Using accelerometry for measurement of motor behavior in children: Relationship of real-world movement to standardized evaluation

Referent data for investigations of upper limb accelerometry: harmonized data from three cohorts of typically-developing children

Aim

The rise of wearable sensing technology shows promise for addressing the challenges of measuring motor behavior in pediatric populations. The current pediatric wearable sensing literature is highly variable with respect to the number of sensors used, sensor placement, wearing time, and how data extracted from the sensors are analyzed. Many studies derive conceptually similar variables via different calculation methods, making it hard to compare across studies and clinical populations. In hopes of moving the field forward, this report provides referent upper limb wearable sensor data from accelerometers on 25 variables in typically-developing children, ages 3-17 years.

Methods

This is a secondary analysis of data from three pediatric cohorts of children 3-17 years of age. Participants (n = 222) in the cohorts wore bilateral wrist accelerometers for 2-4 days for a total of 622 recording days. Accelerometer data were reprocessed to compute 25 variables that quantified upper limb movement duration, intensity, symmetry, and complexity. Analyses examined the influence of hand dominance, age, gender, reliability, day-to-day stability, and the relationships between variables.

Results

The majority of variables were similar on the dominant and non-dominant sides, declined slightly with age, and were not different between boys and girls. ICC values were moderate to excellent. Variation within individuals across days generally ranged from 3% to 32%. A web-based R shiny object is available for data viewing.

Interpretation

With the use of wearable movement sensors increasing rapidly, these data provide key, referent information for researchers as they design studies, and analyze and interpret data from neurodevelopmental and other pediatric clinical populations. These data may be of particularly high value for pediatric rare diseases.

Associations Between Coordination and Wearable Sensor Variables Vary by Recording Context but Not Assessment Type

Motor coordination is an important driver of development and improved coordination assessments could facilitate better screening, diagnosis, and intervention for children at risk of developmental disorders. Wearable sensors could provide data that enhance the characterization of coordination and the clinical utility of that data may vary depending on how sensor variables from different recording contexts relate to coordination. We used wearable sensors at the wrists to capture upper-limb movement in 85 children aged 6-12. Sensor variables were extracted from two recording contexts. Structured recordings occurred in the lab during a unilateral throwing task. Unstructured recordings occurred during free-living activity. The objective was to determine the influence of recording context (unstructured versus structured) and assessment type (direct vs. indirect) on the association between sensor variables and coordination. The greatest associations were between six sensor variables from the structured context and the direct measure of coordination. Worse coordination scores were associated with upper-limb movements that had higher peak magnitudes, greater variance, and less smoothness. The associations were consistent across both arms, even though the structured task was unilateral. This finding suggests that wearable sensors could be paired with a simple, structured task to yield clinically informative variables that relate to motor coordination.

Upper extremity asymmetry due to nerve injuries or central neurologic conditions: a scoping review

BACKGROUND

Peripheral nerve injuries and central neurologic conditions can result in extensive disabilities. In cases with unilateral impairment, assessing the asymmetry between the upper extremity has been used to assess outcomes of treatment and severity of injury. A wide variety of validated and novel tests and sensors have been utilized to determine the upper extremity asymmetry. The purpose of this article is to review the literature and define the current state of the art for describing upper extremity asymmetry in patients with peripheral nerve injuries or central neurologic conditions.

METHOD

An electronic literature search of PubMed, Scopus, Web of Science, OVID was performed for publications between 2000 to 2022. Eligibility criteria were subjects with neurological conditions/injuries who were analyzed for dissimilarities in use between the upper extremities. Data related to study population, target condition/injury, types of tests performed, sensors used, real-world data collection, outcome measures of interest, and results of the study were extracted. Sackett's Level of Evidence was used to judge the quality of the articles.

RESULTS

Of the 7281 unique articles, 112 articles met the inclusion criteria for the review. Eight target conditions/injuries were identified (Brachial Plexus Injury, Cerebral Palsy, Multiple Sclerosis, Parkinson's Disease, Peripheral Nerve Injury, Spinal Cord Injury, Schizophrenia, and stroke). The tests performed were classified into thirteen categories based on the nature of the test and data collected. The general results related to upper extremity asymmetry were listed for all the reviewed articles. Stroke was the most studied condition, followed by cerebral palsy, with kinematics and strength measurement tests being the most frequently used tests. Studies with a level of evidence level II and III increased between 2000 and 2021. The use of real-world evidence-based data, and objective data collection tests also increased in the same period.

CONCLUSION

Adequately powered randomized controlled trials should be used to study upper extremity asymmetry. Neurological conditions other than stroke should be studied further. Upper extremity asymmetry should be measured using objective outcome measures like motion tracking and activity monitoring in the patient's daily living environment.

Bimanual Movement Characteristics and Real-World Performance Following Hand-Arm Bimanual Intensive Therapy in Children with Unilateral Cerebral Palsy

The purpose of this study was to quantify characteristics of bimanual movement intensity during 30 h of hand-arm bimanual intensive therapy (HABIT) and bimanual performance (activities and participation) in real-world settings using accelerometers in children with unilateral cerebral palsy (UCP). Twenty-five children with UCP participated in a 30 h HABIT program. Data were collected from bilateral wrist-worn accelerometers during 30 h of HABIT to quantify the movement intensity and three days pre- and post-HABIT to assess real-world performance gains. Movement intensity and performance gains were measured using six standard accelerometer-derived variables. Bimanual capacity (body function and activities) was assessed using standardized hand function tests. We found that accelerometer variables increased significantly during HABIT, indicating increased bimanual symmetry and intensity. Post-HABIT, children demonstrated significant improvements in all accelerometer metrics, reflecting real-world performance gains. Children also achieved significant and clinically relevant changes in hand capacity following HABIT. Therefore, our findings suggest that accelerometers can objectively quantify bimanual movement intensity during HABIT. Moreover, HABIT enhances hand function as well as activities and participation in real-world situations in children with UCP.

Detecting Asymmetry of Upper Limb Activity with Accelerometry in Infants at Risk for Unilateral Spastic Cerebral Palsy

AIMS

To examine whether accelerometry can quantitate asymmetry of upper limb activity in infants aged 3-12 months at risk for developing unilateral spastic cerebral palsy (USCP).

METHOD

A prospective study was performed in 50 infants with unilateral perinatal brain injury at high risk of developing USCP. Triaxial accelerometers were worn on the ipsilateral and contralesional upper limb during the Hand Assessment for Infants (HAI). Infants were grouped in three age intervals (3-5 months, 5-7.5 months and 7.5 until 12 months). Each age interval group was divided in a group with and without asymmetrical hand function based on HAI cutoff values suggestive of USCP.

RESULTS

In a total of 82 assessments, the asymmetry index for mean upper limb activity was higher in infants with asymmetrical hand function compared to infants with symmetrical hand function in all three age groups (ranging from 41 to 51% versus - 2-6%, p < 0.01), while the total activity of both upper limbs did not differ.

CONCLUSIONS

Upper limb accelerometry can identify asymmetrical hand function in the upper limbs in infants with unilateral perinatal brain injury from 3 months onwards and is complementary to the Hand Assessment for Infants.

Does accelerometry reflect hand function in infants at risk of unilateral cerebral palsy? A secondary analysis of BB-Bim results

BACKGROUND

Infants at high-risk of unilateral Cerebral Palsy (UCP) may have asymmetry in upper extremity movement and function, which should be identified as soon as possible for management.

AIMS

To explore the feasibility of using two AX3 Axivity monitors in wrist-worn bracelets to quantify movements, and to identify whether accelerometry parameters are consistent with hand function.

METHODS AND PROCEDURES

6 infants at high risk of UCP (aged 3 to -12 months) were included in a Single-Case Experimental Design to explore the impact of an 8-week bimanual stimulation home program.

OUTCOMES

Each week of the baseline (randomized duration 4-7 weeks) and 8-week program, the Hand Assessment for Infants (HAI) was performed and accelerometry parameters were collected during HAI and also during spontaneous activity, several times a week.

RESULTS

Actimetry was analyzed during HAI and 238 spontaneous activity sessions (mean 42 ± 21 min). Actimetry ratios distribution and evolution show a high variability, especially for spontaneous activity. No strong correlation was found between HAI scores and accelerometry parameters, either collected during HAI, or during spontaneous activity times.

CONCLUSION AND IMPLICATIONS

Despite its feasibility, using accelerometry bracelets looks unreliable for detecting and monitoring hand function in infants under one year.

Bilateral actigraphic quantification of upper extremity movement in hemiparetic children with perinatal stroke: a case control study

BACKGROUND

Hemiparetic cerebral palsy impacts millions of people worldwide. Assessment of bilateral motor function in real life remains a major challenge. We evaluated quantification of upper extremity movement in hemiparetic children using bilateral actigraphy. We hypothesized that movement asymmetry correlates with standard motor outcome measures.

METHODS

Hemiparetic and control participants wore bilateral wrist Actiwatch2 (Philips) for 48 h with movement counts recorded in 15-s intervals. The primary outcome was a novel statistic of movement asymmetry, the Actigraphic Movement Asymmetry Index (AMAI). Relationships between AMAI and standard motor outcomes (Assisting Hand Assessment, Melbourne Assessment, and Box and Block Test [BB]) were explored with Pearson or Spearman correlation.

RESULTS

30 stroke (mean 11 years 2 months (3 years 10 months); 13 female, 17 male) and 23 control (mean 11 years 1 month (4 years 5 months); 8 female, 15 male) were enrolled. Stroke participants demonstrated higher asymmetry. Correlations between AMAI and standard tests were moderate and strongest during sleep (BB: r = 0.68, p < 0.01).

CONCLUSIONS

Standard tests may not reflect the extent of movement asymmetry during daily life in hemiparetic children. Bilateral actigraphy may be a valuable complementary tool for measuring arm movement, potentially enabling improved evaluation of therapies with a focus on child participation.

Toward a More Comprehensive Assessment of School Age Children with Hemiplegic Cerebral Palsy

Background:

Cerebral palsy (CP) is the leading cause of disability in children. While motor deficits define CP, many patients experience behavioral and cognitive deficits which limit participation. The purpose of this study was to contribute to our understanding of developmental delay and how to measure these deficits among children with CP.

Methods:

Children 5 to 15 years with hemiplegic CP were recruited. Cognition and motor ability were assessed. The brain injury associated with observed motor deficits was identified. Accelerometers measured real-world bilateral upper extremity movement and caregivers completed behavioral assessments.

Results:

Eleven children participated, 6 with presumed perinatal stroke. Four children scored below average intelligence quotient while other measures of cognition were within normal limits (except processing speed). Motor scores confirmed asymmetrical deficits. Approximately one third of scores indicated deficits in attention, behavior, or depression.

Conclusions:

Our findings corroborate that children with CP experience challenges that are broader than motor impairment alone. Despite the variation in brain injury, all participants completed study procedures.

Implications:

Our findings suggest that measuring behavior in children with CP may require a more comprehensive approach and that caregivers are amenable to using online collection tools which may assist in addressing the therapeutic needs of children with CP.

Implementation of Wearable Sensing Technology for Movement: Pushing Forward into the Routine Physical Rehabilitation Care Field

While the promise of wearable sensor technology to transform physical rehabilitation has been around for a number of years, the reality is that wearable sensor technology for the measurement of human movement has remained largely confined to rehabilitation research labs with limited ventures into clinical practice. The purposes of this paper are to: (1) discuss the major barriers in clinical practice and available wearable sensing technology; (2) propose benchmarks for wearable device systems that would make it feasible to implement them in clinical practice across the world and (3) evaluate a current wearable device system against the benchmarks as an example. If we can overcome the barriers and achieve the benchmarks collectively, the field of rehabilitation will move forward towards better movement interventions that produce improved function not just in the clinic or lab, but out in peoples' homes and communities.