Validity, reliability, and sensitivity to motor impairment severity of a multi-touch app designed to assess hand mobility, coordination, and function after stroke

Validation of the Kinematic Assessment Protocol Used in the Technology-Supported Neurorehabilitation System, Rehabilitation Technologies for Hand and Arm (R3THA™), in Children and Teenagers with Cerebral Palsy

This study evaluates the R3THA™ assessment protocol (R3THA-AP™), a technology-supported testing module for personalized rehabilitation in children with cerebral palsy (CP). It focuses on the reliability and validity of the R3THA-AP in assessing hand and arm function, by comparing kinematic assessments with standard clinical assessments. Conducted during a 4-week summer camp, the study assessed the functional and impairment levels of children with CP aged 3-18. The findings suggest that R3THA is more reliable for children aged 8 and older, indicating that age significantly influences the protocol's effectiveness. The results also showed that the R3THA-AP's kinematic measurements of hand and wrist movements are positively correlated with the Box and Blocks Test Index (BBTI), reflecting hand function and dexterity. Additionally, the R3THA-AP's accuracy metrics for hand and wrist activities align with the Melbourne Assessment 2's Range of Motion (MA2-ROM) scores, suggesting a meaningful relationship between R3THA-AP data and clinical assessments of motor skills. However, no significant correlations were observed between the R3THA-AP and MA2's accuracy and dexterity measurements, indicating areas for further research. These findings validate the R3THA-AP's utility in assessing motor abilities in CP patients, supporting its integration into clinical practice.

Portable Touchscreen Assessment of Motor Skill: A Registered Report of the Reliability and Validity of EDNA MoTap

Portable and flexible administration of manual dexterity assessments is necessary to monitor recovery from brain injury and the effects of interventions across clinic and home settings, especially when in-person testing is not possible or convenient. This paper aims to assess the concurrent validity and test-retest reliability of a new suite of touchscreen-based manual dexterity tests (called EDNA™MoTap) that are designed for portable and efficient administration. A minimum sample of 49 healthy young adults will be conveniently recruited. The EDNA™MoTap tasks will be assessed for concurrent validity against standardized tools (the Box and Block Test [BBT] and the Purdue Pegboard Test) and for test-retest reliability over a 1- to 2-week interval. Correlation coefficients of r > .6 will indicate acceptable validity, and intraclass correlation coefficient (ICC) values > .75 will indicate acceptable reliability for healthy adults. The sample were primarily right-handed (91%) adults aged 19 and 34 years (M = 24.93, SD = 4.21, 50% female). The MoTap tasks did not demonstrate acceptable validity, with tasks showing weak-to-moderate associations with the criterion assessments. Some outcomes demonstrated acceptable test-retest reliability; however, this was not consistent. Touchscreen-based assessments of dexterity remain relevant; however, there is a need for further development of the EDNA™MoTap task administration.

Efficacy of personalized rTMS to enhance upper limb function in subacute stroke patients: a protocol for a multi-center, randomized controlled study

Background

Repetitive transcranial magnetic stimulation (rTMS) is widely used therapy to enhance motor deficit in stroke patients. To date, rTMS protocols used in stroke patients are relatively unified. However, as the pathophysiology of stroke is diverse and individual functional deficits are distinctive, more precise application of rTMS is warranted. Therefore, the objective of this study was to determine the effects of personalized protocols of rTMS therapy based on the functional reserve of each stroke patient in subacute phase.

Methods

This study will recruit 120 patients with stroke in subacute phase suffering from the upper extremity motor impairment, from five different hospitals in Korea. The participants will be allocated into three different study conditions based on the functional reserve of each participant, measured by the results of TMS-induced motor evoked potentials (MEPs), and brain MRI with diffusion tensor imaging (DTI) evaluations. The participants of the intervention-group in the three study conditions will receive different protocols of rTMS intervention, a total of 10 sessions for 2 weeks: high-frequency rTMS on ipsilesional primary motor cortex (M1), high-frequency rTMS on ipsilesional ventral premotor cortex, and high-frequency rTMS on contralesional M1. The participants of the control-group in all three study conditions will receive the same rTMS protocol: low-frequency rTMS on contralesional M1. For outcome measures, the following assessments will be performed at baseline (T0), during-intervention (T1), post-intervention (T2), and follow-up (T3) periods: Fugl-Meyer Assessment (FMA), Box-and-block test, Action Research Arm Test, Jebsen-Taylor hand function test, hand grip strength, Functional Ambulatory Category, fractional anisotropy measured by the DTI, and brain network connectivity obtained from MRI. The primary outcome will be the difference of upper limb function, as measured by FMA from T0 to T2. The secondary outcomes will be the differences of other assessments.

Discussion

This study will determine the effects of applying different protocols of rTMS therapy based on the functional reserve of each patient. In addition, this methodology may prove to be more efficient than conventional rTMS protocols. Therefore, effective personalized application of rTMS to stroke patients can be achieved based on their severity, predicted mechanism of motor recovery, or functional reserves.

Clinical trial registration

https://clinicaltrials.gov/, identifier NCT06270238.

An Overall Automated Architecture Based on the Tapping Test Measurement Protocol: Hand Dexterity Assessment through an Innovative Objective Method

The present work focuses on the tapping test, which is a method that is commonly used in the literature to assess dexterity, speed, and motor coordination by repeatedly moving fingers, performing a tapping action on a flat surface. During the test, the activation of specific brain regions enhances fine motor abilities, improving motor control. The research also explores neuromuscular and biomechanical factors related to finger dexterity, revealing neuroplastic adaptation to repetitive movements. To give an objective evaluation of all cited physiological aspects, this work proposes a measurement architecture consisting of the following: (i) a novel measurement protocol to assess the coordinative and conditional capabilities of a population of participants; (ii) a suitable measurement platform, consisting of synchronized and non-invasive inertial sensors to be worn at finger level; (iii) a data analysis processing stage, able to provide the final user (medical doctor or training coach) with a plethora of useful information about the carried-out tests, going far beyond state-of-the-art results from classical tapping test examinations. Particularly, the proposed study underscores the importance interdigital autonomy for complex finger motions, despite the challenges posed by anatomical connections; this deepens our understanding of upper limb coordination and the impact of neuroplasticity, holding significance for motor abilities assessment, improvement, and therapeutic strategies to enhance finger precision. The proof-of-concept test is performed by considering a population of college students. The obtained results allow us to consider the proposed architecture to be valuable for many application scenarios, such as the ones related to neurodegenerative disease evolution monitoring.

Quantitative Assessment via Multi-Domain Fusion of Muscle Synergy Associated With Upper-Limb Motor Function for Stroke Rehabilitation

Quantitative assessment of upper limb motor function aids therapists in providing appropriate rehabilitation strategies, which plays an essential role in post-stroke rehabilitation. Traditional assessments, relying on clinical scales or kinematic metrics, often involve subjective scores or are influenced by compensatory strategies. Recently, the use of muscle synergies, representing simplified neuromuscular control, has emerged as a promising approach for post-stroke assessment. In general, muscle synergies are decomposed into two components: synergy vectors and synergy activation. Synergy vectors represent the relative weighting of each muscle within each synergy, that is muscle coordination; synergy activation represents the recruitment of the muscle synergy over time, that is muscle activation strength. Both components are vital for adequately assessing patients' motor function. Therefore, we integrate the spatial domain and temporal domain features extracted from synergy vectors and synergy activation, constructing a multi-domain assessment system using a Random Forest classifier, which may provide great qualitative classification accuracy. Furthermore, a novel functional score is generated from the probabilities belonging to the pathological group. Finally, A study involving ten healthy subjects and ten post-stroke patients validates the proposed method. The experimental results show that the classification accuracy was enhanced to 98.56% by fusing the characteristics derived from different domains, which was higher than that based on spatial domain (94.90%) and temporal domain (91.08%), respectively. Furthermore, the assessment score generated by multi-domain fusion framework exhibited a significant correlation with the clinical score. These promising results show the potential of applying the proposed method to clinical assessments for post-stroke patients.

Reliability and Construct Validity of a Mobile Application for the Finger Tapping Test Evaluation in People with Multiple Sclerosis

The finger tapping test (FTT) is a tool to evaluate the motor performance of the hand and fingers and eye-hand coordination with applicability in people with multiple sclerosis (pwMS). The aim of this study was to evaluate the intra- and inter-rater reliability of the TappingPro® mobile app and the construct validity between this app and validated clinical scales for motor performance in healthy subjects and pwMS. 42 healthy subjects (mean age 25.05) and 13 pwMS (mean age 51.69, EDSS between 3 and 7.5E) participated. FTT was performed with the TappingPro® mobile app. All participants were examined twice, with a one-week interval between the two appointments. For the analysis of construct validity, the Jamar® hydraulic hand dynamometer, Box and Blocks Test (BBT), and Nine Hole Peg Test (NHPT) were used. The intra-rater reliability showed a good correlation (Intraclass Correlation Coefficient, ICC > 0.787) for both upper limbs and both times of FTT for healthy subjects, and an excellent correlation (ICC > 0.956) for upper limbs and both times of FTT for pwMS. The ICC for the inter-rater reliability was good (ICC = 0.869) for the non-dominant upper limb in the FTT 10 s of the healthy subjects, and excellent (ICC > 0.904) for all the other measurements of the healthy subjects and pwMS. However, the Bland-Altman plots showed disagreement between observers and measurements that should be considered in the interpretation of clinical evaluations. The correlation analysis for healthy subjects showed poor associations between all variables, except for the association between hand grip strength and the FTT 60 s in the non-dominant upper limb, which had a moderate coefficient. For pwMS, there were moderate to excellent associations between BBT and the NHPT and FTT for both upper limbs. The correlations between hand grip strength and FFT were poor. This mobile app could be a useful and low-cost assessment tool in pwMS, allowing a simple evaluation and follow-up that has excellent correlation with clinical scales validated in this pathology.

Extended reality to assess post-stroke manual dexterity: contrasts between the classic box and block test, immersive virtual reality with controllers, with hand-tracking, and mixed-reality tests

BACKGROUND

Recent technological advancements present promising opportunities to enhance the frequency and objectivity of functional assessments, aligning with recent stroke rehabilitation guidelines. Within this framework, we designed and adapted different manual dexterity tests in extended reality (XR), using immersive virtual reality (VR) with controllers (BBT-VR-C), immersive VR with hand-tracking (BBT-VR-HT), and mixed-reality (MD-MR).

OBJECTIVE

This study primarily aimed to assess and compare the validity of the BBT-VR-C, BBT-VR-HT and MD-MR to assess post-stroke manual dexterity. Secondary objectives were to evaluate reliability, usability and to define arm kinematics measures.

METHODS

A sample of 21 healthy control participants (HCP) and 21 stroke individuals with hemiparesis (IHP) completed three trials of the traditional BBT, the BBT-VR-C, BBT-VR-HT and MD-MR. Content validity of the different tests were evaluated by asking five healthcare professionals to rate the difficulty of performing each test in comparison to the traditional BBT. Convergent validity was evaluated through correlations between the scores of the traditional BBT and the XR tests. Test-retest reliability was assessed through correlations between the second and third trial and usability was assessed using the System Usability Scale (SUS). Lastly, upper limb movement smoothness (SPARC) was compared between IHP and HCP for both BBT-VR test versions.

RESULTS

For content validity, healthcare professionals rated the BBT-VR-HT (0[0-1]) and BBT-MR (0[0-1]) as equally difficult to the traditional BBT, whereas they rated BBT-VR-C as more difficult than the traditional BBT (1[0-2]). For IHP convergent validity, the Pearson tests demonstrated larger correlations between the scores of BBT and BBT-VR-HT (r = 0.94;p < 0.001), and BBT and MD-MR (r = 0.95;p < 0.001) than BBT and BBT-VR-C (r = 0.65;p = 0.001). BBT-VR-HT and MD-MR usability were both rated as excellent, with median SUS scores of 83[57.5-91.3] and 83[53.8-92.5] respectively. Excellent reliability was found for the BBT-VR-C (ICC = 0.96;p < 0.001), BBT-VR-HT (ICC = 0.96;p < 0.001) and BBT-MR (ICC = 0.99;p < 0.001). The usability of the BBT-VR-C was rated as good with a median SUS of 70[43.8-83.8]. Upper limb movements of HCP were significantly smoother than for IHP when completing either the BBT-VR-C (t = 2.05;p = 0.043) and the BBT-VR-HT (t = 5.21;p < 0.001).

CONCLUSION

The different XR manual tests are valid, short-term reliable and usable tools to assess post-stroke manual dexterity.

TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT04694833 ; Unique identifier: NCT04694833, Date of registration: 11/24/2020.

Effects of Immersive Virtual Reality on Upper-Extremity Stroke Rehabilitation: A Systematic Review with Meta-Analysis

Virtual reality (VR) is an innovative rehabilitation tool increasingly used in stroke rehabilitation. Fully immersive VR is a type of VR that closely simulates real-life scenarios, providing a high level of immersion, and has shown promising results in improving rehabilitation functions. This study aimed to assess the effect of immersive VR-based therapy for stroke patients on the upper extremities, activities of daily living (ADLs), and pain reduction and its acceptability and side effects. For this review, we gathered all suitable randomized controlled trials from PubMed, EMBASE, Cochrane Library, Scopus, and Web of Science. Out of 1532, 10 articles were included, with 324 participants. The results show that immersive VR offers greater benefits in comparison with conventional rehabilitation, with significant improvements observed in ADLs (SMD 0.58, 95% CI 0.25 to 0.91, I2 = 0%, p = 0.0005), overall function as measured by the Fugl-Meyer Assessment (MD 6.33, 95% CI 4.15 to 8.50, I2 = 25%, p = 0.00001), and subscales for the shoulder (MD 4.96, 95% CI-1.90-8.03, I2 = 25%, p = 0.002), wrist (MD 2.41, 95% CI-0.56-4.26, I2 = 0%, p = 0.01), and hand (MD 2.60, 95% CI-0.70-4.5°, I2 = 0%, p = 0.007). These findings highlight the potential of immersive VR as a valuable therapeutic option for stroke survivors, enhancing their ADL performance and upper-limb function. The immersive nature of VR provides an engaging and immersive environment for rehabilitation.

High-Frequency Ipsilesional versus Low-Frequency Contralesional Transcranial Magnetic Stimulation after Stroke: Differential Effects on Ipsilesional Upper Extremity Motor Recovery

Background and Objectives: Stroke is a major cause of death and disability worldwide; therefore, transcranial magnetic stimulation (TMS) is being widely studied and clinically applied to improve motor deficits in the affected arm. However, recent studies indicate that the function of both arms can be affected after stroke. It currently remains unknown how various TMS methods affect the function of the ipsilesional upper extremity. Materials and Methods: Thirty-five subacute stroke patients with upper extremity motor deficits were enrolled in this study and randomly allocated into three groups, receiving either (1) low-frequency rTMS over the contralesional hemisphere; (2) high-frequency rTMS over the ipsilesional hemisphere; or (3) no stimulation. Experimental groups received 10 rTMS sessions over two weeks alongside standard rehabilitation, and the control group received the same procedures except for rTMS. Both affected and unaffected upper extremity motor function was evaluated using hand grip strength and Functional Independence Measure (FIM) tests before and after rehabilitation (7 weeks apart). Results: All groups showed significant improvement in both the affected and unaffected hand grip and FIM scores (p < 0.05). HF-rTMS led to a notably higher increase in unaffected hand grip strength than the control group (p = 0.007). There was no difference in the improvement in affected upper extremity motor function between the groups. The FIM score increase was lower in the control group compared to experimental groups, although not statistically significant. Conclusions: This study demonstrates the positive effect of ipsilesional HF-rTMS on the improvement in unaffected arm motor function and reveals the positive effect of both LF- and HF-rTMS on the affected upper extremity motor function recovery.

Qualitative feasibility study of the mobile app Destroke for clinical stroke monitoring based on the NIH stroke scale

BACKGROUND

Stroke is a leading cause of severe disability in the United States, but there is no effective method for patients to accurately detect the signs of stroke at home. We developed a mobile app, Destroke, that allows remote performance of a modified NIH stroke scale (NIHSS) by patients.

AIMS

To assess the feasibility of a mobile app for stroke monitoring and education by patients with a history of stroke.

MATERIALS AND METHODS

We enrolled 25 patients with a history of stroke in a prospective open-label study to evaluate the feasibility of the Destroke app in patients with stroke. Nineteen patients completed all study assessments, with a median time from stroke onset to enrollment of 5.6 years (range 0.1-12 years). We designed a modified NIHSS that assessed 12 out of 16 tasks on the NIHSS. Patients completed this test eight times over a 28-day period. We conducted pre-study surveys that assessed demographic information, stroke and cardiovascular history, baseline NIHSS, and experience using mobile technologies, and mid- and post-study surveys that assessed patient satisfaction on app usage and confidence in stroke detection.

RESULTS

Ten men and nine women participated in this study (median age of 64 (33-76)), representing ten US states and Washington D.C. Median baseline NIHSS was 0 (0-4). 15 patients reported using health apps. On a 5-point Likert scale, patients rated the app as 4.2 on being able to understand and use the app and 4.3 on using the app when instructed by their doctor. For eight patients with poor confidence in detecting the signs of a stroke before the study, six showed higher confidence after the study.

CONCLUSIONS

The use of an at-home stroke monitoring app is feasible by patients with a history of stroke and improves confidence in detecting the signs of stroke.

A Combination of Long-Duration Electrical Stimulation with External Shoulder Support during Routine Daily Activities in Patients with Post-Hemiplegic Shoulder Subluxation: A Randomized Controlled Study

The study objective was to determine the effect of long-duration neuromuscular electric stimulation (NMES) on shoulder subluxation and upper-extremity function during the acute post-stroke stage. Twenty-eight subjects (mean age ± standard deviation -70.0 ± 14.0 years) were randomly assigned to an experimental or to a control group receiving NMES to the supraspinatus and posterior deltoid muscles or sham treatment for 6 weeks. All the subjects continued standard rehabilitation and external shoulder support (EST). Assessments were conducted pre- and post-intervention and at a 2 week follow-up session by an assessor blind to group allocation. Outcome measures included the degree of shoulder subluxation, Fugl-Meyer assessment-upper extremity (FMA-UE) test, FMA-hand and finger subscales, Functional Independence Measure (FIM), and shoulder pain (using the Numeric Pain Rate Scale). Shoulder subluxation was significantly lower, while the FMA-UE and FMA-hand and finger subscales were significantly improved in the experimental group post-intervention and at follow-up compared to the control group. FIM at follow-up improved more in the experimental group. No change was observed in pain level in both groups. Supplementing NMES to standard rehabilitation and EST is beneficial in reducing shoulder subluxation and improving upper-extremity function. Further research is necessary to determine effect of longer treatment duration and longer follow-up periods.

A novel tablet-based application for assessment of manual dexterity and its components: a reliability and validity study in healthy subjects

BACKGROUND

We developed five tablet-based tasks (applications) to measure multiple components of manual dexterity.

AIM

to test reliability and validity of tablet-based dexterity measures in healthy participants.

METHODS

Tasks included: (1) Finger recognition to assess mental rotation capacity. The subject taps with the finger indicated on a virtual hand in three orientations (reaction time, correct trials). (2) Rhythm tapping to evaluate timing of finger movements performed with, and subsequently without, an auditory cue (inter-stimulus interval). (3) Multi-finger tapping to assess independent finger movements (reaction time, correct trials, unwanted finger movements). (4) Sequence tapping to assess production and memorization of visually cued finger sequences (successful taps). (5) Line-tracking to assess movement speed and accuracy while tracking an unpredictably moving line on the screen with the fingertip (duration, error). To study inter-rater reliability, 34 healthy subjects (mean age 35 years) performed the tablet tasks twice with two raters. Relative reliability (Intra-class correlation, ICC) and absolute reliability (Standard error of measurement, SEM) were established. Task validity was evaluated in 54 healthy subjects (mean age 49 years, range: 20-78 years) by correlating tablet measures with age, clinical dexterity assessments (time taken to pick-up objects in Box and Block Test, BBT and Moberg Pick Up Test, MPUT) and with measures obtained using a finger force-sensor device.

RESULTS

Most timing measures showed excellent reliability. Poor to excellent reliability was found for correct trials across tasks, and reliability was poor for unwanted movements. Inter-session learning occurred in some measures. Age correlated with slower and more variable reaction times in finger recognition, less correct trials in multi-finger tapping, and slower line-tracking. Reaction times correlated with those obtained using a finger force-sensor device. No significant correlations between tablet measures and BBT or MPUT were found. Inter-task correlation among tablet-derived measures was weak.

CONCLUSIONS

Most tablet-based dexterity measures showed good-to-excellent reliability (ICC ≥ 0.60) except for unwanted movements during multi-finger tapping. Age-related decline in performance and association with finger force-sensor measures support validity of tablet measures. Tablet-based components of dexterity complement conventional clinical dexterity assessments. Future work is required to establish measurement properties in patients with neurological and psychiatric disorders.

Digital Biomarkers in Multiple Sclerosis

For incurable diseases, such as multiple sclerosis (MS), the prevention of progression and the preservation of quality of life play a crucial role over the entire therapy period. In MS, patients tend to become ill at a younger age and are so variable in terms of their disease course that there is no standard therapy. Therefore, it is necessary to enable a therapy that is as personalized as possible and to respond promptly to any changes, whether with noticeable symptoms or symptomless. Here, measurable parameters of biological processes can be used, which provide good information with regard to prognostic and diagnostic aspects, disease activity and response to therapy, so-called biomarkers Increasing digitalization and the availability of easy-to-use devices and technology also enable healthcare professionals to use a new class of digital biomarkers-digital health technologies-to explain, influence and/or predict health-related outcomes. The technology and devices from which these digital biomarkers stem are quite broad, and range from wearables that collect patients' activity during digitalized functional tests (e.g., the Multiple Sclerosis Performance Test, dual-tasking performance and speech) to digitalized diagnostic procedures (e.g., optical coherence tomography) and software-supported magnetic resonance imaging evaluation. These technologies offer a timesaving way to collect valuable data on a regular basis over a long period of time, not only once or twice a year during patients' routine visit at the clinic. Therefore, they lead to real-life data acquisition, closer patient monitoring and thus a patient dataset useful for precision medicine. Despite the great benefit of such increasing digitalization, for now, the path to implementing digital biomarkers is widely unknown or inconsistent. Challenges around validation, infrastructure, evidence generation, consistent data collection and analysis still persist. In this narrative review, we explore existing and future opportunities to capture clinical digital biomarkers in the care of people with MS, which may lead to a digital twin of the patient. To do this, we searched published papers for existing opportunities to capture clinical digital biomarkers for different functional systems in the context of MS, and also gathered perspectives on digital biomarkers under development or already existing as a research approach.