (51.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003eEmployment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003e\u0026nbsp;Employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e34 (48.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003e\u0026nbsp;Retired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e24 (34.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003e\u0026nbsp;Other not employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e12 (17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003eClinical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003eBreast Cancer Stage at Diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e9 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e34 (48.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e27 (38.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003ePrimary Surgical Treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003eLumpectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e37 (52.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003eUnilateral mastectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e30 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003eBilateral mastectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e3 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003eAxillary surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003e\u0026nbsp;ALND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e32 (45.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003e\u0026nbsp;SLNB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e38 (54.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003eReceived radiation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003e\u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e24 (34.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003e\u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e46 (65.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003eReceived chemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e14 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e56 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003eOn endocrine therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003e\u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e4 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 358px;\"\u003e\n \u003cp\u003e\u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e66 (94.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eValues are presented as mean \u0026plusmn; standard deviation or number (%).\u0026nbsp;\u003cstrong\u003eALND\u003c/strong\u003e, axillary lymph node dissection; \u003cstrong\u003eSLNB\u003c/strong\u003e, sentinel lymph node biopsy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescriptive Statistics of ReMAP Kinematic Metrics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSummary statistics for the ReMAP-derived kinematic metrics are presented in Table 2. Across participants, mediolateral center-of-mass sway, inter-limb coordination indices, and energy ratio values exhibited broad distributions without evidence of floor or ceiling effects. Metrics derived from different movement quality domains demonstrated distinct distributions, supporting the conceptual separation of postural stability, coordination, and movement efficiency as related but nonredundant constructs.\u003c/p\u003e\n\u003cp\u003eMeasurement error indices derived from reliability estimates are presented in Table 2. Standard error of measurement (SEM) and minimal detectable change at the 95% confidence level (MDC₉₅) varied by metric, reflecting domain-specific differences in task sensitivity and measurement precision.\u003c/p\u003e\n\u003cp\u003eTable 2. Descriptive statistics of ReMAP movement quality metrics\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eDomain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eMetric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eMean\u0026nbsp;\u0026plusmn;\u0026nbsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMedian [Q1, Q3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eSEM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eMDC\u003csub\u003e95\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003ePostural stability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eCOM sway (ML)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e78.38\u0026nbsp;\u0026plusmn;\u0026nbsp;22.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e74.24 [66.42, 89.37]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e20.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e56.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eMotor control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eTrajectory variability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e72.88\u0026nbsp;\u0026plusmn;\u0026nbsp;38.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e84.17 [25.61, 98.28]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e24.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e67.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eCoordination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eLateral correction rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1.82\u0026nbsp;\u0026plusmn;\u0026nbsp;2.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e0.15 [0.13, 5.40]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eEfficiency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eEnergy ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e61.26\u0026nbsp;\u0026plusmn;\u0026nbsp;43.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e62.44 [20.17, 84.08]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e31.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e88.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eValues are presented as mean \u0026plusmn; SD and median [interquartile range]. Participant-level metrics were calculated by averaging task-level values across all task sequences.\u0026nbsp;SEM indicates standard error of measurement. MDC₉₅ represents the minimal detectable change at the 95% confidence level, calculated as SEM \u0026times; 1.96 \u0026times; \u0026radic;2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConstruct Validity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConstruct validity analyses demonstrated generally weak associations between ReMAP-derived kinematic metrics and clinical reference measures of functional mobility and balance (Table 3). Among coordination-related metrics, lateral correction rate showed a significant monotonic association with TUG performance (Spearman \u0026rho; = 0.295, p = 0.015), whereas Pearson correlation was not significant, consistent with a non-normal distribution and a rank-based relationship. Other metrics, including postural stability (COM sway), movement efficiency (energy ratio), and motor control (trajectory variability), demonstrated weak and non-significant associations with TUG.\u003c/p\u003e\n\u003cp\u003eOverall, these findings support the construct validity of the ReMAP Assessment by demonstrating that its kinematic metrics capture qualitative dimensions of movement behavior that are not strongly reflected by commonly used performance-based mobility measures.\u003c/p\u003e\n\u003cp\u003eTable 3. Construct validity of ReMAP movement quality metrics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eMetric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003ePearson r (p)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eSpearman \u0026rho; (p)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eCOM sway (mediolateral)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eTUG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.018 (0.883)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.016 (0.898)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eTrajectory variability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eTUG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e-0.018 (0.882)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.010 (0.935)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eLateral correction rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eTUG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.130 (0.293)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.295 (0.015)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eEnergy ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eTUG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e-0.049 (0.691)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e-0.042 (0.735)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ePearson and Spearman correlation coefficients were calculated to examine associations between ReMAP-derived kinematic metrics and established clinical reference measures. Clinical reference measure included the Timed Up and Go test (best of two trials). Participant-level ReMAP metrics were calculated by averaging task-level values across all task sequences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInternal reliability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWithin-session internal reliability was assessed using intraclass correlation coefficients across repeated task segments. Reliability varied across movement quality domains. Coordination-related metrics demonstrated the highest reliability, with lateral correction rate exhibiting excellent internal reliability (ICC[3,1] = 0.94, 95% CI 0.92\u0026ndash;0.96). Motor control, quantified by trajectory variability, showed good reliability (ICC[3,1] = 0.61, 95% CI 0.50\u0026ndash;0.70). Movement efficiency (energy ratio) demonstrated moderate reliability (ICC[3,1] = 0.47, 95% CI 0.36\u0026ndash;0.59). In contrast, COM sway (mediolateral) showed lower reliability (ICC[3,1] = 0.17, 95% CI 0.09\u0026ndash;0.30). Intraclass correlation coefficients (ICCs) were calculated to evaluate within-session internal reliability of ReMAP-derived kinematic metrics across repeated task segments. ICCs were estimated using a two-way mixed-effects model for single measures and consistency (ICC[3,1]). Participant-level metrics were derived from task-level values obtained from sequential functional task segments.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study describes the development and initial validation of the Rehabilitation Movement Assessment Protocol (ReMAP), a video-based assessment designed to characterize movement quality in cancer survivors. The principal finding of this study is that ReMAP-derived kinematic metrics capture qualitative aspects of movement behavior that are distinct from conventional performance-based mobility measures. These findings support the concept that movement quality represents a complementary construct to task performance and may help explain functional difficulties experienced by cancer survivors despite preserved performance on standard mobility tests.\u003c/p\u003e \u003cp\u003eAcross the examined movement quality domains, ReMAP metrics demonstrated domain-specific reliability patterns. Measures reflecting inter-limb coordination and motor control showed moderate to high reliability, suggesting that these domains capture stable, individual-specific movement strategies consistently expressed across task execution. In contrast, postural sway exhibited lower reliability, which likely reflects sensitivity to immediate task demands rather than measurement instability. In the context of sequential and unfamiliar functional tasks, variability in postural sway may represent adaptive adjustments to changing balance requirements rather than random error. This interpretation aligns with contemporary motor control frameworks that conceptualize movement variability as a functional and informative component of motor behavior.\u003c/p\u003e \u003cp\u003eFrom a cancer survivorship perspective, these findings are clinically meaningful. Functional impairment following cancer treatment often arises from disrupted sensorimotor integration, altered proprioception, and inefficient coordination rather than focal neurological deficits or generalized deconditioning [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Such treatment-related movement alterations may contribute to increased effort, fatigue, and reduced confidence during everyday activities, even when overall task completion remains intact [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. By quantifying movement quality across multiple domains, the ReMAP Assessment provides a structured approach for identifying these subtle but impactful movement characteristics that are not readily captured by conventional mobility tests [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTaken together, the present findings support the use of ReMAP as a movement phenotyping tool in cancer survivorship research and rehabilitation practice. Rather than replacing existing performance-based assessments, ReMAP is intended to complement them by providing insight into how functional tasks are executed [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This information may be valuable for tailoring rehabilitation strategies, monitoring functional recovery, and advancing the understanding of movement-related sequelae of cancer treatment. A key strength of the ReMAP Assessment is its use of sequential, unfamiliar functional tasks performed without pauses. By minimizing reliance on task familiarity, the assessment challenges real-time sensorimotor processing and increases sensitivity to qualitative movement deficits. In addition, the use of standard RGB video and pose-estimation technology enables objective, quantitative analysis of movement quality without the need for laboratory-grade motion capture systems or wearable sensors. This approach enhances feasibility, scalability, and potential clinical adoption while maintaining methodological rigor.\u003c/p\u003e \u003cp\u003ePrior studies in cancer survivorship have primarily relied on performance-based measures such as gait speed, balance duration, and the Timed Up and Go test to characterize functional mobility. While these measures are clinically useful, they predominantly capture task completion time or endurance and provide limited insight into how movements are executed [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Previous work has demonstrated that cancer survivors frequently exhibit balance impairments and altered movement strategies despite preserved muscle strength or aerobic capacity, suggesting a dissociation between physical capacity and movement control [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Consistent with this literature, the generally weak associations observed between ReMAP movement quality metrics and conventional clinical reference measures support the conceptual distinction between movement quality and performance-based outcomes. Rather than indicating poor validity, these findings suggest that ReMAP captures qualitative dimensions of movement behavior\u0026mdash;such as coordination strategies, movement efficiency, and motor control\u0026mdash;that are not reflected by time-based functional tests [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Similar dissociations have been reported in movement science research, in which kinematic measures of variability and coordination provide complementary information beyond traditional clinical scores [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe domain-specific reliability patterns observed in the present study further align with prior work on motor control and movement variability. Coordination-related metrics demonstrated high reliability, consistent with evidence that inter-limb coordination and corrective motor strategies represent relatively stable individual characteristics [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In contrast, postural sway exhibited lower reliability, likely reflecting its sensitivity to task-specific balance demands rather than measurement instability. This pattern parallels findings from postural control research, where variability is understood as an adaptive response to task constraints rather than random error [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, internal reliability differed across movement quality domains, ranging from low reliability for postural sway to excellent reliability for coordination-related metrics. Movement efficiency and motor control measures demonstrated moderate to good reliability, indicating domain-specific variation in measurement stability. underlying control characteristics captured by the ReMAP Assessment. Coordination-related metrics demonstrated the highest reliability, suggesting that corrective coordination strategies represent stable, trait-like features of individual movement behavior that are consistently expressed across varying task demands. Measures of movement efficiency and motor control showed moderate to good reliability, reflecting their dependence on both individual movement strategies and task-specific constraints.\u003c/p\u003e \u003cp\u003eIn contrast, postural sway exhibited lower reliability, which likely reflects its sensitivity to immediate task demands rather than measurement instability. In the context of sequential and unfamiliar functional tasks, variability in postural sway may represent adaptive adjustments to changing balance requirements rather than random error [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This interpretation aligns with contemporary movement science perspectives, in which variability is understood as a functional component of motor control rather than an undesirable source of noise [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Together, these findings support the conceptual coherence of the ReMAP framework and underscore the importance of interpreting reliability within the context of domain-specific movement demands.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStudy Limitations\u003c/h2\u003e \u003cp\u003eSeveral limitations of this study should be acknowledged. First, this investigation represents an initial validation of the ReMAP Assessment using a cross-sectional design and baseline data only. As such, test\u0026ndash;retest reliability and responsiveness to change were not evaluated and should be examined in future longitudinal studies. Second, the study sample consisted exclusively of breast cancer survivors recruited from outpatient rehabilitation clinics, which may limit generalizability to other cancer types or survivorship contexts. Third, kinematic metrics were derived from two-dimensional, markerless video-based pose estimation, which may not capture all aspects of three-dimensional movement. However, this approach was intentionally selected to enhance clinical feasibility and scalability. Finally, reference measures were limited to commonly used clinical mobility tests; future studies incorporating patient-reported outcomes and prospective functional endpoints may further elucidate the clinical relevance of movement quality phenotypes identified by ReMAP.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe Rehabilitation Movement Assessment Protocol (ReMAP) is a standardized, video-based assessment designed to characterize movement quality in cancer survivors. This initial validation study demonstrates that ReMAP captures qualitative aspects of movement behavior that are distinct from conventional performance-based mobility measures and are relevant to the functional challenges experienced during cancer survivorship. By providing a feasible approach to quantifying postural stability, motor control, coordination, and movement efficiency, ReMAP offers a novel framework for movement phenotyping in oncology rehabilitation. Further studies are warranted to evaluate its longitudinal properties and clinical utility across diverse cancer populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eE.J Yang designed the study and acquired funding. H.S Kim, H.R.Jeon, M.R. Suh, S.Y. Ahn, J.A.Yoon, S.Y.Lee and Y.H.Won recruited the patients. J.Y.Lee and S.H.Chung performed data analysis. S.H.Chung wrote the first draft of the manuscript. All authors critically revised and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by a grant from the National R\u0026amp;D Program for Cancer Control, Ministry of Health \u0026amp; Welfare, Republic of Korea (HA21C0216).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with ethical standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed involving human participants were in accordance with the ethical standards of the Institutional Review Boards of all participating institutions, including Daerim St. Mary\u0026rsquo;s Hospital (IRB No. DMC-22-047), Pusan National University Hospital (2305-025-126), CHA University Bundang Medical Center (CHAMC 2023-04-062-002), National Health Insurance Service Ilsan Hospital (NHIMC 2023-03-056-001), Jeju National University Hospital (JEJUNUH 2023-03-006), Chungnam National University Hospital (CNUH 2022-12-075-001), and Jeonbuk National University Hospital (CUH 2023-04-003-002). Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians 2018;68(6):394-424.\u003c/li\u003e\n\u003cli\u003eStubblefield MD, McNeely ML, Alfano CM, Mayer DK. A prospective surveillance model for physical rehabilitation of women with breast cancer: chemotherapy-induced peripheral neuropathy. Cancer 2012;118(8 Suppl):2250-60.\u003c/li\u003e\n\u003cli\u003eYamani N, Ahmed A, Khan M, Wilson Z, Shakoor M, Qadri SF et al. Effectiveness of exercise modalities on breast cancer patient outcomes: a systematic review and meta-analysis. Cardiooncology 2024;10(1):38.\u003c/li\u003e\n\u003cli\u003eZhao J, Wang G, Chen L, Yu S, Li W. Risk factors for falls in hospitalized patients with cancer: A systematic review and meta-analysis. Asia Pac J Oncol Nurs 2022;9(8):100107.\u003c/li\u003e\n\u003cli\u003eWinters-Stone KM, Torgrimson B, Horak F, Eisner A, Nail L, Leo MC et al. Identifying factors associated with falls in postmenopausal breast cancer survivors: a multi-disciplinary approach. Arch Phys Med Rehabil 2011;92(4):646-52.\u003c/li\u003e\n\u003cli\u003eDevoogdt N, De Groef A. Physiotherapy management of breast cancer treatment-related sequelae. J Physiother 2024;70(2):90-105.\u003c/li\u003e\n\u003cli\u003eFairman CM, Zourdos MC, Helms ER, Focht BC. A scientific rationale to improve resistance training prescription in exercise oncology. Sports Medicine 2017;47(8):1457-65.\u003c/li\u003e\n\u003cli\u003eSantacaterina F, Campagnola B, Bressi F, Zollo L, Sterzi S, Bravi M. Telerehabilitation in Postoperative Breast Cancer Care: Systematic Review and Meta-Analysis. JMIR Rehabil Assist Technol 2025;12:e77161.\u003c/li\u003e\n\u003cli\u003eRoeles S, Rowe PJ, Bruijn SM, Childs CR, Tarfali GD, Steenbrink F et al. Gait stability in response to platform, belt, and sensory perturbations in young and older adults. Med Biol Eng Comput 2018;56(12):2325-35.\u003c/li\u003e\n\u003cli\u003eMesquita R, Wilke S, Smid DE, Janssen DJ, Franssen FM, Probst VS et al. Measurement properties of the Timed Up \u0026amp; Go test in patients with COPD. Chron Respir Dis 2016;13(4):344-52.\u003c/li\u003e\n\u003cli\u003eNeil SE, Klika RJ, Garland SJ, McKenzie DC, Campbell KL. Cardiorespiratory and neuromuscular deconditioning in fatigued and non-fatigued breast cancer survivors. Support Care Cancer 2013;21(3):873-81.\u003c/li\u003e\n\u003cli\u003eCampbell KL, Winters-Stone KM, Wiskemann J, May AM, Schwartz AL, Courneya KS et al. Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable. Med Sci Sports Exerc 2019;51(11):2375-90.\u003c/li\u003e\n\u003cli\u003eBeauchet O, Fantino B, Allali G, Muir SW, Montero-Odasso M, Annweiler C. Timed Up and Go test and risk of falls in older adults: a systematic review. J Nutr Health Aging 2011;15(10):933-8.\u003c/li\u003e\n\u003cli\u003eGarcia MB, Schadler KL, Chandra J, Clinton SK, Courneya KS, Cruz-Monserrate Z et al. Translating energy balance research from the bench to the clinic to the community: Parallel animal-human studies in cancer. CA Cancer J Clin 2023;73(4):425-42.\u003c/li\u003e\n\u003cli\u003eStergiou N, Harbourne R, Cavanaugh J. Optimal movement variability: a new theoretical perspective for neurologic physical therapy. J Neurol Phys Ther 2006;30(3):120-9.\u003c/li\u003e\n\u003cli\u003ePodsiadlo D, Richardson S. The timed \u0026quot;Up \u0026amp; Go\u0026quot;: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39(2):142-8.\u003c/li\u003e\n\u003cli\u003eMontero-Odasso M, Muir SW, Gopaul K, Annweiler C, Beauchet O. Gait velocity versus the timed up and go test: which one to use for the prediction of falls and other adverse health outcomes in primary care? J Am Geriatr Soc 2011;59(11):2191-2; author reply 2-3.\u003c/li\u003e\n\u003cli\u003eWinters-Stone KM, Horak F, Jacobs PG, Trubowitz P, Dieckmann NF, Stoyles S et al. Falls, Functioning, and Disability Among Women With Persistent Symptoms of Chemotherapy-Induced Peripheral Neuropathy. J Clin Oncol 2017;35(23):2604-12.\u003c/li\u003e\n\u003cli\u003eSchmitz KH, Campbell AM, Stuiver MM, Pinto BM, Schwartz AL, Morris GS et al. Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer. CA Cancer J Clin 2019;69(6):468-84.\u003c/li\u003e\n\u003cli\u003eVerghese J, Holtzer R, Lipton RB, Wang C. Quantitative gait markers and incident fall risk in older adults. J Gerontol A Biol Sci Med Sci 2009;64(8):896-901.\u003c/li\u003e\n\u003cli\u003eSeifert L, Button C, Davids K. Key properties of expert movement systems in sport : an ecological dynamics perspective. Sports Med 2013;43(3):167-78.\u003c/li\u003e\n\u003cli\u003eLatash ML. Understanding and Synergy: A Single Concept at Different Levels of Analysis? Front Syst Neurosci 2021;15:735406.\u003c/li\u003e\n\u003cli\u003evan Wegen EE, van Emmerik RE, Riccio GE. Postural orientation: age-related changes in variability and time-to-boundary. Hum Mov Sci 2002;21(1):61-84.\u003c/li\u003e\n\u003cli\u003eHarbourne RT, Stergiou N. Movement variability and the use of nonlinear tools: principles to guide physical therapist practice. Phys Ther 2009;89(3):267-82.\u003c/li\u003e\n\u003cli\u003eLatash ML. The bliss (not the problem) of motor abundance (not redundancy). Exp Brain Res 2012;217(1):1-5.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cancer survivors, Movement quality, Functional Mobility, Postural Balance, Motion Analysis, Measurement properties","lastPublishedDoi":"10.21203/rs.3.rs-8725974/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8725974/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose \u003c/strong\u003eCancer survivors frequently experience persistent movement inefficiencies and coordination deficits following cancer treatment, which may not be fully captured by commonly used performance-based mobility tests. The purpose of this study was to develop and validate a clinically feasible, video-based assessment designed to characterize movement quality in cancer survivors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003eThis cross-sectional validation study included 70 breast cancer survivors recruited from outpatient rehabilitation clinics. The Rehabilitation Movement Assessment Protocol (ReMAP) consists of standardized, sequential, and unfamiliar functional tasks designed to elicit real-time sensorimotor control demands. Movement quality was quantified using kinematic metrics derived from markerless video-based pose estimation, reflecting postural stability, motor control, inter-limb coordination, and movement efficiency. Construct validity was examined using correlations with clinical reference measures, and within-session internal reliability and measurement error were evaluated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eReMAP-derived kinematic metrics demonstrated distinct associations with conventional mobility measures, supporting construct distinction between movement quality and task performance. Reliability varied across movement quality domains, with coordination and motor control metrics demonstrating higher reliability than postural sway measures. Measurement error indices were within acceptable ranges for clinical assessment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions \u003c/strong\u003eThe ReMAP Assessment provides a feasible approach for quantifying movement quality in cancer survivors and captures functional characteristics not readily identified by performance-based mobility tests. These findings support the use of ReMAP as a movement phenotyping tool in cancer survivorship research and rehabilitation practice. Implications for Cancer Survivors For cancer survivors, functional limitations often reflect inefficient coordination and altered movement control rather than reduced task completion speed alone. By characterizing how functional movements are executed, the ReMAP Assessment provides clinically relevant information that may help identify subtle movement inefficiencies associated with fatigue and reduced functional confidence. This approach has potential to support more individualized rehabilitation strategies and improve functional participation in cancer survivorship.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Development and Validation of a s Standardized Video-Based Assessment of Movement Quality in Breast Cancer Survivors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-30 09:17:12","doi":"10.21203/rs.3.rs-8725974/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c65975e6-7559-4a3e-930b-56c57ed09e92","owner":[],"postedDate":"January 30th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T11:10:41+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-30 09:17:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8725974","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8725974","identity":"rs-8725974","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}