Novel technology for mobility and balance tracking in patients with multiple sclerosis: a systematic review

Examining the Use of Autonomous Systems for Home Health Support Using a Smart Mirror

The home is becoming a key location for healthcare delivery, including the use of technology driven by autonomous systems (AS) to monitor and support healthcare plans. Using the example of a smart mirror, this paper describes the outcomes of focus groups with people with multiple sclerosis (MS; n = 6) and people who have had a stroke (n = 15) to understand their attitudes towards the use of AS for healthcare in the home. Qualitative data were analysed using a thematic analysis. The results indicate that the use of such technology depends on the level of adaptability and responsiveness to users' specific circumstances, including their relationships with the healthcare system. A smart mirror would need to support manual entry, responsive goal setting, the effective aggregation of data sources and integration with other technology, have a range of input methods, be supportive rather than prescriptive in messaging, and give the user full control of their data. The barriers to its adoption include a perceived lack of portability and practicality, a lack of accessibility and inclusivity, a sense of redundancy, feeling overwhelmed by multiple technological devices, and a lack of trust in data sharing. These results inform the development and deployment of future health technologies based on the lived experiences of people with health conditions who require ongoing care.

Evaluation of unsupervised 30-second chair stand test performance assessed by wearable sensors to predict fall status in multiple sclerosis

BACKGROUND

One in two people with multiple sclerosis (PwMS) will fall in a three-month period. Predicting which patients will fall remains a challenge for clinicians. Standardized functional assessments provide insight into balance deficits and fall risk but their use has been limited to supervised visits.

RESEARCH QUESTION

The study aim was to characterize unsupervised 30-second chair stand test (30CST) performance using accelerometer-derived metrics and assess its ability to classify fall status in PwMS compared to supervised 30CST.

METHODS

Thirty-seven PwMS (21 fallers) performed instrumented supervised and unsupervised 30CSTs with a single wearable sensor on the thigh. In unsupervised conditions, participants performed bi-hourly 30CSTs and rated their balance confidence and fatigue over 48-hours. ROC analysis was used to classify fall status for 30CST performance.

RESULTS

Non-fallers (p = 0.02) but not fallers (p = 0.23) differed in their average unsupervised 30CST performance (repetitions) compared to their supervised performance. The unsupervised maximum number of 30CST repetitions performed optimized ROC classification AUC (0.79), accuracy (78.4%) and specificity (90.0%) for fall status with an optimal cutoff of 17 repetitions.

SIGNIFICANCE

Brief durations of instrumented unsupervised monitoring as an adjunct to routine clinical assessments could improve the ability for predicting fall risk and fluctuations in functional mobility in PwMS.

Inertial Sensor Reliability and Validity for Static and Dynamic Balance in Healthy Adults: A Systematic Review

Compared to laboratory equipment inertial sensors are inexpensive and portable, permitting the measurement of postural sway and balance to be conducted in any setting. This systematic review investigated the inter-sensor and test-retest reliability, and concurrent and discriminant validity to measure static and dynamic balance in healthy adults. Medline, PubMed, Embase, Scopus, CINAHL, and Web of Science were searched to January 2021. Nineteen studies met the inclusion criteria. Meta-analysis was possible for reliability studies only and it was found that inertial sensors are reliable to measure static standing eyes open. A synthesis of the included studies shows moderate to good reliability for dynamic balance. Concurrent validity is moderate for both static and dynamic balance. Sensors discriminate old from young adults by amplitude of mediolateral sway, gait velocity, step length, and turn speed. Fallers are discriminated from non-fallers by sensor measures during walking, stepping, and sit to stand. The accuracy of discrimination is unable to be determined conclusively. Using inertial sensors to measure postural sway in healthy adults provides real-time data collected in the natural environment and enables discrimination between fallers and non-fallers. The ability of inertial sensors to identify differences in postural sway components related to altered performance in clinical tests can inform targeted interventions for the prevention of falls and near falls.

Smartphone applications to assess gait and postural control in people with multiple sclerosis: A systematic review

BACKGROUND

Methods to effectively assess gait and balance impairments are necessary to guide interventions among people with Multiple Sclerosis (PwMS). Smartphone-based evaluations are becoming popular due to the ubiquitous use of smartphones in society.

OBJECTIVE

To determine the current state of smartphone applications that assess gait and balance among PwMS.

METHODS

Two independent reviewers screened articles retrieved from PubMed, Web of Science, Scopus, CINAHL, and SportDiscuss. Articles meeting eligibility criteria were summarized and qualitatively discussed. Participant characteristics, validity, reliability, sensitivity and specificity measures, and main results of smartphone-based gait and balance evaluations were summarized. Methodological quality appraisal of the studies was performed using the quality assessment tool for observational cohort and cross-sectional studies.

RESULTS

Eight articles were included in this review. The studies present mostly with low risk of bias. All studies successfully tested the use of smartphone applications in assessing gait and balance among PwMS. In total, 75% of the studies evaluated the validity; 38% evaluated the reliability, sensitivity, and specificity of smartphone applications to assess gait and balance. Of those, all studies except one found smartphone applications to be appropriately valid, reliable, sensitive, and specific in assessing gait and balance. Most studies (88%) reported PwMS and clinicians as their intended users.

CONCLUSION

There is evidence supporting the use of smartphone applications to assess gait and balance among PwMS. Future studies should further examine the psychometric properties of smartphone-based gait and postural control assessments as well as the sensitivity and specificity to improve the interpretation of the results.

Smartphone accelerometry to assess postural control in individuals with multiple sclerosis

BACKGROUND

Falls are a major health concern for people with Multiple Sclerosis (pwMS), and impaired postural control is an important predictor of falls. Lab-based technology to measure posture is precise but expensive, and clinical tests may not capture underlying impairments. An alternative solution is to leverage smartphone accelerometry as it is affordable, ubiquitous, and portable.

RESEARCH QUESTION

Can smartphone accelerometry measure postural control compared to a force plate and research grade accelerometer in pwMS, and can smartphone accelerometry discriminate between assisted device and non-assisted device users?

METHODS

27 pwMS (12 assisted device users, 15 non-assisted device users) stood on a force plate while holding a smartphone with an attached research grade accelerometer against their chest. Participants performed two, 30 s trials of: eyes open, eyes closed, semi-tandem, tandem, and single leg. Acceleration and center of pressure were extracted, and Root Mean Square (RMS) and 95 % confidence ellipse were calculated. Spearman's correlations were performed, and receiving operating characteristic (ROC) curves and the Area Under the Curve (AUC) were calculated.

RESULTS

There were moderate to high correlations between the smartphone and accelerometer for RMS (ρ = 0.85 - 1.0; p = 0.001 - <0.001) and 95 % area ellipse (ρ = 0.92 - 0.99; p = <0.001). There were weak to moderate correlations between the smartphone and force plate for RMS (ρ = 0.38 - 0.92; p = 0.06 - <0.001) and 95 % area ellipse (ρ = 0.69 - 0.90 p = 0.002 - <0.001). To discriminate between assisted device usage, ROC curves for smartphone outputs were constructed, the AUC was high and statistically significant (p < 0.001 - 0.02).

SIGNIFICANCE

There is potential to leverage smartphone accelerometery to measure postural control in pwMS. These finding provide preliminary results to support the development of a mobile health application to measure fall risk for pwMS.

Effectiveness of Motor Imagery on Motor Recovery in Patients with Multiple Sclerosis: Systematic Review

The effects of motor imagery (MI) on functional recovery of patients with neurological pathologies, such as stroke, has been recently proven. The aim of this study is to evaluate the effectiveness of MI on motor recovery and quality of life (QOL) in patients with multiple sclerosis (pwMS). A search was carried out in the following scientific databases: PubMed, CINAHL, PEDro, Scopus, Cochrane and Web of Science, up to November 2020. The grey literature and reference lists of potentially relevant articles were also searched. The Checklist for Measuring Quality and The Cochrane collaboration’s tool were used to assess the methodological quality and risk of bias of the studies. Five studies were included in the systematic review. Findings showed that pwMS using MI had significant improvements in walking speed and distance, fatigue and QOL. In addition, several benefits were also found in dynamic balance and perceived walking ability. Although the evidence is limited, rehabilitation using MI with the application of musical and verbal guides (compared to non-intervention or other interventions), can produce benefits on gait, fatigue and QOL in pwMS with a low score in the Expanded Disability Status Scale.

The Dresden Protocol for Multidimensional Walking Assessment (DMWA) in Clinical Practice

Walking impairments represent one of the most debilitating symptom areas for people with multiple sclerosis (MS). It is important to detect even slightest walking impairments in order to start and optimize necessary interventions in time to counteract further progression of the disability. For this reason, a regular monitoring through gait analysis is highly necessary. At advanced stages of MS with significant walking impairment, this assessment is also necessary to optimize symptomatic treatment, choose the most suitable walking aid and plan individualized rehabilitation. In clinical practice, walking impairment is only assessed at higher levels of the disease using e.g., the Expanded Disability Status Scale (EDSS). In contrast to the EDSS, standardized functional tests such as walking speed, walking endurance and balance as well as walking quality and gait-related patient-reported outcomes allow a more holistic and sensitive assessment of walking impairment. In recent years, the MS Center Dresden has established a standardized monitoring procedure for the routine multidimensional assessment of gait and balance disorders. In the following protocol, we present the techniques and procedures for the analysis of gait and balance of people with MS at the MS Center Dresden. Patients are assessed with a multidimensional gait analysis at least once a year. This enables long-term monitoring of walking impairment, which allows early active intervention regarding further progression of disease and improves the current standard clinical practice.

Bipedal hopping as a new measure to detect subtle sensorimotor impairment in people with multiple sclerosis

BACKGROUND

Bipedal hopping has the potential to detect subtle multiple sclerosis (MS)-related impairments, especially among patients who "pass" typical movement tests. In this narrative review, we outline the biomechanics of bipedal hopping and propose its usefulness as a novel outcome measure for people with MS having mild disability.

METHODS

We summarize articles that (1) examined the biomechanics of jumping or hopping and (2) tested the validity and/or reliability of hopping tests. We consolidated consistencies and gaps in research and opportunities for future development of the bipedal hop test.

RESULTS

Bipedal hopping requires immense power, coordination, balance, and ability to reduce co-contraction; movement components typically affected by MS. These impairments can be measured and differentiated by examining specific variables, such as hop length (power), symmetry (coordination), center of pressure (balance), and coefficient of variability (co-contraction/spasticity). Bipedal hopping challenges these aspects of movement and exposes sensorimotor impairments that may not have been apparent during walking.

CONCLUSIONS

Testing of bipedal hopping on an instrumented walkway may detect and monitor sensorimotor control in people with MS who do not currently present with clinical deficits. Early measurement is imperative for precise rehabilitation prescription to slow disability progression prior to onset of measurable gait impairment.Implications for rehabilitationJumping and hopping tests detect lower limb and balance impairments in children, athletes, and older adults.Bipedal hop test measures multiple domains: power, coordination, balance, and muscle timing.Bipedal hop test may expose subtle sensorimotor impairments in people with multiple sclerosis.Multiple variables measured can discern type of sensorimotor impairment to direct personalized rehabilitation programs.

Walking-related digital mobility outcomes as clinical trial endpoint measures: protocol for a scoping review

INTRODUCTION

Advances in wearable sensor technology now enable frequent, objective monitoring of real-world walking. Walking-related digital mobility outcomes (DMOs), such as real-world walking speed, have the potential to be more sensitive to mobility changes than traditional clinical assessments. However, it is not yet clear which DMOs are most suitable for formal validation. In this review, we will explore the evidence on discriminant ability, construct validity, prognostic value and responsiveness of walking-related DMOs in four disease areas: Parkinson's disease, multiple sclerosis, chronic obstructive pulmonary disease and proximal femoral fracture.

METHODS AND ANALYSIS

Arksey and O'Malley's methodological framework for scoping reviews will guide study conduct. We will search seven databases (Medline, CINAHL, Scopus, Web of Science, EMBASE, IEEE Digital Library and Cochrane Library) and grey literature for studies which (1) measure differences in DMOs between healthy and pathological walking, (2) assess relationships between DMOs and traditional clinical measures, (3) assess the prognostic value of DMOs and (4) use DMOs as endpoints in interventional clinical trials. Two reviewers will screen each abstract and full-text manuscript according to predefined eligibility criteria. We will then chart extracted data, map the literature, perform a narrative synthesis and identify gaps.

ETHICS AND DISSEMINATION

As this review is limited to publicly available materials, it does not require ethical approval. This work is part of Mobilise-D, an Innovative Medicines Initiative Joint Undertaking which aims to deliver, validate and obtain regulatory approval for DMOs. Results will be shared with the scientific community and general public in cooperation with the Mobilise-D communication team.

REGISTRATION

Study materials and updates will be made available through the Center for Open Science's OSFRegistry (https://osf.io/k7395).

Metrics extracted from a single wearable sensor during sit-stand transitions relate to mobility impairment and fall risk in people with multiple sclerosis

BACKGROUND

Approximately half of the 2.3 million people with multiple sclerosis (PwMS) will fall in any three-month period. Currently clinicians rely on self-report measures or simple functional assessments, administered at discrete time points, to assess fall risk. Wearable inertial sensors are a promising technology for increasing the sensitivity of clinical assessments to accurately predict fall risk, but current accelerometer-based approaches are limited.

RESEARCH QUESTION

Will metrics derived from wearable accelerometers during a 30-second chair stand test (30CST) correlate with clinical measures of disease severity, balance confidence and fatigue in PwMS, and can these metrics be used to accurately discriminate fallers from non-fallers?

METHODS

Thirty-eight PwMS (21 fallers) completed self-report outcome measures then performed the 30CST while triaxial acceleration data were collected from inertial sensors adhered to the thigh and chest. Accelerometer metrics were derived for the sit-to-stand and stand-to-sit transitions and relationships with clinical metrics were assessed. Finally, the metrics were used to develop a logistic regression model to classify fall status.

RESULTS

Accelerometer-derived metrics were significantly associated with multiple clinical metrics that capture disease severity, balance confidence and fatigue. Performance of a logistic regression for classifying fall status was enhanced by including accelerometer features (accuracy 74%, AUC 0.78) compared to the standard of care (accuracy 68%, AUC 0.74) or patient reported outcomes (accuracy 71%, AUC 0.75).

SIGNIFICANCE

Accelerometer derived metrics were associated with clinically relevant measures of disease severity, fatigue and balance confidence during a balance challenging task. Inertial sensors could feasibly be utilized to enhance the accuracy of functional assessments to identify fall risk in PwMS. Simplicity of these accelerometer-based metrics could facilitate deployment for community-based monitoring.

Using Body-Worn Sensors to Detect Changes in Balance and Mobility After Acute Aerobic Exercise in Adults with Multiple Sclerosis

Background

Current mobility and functional assessments do not capture the subtle changes in balance and gait that may predispose people with multiple sclerosis (MS) to falling. The purpose of this study was to use clinical and instrumented measures to examine the effects of an acute bout of aerobic exercise on balance and gait in individuals with MS.

Methods

Ten adults with MS performed 15 minutes of moderate-intensity recumbent cycling or 15 minutes of rest. Exercise and rest visit order was randomized and separated by 1 week. Balance and mobility were assessed before, immediately after, and 2 hours after each test condition.

Results

There were no significant differences across measurement periods for Timed 25-Foot Walk test times or Brief Balance Evaluation Systems Test scores. Significant improvements in mean sway radius and sway velocity when standing on foam and in percentage of stance stride time variability were found immediately after exercise compared with immediately after rest.

Conclusions

This study lends further evidence that individuals with MS can safely engage in single bouts of aerobic exercise without detrimental short-term effects on function and may actually receive some short-term benefit regarding standing postural sway and gait variability. Future research should examine the dose-dependent relationship of varying types, intensities, or timing of exercise necessary to elicit short-term functional benefit and long-term health outcomes.

Toward Digital Self-monitoring of Multiple Sclerosis: Investigating First Experiences, Needs, and Wishes of People with MS

Background

Digital self-monitoring, such as through smartphone applications (apps) or activity trackers, could be applied to monitor the health of people with multiple sclerosis (MS). This self-monitoring could facilitate personalized therapies and self-management of MS. The acceptance of digital self-monitoring tools by patients depends on them being able and willing to use these tools in their daily lives.

Methods

In-depth interviews were conducted with seven adults with MS before and after participation in a study in which they used an activity tracker and an MS-specific smartphone app for 4 weeks. We inquired about experiences with the tools in daily life and needs and wishes regarding further development and implementation of digital self-monitoring for people with MS.

Results

The smartphone app and the activity tracker increased respondents' awareness of their physical status and stimulated them to act on the data. Challenges, such as confrontation with their MS and difficulties with data interpretation, were discussed. The respondents desired 1) adaptation of digital self-monitoring tools to a patient's personal situation, 2) guidance to increase the value of the data, and 3) integration of digital self-monitoring into treatment plans.

Conclusions

These findings show that patients can provide detailed descriptions of their daily life experiences with new technologies. Mapping these experiences could help in better aligning the development and implementation of digital self-monitoring tools, in this case smartphones and activity trackers, with the needs and wishes of people with MS.

Wearable Inertial Sensors to Assess Standing Balance: A Systematic Review

Wearable sensors are de facto revolutionizing the assessment of standing balance. The aim of this work is to review the state-of-the-art literature that adopts this new posturographic paradigm, i.e., to analyse human postural sway through inertial sensors directly worn on the subject body. After a systematic search on PubMed and Scopus databases, two raters evaluated the quality of 73 full-text articles, selecting 47 high-quality contributions. A good inter-rater reliability was obtained (Cohen's kappa = 0.79). This selection of papers was used to summarize the available knowledge on the types of sensors used and their positioning, the data acquisition protocols and the main applications in this field (e.g., "active aging", biofeedback-based rehabilitation for fall prevention, and the management of Parkinson's disease and other balance-related pathologies), as well as the most adopted outcome measures. A critical discussion on the validation of wearable systems against gold standards is also presented.