Automatic Spontaneous Speech Analysis for the Detection of Cognitive Functional Decline in Older Adults: Multilanguage Cross-Sectional Study

BACKGROUND

The rise in life expectancy is associated with an increase in long-term and gradual cognitive decline. Treatment effectiveness is enhanced at the early stage of the disease. Therefore, there is a need to find low-cost and ecological solutions for mass screening of community-dwelling older adults.

OBJECTIVE

This work aims to exploit automatic analysis of free speech to identify signs of cognitive function decline.

METHODS

A sample of 266 participants older than 65 years were recruited in Italy and Spain and were divided into 3 groups according to their Mini-Mental Status Examination (MMSE) scores. People were asked to tell a story and describe a picture, and voice recordings were used to extract high-level features on different time scales automatically. Based on these features, machine learning algorithms were trained to solve binary and multiclass classification problems by using both mono- and cross-lingual approaches. The algorithms were enriched using Shapley Additive Explanations for model explainability.

RESULTS

In the Italian data set, healthy participants (MMSE score≥27) were automatically discriminated from participants with mildly impaired cognitive function (20≤MMSE score≤26) and from those with moderate to severe impairment of cognitive function (11≤MMSE score≤19) with accuracy of 80% and 86%, respectively. Slightly lower performance was achieved in the Spanish and multilanguage data sets.

CONCLUSIONS

This work proposes a transparent and unobtrusive assessment method, which might be included in a mobile app for large-scale monitoring of cognitive functionality in older adults. Voice is confirmed to be an important biomarker of cognitive decline due to its noninvasive and easily accessible nature.

The International Functional Electrical Stimulation Society (IFESS): Highlights from the IFESS conference at Rehabweek 2023

The annual conference of the International Functional Electrical Stimulation Society (IFESS) was held in conjunction with the 7th RehabWeek Congress, from September 24 to 28, 2023 at the Resorts World Convention Centre on Sentosa Island, in Singapore. The Congress was a joint meeting of the International Consortium on Rehabilitation Technology (ICRT) together with 10 other societies in the field of assistive technology and rehabilitation engineering. The conference features comprehensive blend of technical and clinical context of FES, a sustained value the society has offered over many years. The cross- and inter- disciplinary approach of medicine, engineering, and science practiced in the FES community had enabled vibrant interaction, creation, and development of impactful and novel contributions to the field of FES, translating FES directly into highly relevant and sustainable solutions for the users.

Medium-term patient's satisfaction after primary total knee arthroplasty: enhancing prediction for improved care

BACKGROUND

Patient-reported satisfaction after total knee arthroplasty (TKA) is low compared to other orthopedic procedures. Although several factors have been reported to influence TKA outcomes, it is still challenging to identify patients who will experience dissatisfaction five years after surgery, thereby improving their management. Indeed, both perioperative information and follow-up questionnaires seem to lack statistical predictive power.

HYPOTHESIS

This study aims to demonstrate that machine learning can improve the prediction of patient satisfaction, especially when classical statistics fail to identify complex patterns that lead to dissatisfaction.

PATIENTS AND METHODS

Patients who underwent primary TKA were included in a Registry that collected baseline data and clinical outcomes at different follow-ups. The patients were divided into satisfied and dissatisfied groups based on a satisfaction questionnaire administered five years after surgery. Satisfaction was predicted using linear statistical models compared to machine learning algorithms.

RESULTS

A total of 147 subjects were analyzed. Regarding statistics, significant differences between satisfaction levels started emerging only six months after the intervention, and the classification was close to random guessing. However, machine learning algorithms could improve the prediction by 72% soon after the intervention, and an improvement of 178% was possible when including follow-ups up to one year.

DISCUSSION

This study demonstrates the feasibility of a registry-based approach for monitoring and predicting satisfaction using ML algorithms.

LEVEL OF EVIDENCE

III.

"You Need to Set a Daily Schedule": Understanding Successful Aging via Three-Sided Viewpoints

This study aimed to identify the constructs related to successful aging in the context of engagement in social and productive activities. A qualitative design was used to explore three viewpoints on the aging period with 9 focus groups (3 each for adults 65 years or older, older adults' family members, and health professionals) and 18 interviews with older adults (older adults Mage = 71.7 years, Standard Deviation = 4.62). The transcripts were analyzed using constructivist grounded theory principles. Three categories were identified for successful aging: (a) engagement with life, including social participation, fixed/flexible schedule, time, and meaningful occupation; (b) self-management abilities, including producing daily schedules, independence, and initiation/striving toward goals; and (c) diversity among older adults, including their views on retirement, being active or not, and their dreams/values/goals. Considering the diverse nature of older adults, recognizing the importance of life engagement and self-management abilities emphasizes the necessity for an occupation-based, self-tailored approach to enable successful aging.

Movement Sonification Techniques to Improve Balance in Parkinson's Disease: A Pilot Randomized Controlled Trial

BACKGROUND

Movement sonification has been recently introduced into the field of neuromotor rehabilitation alongside Neurologic Music Therapy and music-based interventions. This study introduces the use of musical auditory cues encompassing the melodic-harmonic aspect of music.

METHODS

Nineteen patients with Parkinson's disease were randomly assigned to the experimental (n = 10) and control (n = 9) groups and underwent thrice-weekly sessions of the same gait training program, with or without sonification. Functional and motor parameters, as well as fatigue, quality of life, and the impact of intervention on patients' well-being, were assessed at baseline (PRE), the end of treatment (POST), and at follow-up (FU). Between-group differences were assessed for each outcome measure using linear mixed-effects models. The outcome measure was entered as the dependent variable, group and time as fixed effects, and time by group as the interaction effect.

RESULTS

Mini BESTest and Dynamic Gait Index scores significantly improved in the experimental group (p = 0.01 and p = 0.03, respectively) from PRE to FU, demonstrating a significant impact of the sonification treatment on balance. No other significant differences were observed in the outcome measures.

CONCLUSIONS

Larger sample sizes are needed to confirm the effectiveness of sonification approaches in Parkinson's disease, as well as in other neurological disorders.

Autism in Preschool-Aged Children: The Effects of COVID-19 Lockdown

The COVID-19 lockdown affected children, especially those with autism spectrum disorder, due to the disruption in rehabilitation and educational activities. We conducted a cross-sectional study of 315 preschool-aged children, 35 of which had autism, to investigate this impact. A questionnaire was administered to explore socio-demographic status, familiar/home environment, and COVID-19 exposure. The clinical features of autistic subjects were also examined. Seven variables were considered to describe the effect of pandemic: Remote learning, Behavior changes, Home activities, Sleep habits, Night awakenings, Physical activity, Information about the virus. The lockdown had a significant impact on Remote learning, Behavior changes, and Information about the virus in participants with autism. Moreover, we found a worsening in repetitive movements, echolalia, restricted interests, and aggressive behaviors.

Video-based Goniometer Applications for Measuring Knee Joint Angles during Walking in Neurological Patients: A Validity, Reliability and Usability Study

Easy-to-use evaluation of Range Of Motion (ROM) during walking is necessary to make decisions during neurological rehabilitation programs and during follow-up visits in clinical and remote settings. This study discussed goniometer applications (DrGoniometer and Angles - Video Goniometer) that measure knee joint ROM during walking through smartphone cameras. The primary aim of the study is to test the inter-rater and intra-rater reliability of the collected measurements as well as their concurrent validity with an electro-goniometer. The secondary aim is to evaluate the usability of the two mobile applications. A total of 22 patients with Parkinson's disease (18 males, age 72 (8) years), 22 post-stroke patients (17 males, age 61 (13) years), and as many healthy volunteers (8 males, age 45 (5) years) underwent knee joint ROM evaluations during walking. Clinicians and inexperienced examiners used the two mobile applications to calculate the ROM, and then rated their perceived usability through the System Usability Scale (SUS). Intraclass correlation coefficients (ICC) and correlation coefficients (corr) were calculated. Both applications showed good reliability (ICC > 0.69) and validity (corr > 0.61), and acceptable usability (SUS > 68). Smartphone-based video goniometers could be used to assess the knee ROM during walking in neurological patients, because of their acceptable degree of reliability, validity and usability.

Spiral drawing analysis with a smart ink pen to identify Parkinson's disease fine motor deficits

Introduction

Since the uptake of digitizers, quantitative spiral drawing assessment allowed gaining insight into motor impairments related to Parkinson's disease. However, the reduced naturalness of the gesture and the poor user-friendliness of the data acquisition hamper the adoption of such technologies in the clinical practice. To overcome such limitations, we present a novel smart ink pen for spiral drawing assessment, intending to better characterize Parkinson's disease motor symptoms. The device, used on paper as a normal pen, is enriched with motion and force sensors.

Methods

Forty-five indicators were computed from spirals acquired from 29 Parkinsonian patients and 29 age-matched controls. We investigated between-group differences and correlations with clinical scores. We applied machine learning classification models to test the indicators ability to discriminate between groups, with a focus on model interpretability.

Results

Compared to control, patients' drawings were characterized by reduced fluency and lower but more variable applied force, while tremor occurrence was reflected in kinematic spectral peaks selectively concentrated in the 4-7 Hz band. The indicators revealed aspects of the disease not captured by simple trace inspection, nor by the clinical scales, which, indeed, correlate moderately. The classification achieved 94.38% accuracy, with indicators related to fluency and power distribution emerging as the most important.

Conclusion

Indicators were able to significantly identify Parkinson's disease motor symptoms. Our findings support the introduction of the smart ink pen as a time-efficient tool to juxtapose the clinical assessment with quantitative information, without changing the way the classical examination is performed.

Investigating Visual Perception Impairments through Serious Games and Eye Tracking to Anticipate Handwriting Difficulties

Dysgraphia is a learning disability that causes handwritten production below expectations. Its diagnosis is delayed until the completion of handwriting development. To allow a preventive training program, abilities not directly related to handwriting should be evaluated, and one of them is visual perception. To investigate the role of visual perception in handwriting skills, we gamified standard clinical visual perception tests to be played while wearing an eye tracker at three difficulty levels. Then, we identified children at risk of dysgraphia through the means of a handwriting speed test. Five machine learning models were constructed to predict if the child was at risk, using the CatBoost algorithm with Nested Cross-Validation, with combinations of game performance, eye-tracking, and drawing data as predictors. A total of 53 children participated in the study. The machine learning models obtained good results, particularly with game performances as predictors (F1 score: 0.77 train, 0.71 test). SHAP explainer was used to identify the most impactful features. The game reached an excellent usability score (89.4 ± 9.6). These results are promising to suggest a new tool for dysgraphia early screening based on visual perception skills.

Implementing functional electrical stimulation clinical practice guidelines to support mobility: A stakeholder consultation

Functional Electrical Stimulation (FES) has been used to support mobility for people with upper motor neuron conditions such as stroke and multiple sclerosis for over 25 years. Recent development and publication of clinical practice guidelines (CPGs) provide evidence to guide clinical decision making for application of FES to improve mobility. Understanding key barriers to the implementation of these CPGs is a critical initial step necessary to create tailored knowledge translation strategies. A public involvement and engagement consultation was conducted with international stakeholders including researchers, clinicians and engineers working with FES to inform implementation strategies for CPG use internationally. Reflexive thematic analysis of the consultation transcripts revealed themes including inconsistent use of CPGs, barriers to implementation such as limited access to FES and low clinician confidence, and the need for a tiered education approach with ongoing support. Insights derived from this consultation will inform the development of knowledge translation strategies to support the next steps to implementing FES use for mobility.

Identification and characterization of learning weakness from drawing analysis at the pre-literacy stage

Handwriting learning delays should be addressed early to prevent their exacerbation and long-lasting consequences on whole children's lives. Ideally, proper training should start even before learning how to write. This work presents a novel method to disclose potential handwriting problems, from a pre-literacy stage, based on drawings instead of words production analysis. Two hundred forty-one kindergartners drew on a tablet, and we computed features known to be distinctive of poor handwriting from symbols drawings. We verified that abnormal features patterns reflected abnormal drawings, and found correspondence in experts' evaluation of the potential risk of developing a learning delay in the graphical sphere. A machine learning model was able to discriminate with 0.75 sensitivity and 0.76 specificity children at risk. Finally, we explained why children were considered at risk by the algorithms to inform teachers on the specific weaknesses that need training. Thanks to this system, early intervention to train specific learning delays will be finally possible.

Technology use characteristics among older adults during the COVID-19 pandemic: A cross-cultural survey

Personal computers, tablets, and smartphones may support older adults' engagement when people are required to stay home and opportunities to engage in meaningful activities are reduced during the COVID-19 period. This study aims to screen older adults' technology-use characteristics across social, leisure, and education domains during the COVID-19 pandemic from a crosscultural viewpoint. The sample included 576 participants aged 60 and older from France (n = 62), Spain (n = 110), and Israel (n = 404). Participants completed the technology-use survey, which consists of questions about their facilities, technology usability, need for adaptations to support technology use, and changes in technology use since COVID-19. Significant differences were found between countries in facilities, χ² (2) = 25.16, p < .001, and usability, χ² (2) = 64.14, p < .001, across the three domains. Furthermore, 34% of technological usability was predicted by country and facilities, F (4, 568) = 72.39, p < .001. Participants noted a willingness to use technology if it was adapted for social (61%-73%), leisure (51%-71%), or educational (67%-76%) activities and that they devoted substantially more time to technology across domains (>58%) due to COVID-19. These findings highlight culture and facilities as factors that play an imperative role in supporting and enhancing the usability of technology among older adults.

Validation of Pressure-Sensing Insoles in Patients with Parkinson's Disease during Overground Walking in Single and Cognitive Dual-Task Conditions

There is a need for unobtrusive and valid tools to collect gait parameters in patients with Parkinson's disease (PD). The novel promising tools are pressure-sensing insoles connected to a smartphone app; however, few studies investigated their measurement properties during simple or challenging conditions in PD patients. This study aimed to examine the validity and reliability of gait parameters computed by pressure-sensing insoles (FeetMe^® insoles, Paris, France). Twenty-five PD patients (21 males, mean age: 69 (7) years) completed two walking assessment sessions. In each session, participants walked on an electronic pressure-sensitive walkway (GaitRite^®, CIR System Inc., Franklin, NJ, USA) without other additional instructions (i.e., single-task condition) and while performing a concurrent cognitive task (i.e., dual-task condition). Spatiotemporal gait parameters were measured simultaneously using the pressure-sensing insoles and the electronic walkway. Concurrent validity was assessed by correlation coefficients and Bland-Altman methodology. Test-retest reliability was examined by intraclass correlation coefficients (ICC) and minimal detectable changes (MDC). The validity results showed moderate to excellent correlations and good agreement between the two systems. Concerning test-retest reliability, moderate-to-excellent ICC values and acceptable MDC demonstrated the repeatability of the measured gait parameters. Our findings support the use of these insoles as complementary instruments to conventional tools during single and dual-task conditions.

Self-reported impact of the COVID-19 pandemic and lockdown on young patients with tic disorders: findings from a case-control study

BACKGROUND

Little is known about the perceived impact of the COVID-19 pandemic and subsequent lockdown measures on young patients with tic disorders. Previous studies focused on clinician and parent ratings of tic severity, whereas the only international self-report data are available for adult populations. We present the first findings from a case-control study on children and adolescents with tics during lockdown in Italy.

METHODS

We surveyed 49 patients aged 6-18 years and 245 matched controls with a newly developed questionnaire covering socio-demographic and clinical data, as well as lockdown-related changes to daily life activities.

RESULTS

About half (53.2%) of the Italian school-age patients who took part in our survey experienced changes in tic severity during lockdown. Perceived increases in tic severity (29.8%) were reported more often than decreases (23.4%). Analogous trends were reported for perceived restlessness and, more significantly, irritability, whereas changes in pain symptoms were less common and were similar in both directions. The presence of tics was associated with increased difficulties with remote learning (p = 0.01), but decreased feelings of missing out on social interactions with schoolmates (p = 0.03).

CONCLUSIONS

Self-reported data on the impact of COVID-19 lockdown in school-age patients with tic disorders indicate perceived changes in tic severity, as well as restlessness and irritability, in about half of the cases. These findings could guide both clinicians and teachers in the implementation of targeted adjustments in the delivery of care and educational strategies, respectively.

The reliability of gait parameters captured via instrumented walkways: a systematic review and meta-analysis

INTRODUCTION

Electronic pressure-sensitive walkways are commonly available solutions to quantitatively assess gait parameters for clinical and research purposes. Many studies have evaluated their measurement properties in different conditions with variable findings. In order to be informed about the current evidence of their reliability for optimal clinical and scientific decision making, this systematic review provided a quantitative synthesis of the test-retest reliability and minimal detectable change of the captured gait parameters across different test conditions (single and cognitive dual-task conditions) and population groups.

EVIDENCE ACQUISITION

A literature search was conducted in PubMed, Embase, and Scopus until November 2021 to identify articles that examined the test-retest reliability properties of the gait parameters captured by pressure-sensitive walkways (gait speed, cadence, stride length and time, double support time, base of support) in adult healthy individuals or patients. The methodological quality was rated using the Consensus-Based Standards for the Selection of Health Measurement Instruments Checklist. Data were meta-analyzed on intraclass correlation coefficient to examine the test-retest relative reliability. Quantitative synthesis was performed for absolute reliability, examined by the weighted average of minimal detectable change values.

EVIDENCE SYNTHESIS

A total of 44 studies were included in this systematic review. The methodological quality was adequate in half of the included studies. The main finding was that pressure-sensitive walkways are reliable tools for objective assessment of spatial and temporal gait parameters both in single-and cognitive dual-task conditions. Despite few exceptions, the review identified intraclass correlation coefficient higher than 0.75 and minimal detectable change lower than 30%, demonstrating satisfactory relative and absolute reliability in all examined populations (healthy adults, elderly, patients with cognitive impairment, spinocerebellar ataxia type 14, Huntington's disease, multiple sclerosis, Parkinson's disease, rheumatoid arthritis, spinal cord injury, stroke or vestibular dysfunction).

CONCLUSIONS

Current evidence suggested that, despite different populations and testing protocols used in the included studies, the test-retest reliability of the examined gait parameters was acceptable under single and cognitive dual-task conditions. Further high-quality studies with powered sample sizes are needed to examine the reliability findings of the currently understudied and unexplored pathologies and test conditions.

Leveraging Deep Learning Techniques to Improve P300-Based Brain Computer Interfaces

Brain-Computer Interface (BCI) has become an established technology to interconnect a human brain and an external device. One of the most popular protocols for BCI is based on the extraction of the so-called P300 wave from electroencephalography (EEG) recordings. P300 wave is an event-related potential with a latency of 300 ms after the onset of a rare stimulus. In this paper, we used deep learning architectures, namely convolutional neural networks (CNNs), to improve P300-based BCIs. We propose a novel BCI classifier, called P3CNET, that improved P300 classification accuracy performances of the best state-of-the-art classifier. In addition, we explored pre-processing and training choices that improved the usability of BCI systems. For the pre-processing of EEG data, we explored the optimal signal interval that would improve classification accuracies. Then, we explored the minimum number of calibration sessions to balance higher accuracy and shorter calibration time. To improve the explainability of deep learning architectures, we analyzed the saliency maps of the input EEG signal leading to a correct P300 classification, and we observed that the elimination of less informative electrode channels from the data did not result in better accuracy. All the methodologies and explorations were performed and validated on two different CNN classifiers, demonstrating the generalizability of the obtained results. Finally, we showed the advantages given by transfer learning when using the proposed novel architecture on other P300 datasets. The presented architectures and practical suggestions can be used by BCI practitioners to improve its effectiveness.

A smart ink pen for spiral drawing analysis in patients with Parkinson's disease

Handwriting skills could be highly impaired in patients affected by Parkinson's disease (PD), and for this reason its analysis had always been considered relevant. In handwriting assessment, Archimedes spiral drawing is one of the most proposed tasks, due to its peculiar shape and ease of execution. In the last decades, digitizing tablets had been widely employed for the evaluation of the spiral performance, providing a cheap and non-invasive way to gather quantitative information, to be combined with the classical clinical examination. Despite this advantage, such approach cannot easily be adopted in an unsupervised scenario and lacks the natural feel of the traditional pen-and-paper approach. This work aims at overcoming these limitations by employing a smart ink pen, designed to write on paper and instrumented with inertial and force sensors, to automatically collect data related to spiral drawing execution of PD patients (n=30) and age-matched healthy controls (n=30). From the raw data, several time and frequency domains features were extracted and compared between the groups. The statistical analysis revealed some significant differences, showing less smooth acceleration and force profiles for PD patients. However, given the heterogeneous symptoms presented by the PD cohort, a detailed analysis of exemplifying PD patients was conducted, showing the ability of Archimedes spiral drawing to capture and quantify PD characteristic features.Clinical Relevance- Among the first clinical manifestations of the pathology, handwriting impairment appears in PD patients. It is often underestimated and not investigated properly. This easy-to-use tool could be very useful as a large-scale screening, but also for treatment efficacy evaluation and for the identification of PD subgroups.

Comparing Fatigue Reducing Stimulation Strategies During Cycling Induced by Functional Electrical Stimulation: a Case Study with one Spinal Cord Injured Subject

This case study was designed starting from our experience at CYBATHLON 2020. The specific aim of this work was to compare the effectiveness of different fatigue reducing stimulation strategies during cycling induced by Functional Electrical Stimulation (FES). The compared stimulation strategies were: traditional constant frequency trains (CFTs) at 30 and 40Hz, doublet frequency trains (DFTs) and spatially distributed sequential stimulation (SDSS) on the quadriceps muscles. One Spinal Cord Injured (SCI) subject (39 years, T5-T6, male, ASIA A) was involved in 12 experimental sessions during which the four strategies were tested in a randomized order during FES-induced cycling performed on a passive trike at a constant cadence of 35 RPM. FES was delivered to four muscle groups (quadriceps, gluteal muscles, hamstrings and gastrocnemius) for each leg. The performance was evaluated in terms of saturation time (i.e., the time elapsed from the beginning of the stimulation until the predetermined maximum value of current amplitude is reached) and root mean square error (RMSE) of the actual cadence with respect to the target value. SDSS achieved a statistical lower saturation time and a qualitative higher RMSE of the cadence with respect to CFTs both at 30 and 40Hz.Clinical relevance- Conversely to previous literature, SDSS seems to be ineffective to reduce muscle fatigue during FES-induced cycling. Further experiments are needed to confirm this result.

Investigating the effects of COVID-19 lockdown on Italian children and adolescents with and without neurodevelopmental disorders: a cross-sectional study

We conducted a cross-sectional study to compare the impact of social distancing and lifestyle changes that occurred during Corona Virus Disease 2019 (COVID-19) lockdown on children and adolescents with and without Neurodevelopmental Disorders (NDDs). An online questionnaire was administered in order to investigate the effects of NDD condition, socio-demographic status, familiar/home environment and COVID-19 exposure on their lives during a two months period of social isolation. We used logistic regression, focusing on five endpoints (remote learning, lifestyle, stress/anxiety, sociality, scolding) to define the extent of these effects. Most questions were paired up to parents and children, to verify the occurrence of agreement. 8305 questionnaires were analyzed, 1362 of which completed by NDDs and 6943 by controls. Results showed that the presence of a NDD, compared to controls, had a significant impact on: Remote Learning (i.e. subjects with NDDs experienced more difficulties in attending online classes and studying), Sociality (i.e. subjects with NDDs missed their schoolmates less), Scolding (i.e. subjects with NDDs were scolded more often) and Anxiety (i.e. subjects with NDDs were perceived by their parents as more anxious). Substantial agreement between parents and children arose from questions concerning Remote learning, Lifestyle and Scolding. The current study actually points out that having a NDD gives account for a stronger influence on school performance and on behavioral and psychological aspects, during a two months lockdown. Such results may provide useful information to governments and school authorities on how carrying through supportive strategies for youth affected by NDDs.

A Robotic System with EMG-Triggered Functional Eletrical Stimulation for Restoring Arm Functions in Stroke Survivors

BACKGROUND

Robotic systems combined with Functional Electrical Stimulation (FES) showed promising results on upper-limb motor recovery after stroke, but adequately-sized randomized controlled trials (RCTs) are still missing.

OBJECTIVE

To evaluate whether arm training supported by RETRAINER, a passive exoskeleton integrated with electromyograph-triggered functional electrical stimulation, is superior to advanced conventional therapy (ACT) of equal intensity in the recovery of arm functions, dexterity, strength, activities of daily living, and quality of life after stroke.

METHODS

A single-blind RCT recruiting 72 patients was conducted. Patients, randomly allocated to 2 groups, were trained for 9 weeks, 3 times per week: the experimental group performed task-oriented exercises assisted by RETRAINER for 30 minutes plus ACT (60 minutes), whereas the control group performed only ACT (90 minutes). Patients were assessed before, soon after, and 1 month after the end of the intervention. Outcome measures were as follows: Action Research Arm Test (ARAT), Motricity Index, Motor Activity Log, Box and Blocks Test (BBT), Stroke Specific Quality of Life Scale (SSQoL), and Muscle Research Council.

RESULTS

All outcomes but SSQoL significantly improved over time in both groups (P < .001); a significant interaction effect in favor of the experimental group was found for ARAT and BBT. ARAT showed a between-group change of 11.5 points (P = .010) at the end of the intervention, which increased to 13.6 points 1 month after. Patients considered RETRAINER moderately usable (System Usability Score of 61.5 ± 22.8).

CONCLUSIONS

Hybrid robotic systems, allowing to perform personalized, intensive, and task-oriented training, with an enriched sensory feedback, was superior to ACT in improving arm functions and dexterity after stroke.

Effectiveness and safety of dolutegravir two-drug regimens in virologically suppressed people living with HIV: a systematic literature review and meta-analysis of real-world evidence

Objectives

Dolutegravir (DTG) is widely recommended within three‐drug regimens. However, similar efficacy and tolerability have also been achieved with DTG within two‐drug regimens in clinical trials. This study evaluated the real‐world effectiveness and discontinuations in people living with HIV‐1 (PLHIV) switching to DTG with lamivudine (3TC) or rilpivirine (RPV).

Methods

This was a one‐arm meta‐analysis utilizing data from a systematic literature review. Data from real‐world evidence studies of DTG + RPV and DTG + 3TC were extracted, pooled and analysed. The primary outcome was the proportion of patients with viral failure (VF; ≥ 50 copies/mL in two consecutive measurements and/or ≥ 1000 copies/mL in a single measurement) at week 48 (W48) and week 96 (W96). Other outcomes included virological suppression (VS; < 50 copies/mL) and discontinuations (W48 and W96). Estimates were calculated for VF, VS as per snapshot (VSS) and on treatment analysis (VSOT), and discontinuations.

Results

Pooled mean estimates of VF for DTG + 3TC and DTG + RPV were 0.8% [95% confidence interval (CI): 0.4–1.3] and 0.6% (95% CI: 0.0–1.6), respectively, at W48. VSS rate at W48 was 85.0% (95% CI: 82.3–87.5) for DTG + 3TC regimen and 92.4% (95% CI: 85.0–97.7) in the DTG + RPV regimen. The DTG + 3TC and DTG + RPV regimens led to discontinuations in 13.6% (95% CI: 11.1–16.2) and 7.2% (95% CI: 2.1–14.4) of patients, respectively, at W48. Similar results were observed at W96.

Conclusions

Treatment with DTG + 3TC or DTG + RPV in clinical practice provides a low rate of VF and a high rate of VS when initiated in virologically suppressed PLHIV with diverse backgrounds.

Development and validation of an automated tool to scan scientific literature for the use of specific technologies in the field of cardiology

Background

Review of scientific literature is a time consuming but fundamental step in any kind of scientific research. A consistent manual filtering of papers is always necessary in order to evaluate their relevance with respect to the topic of interest, as the sorting provided by most common research engines is rarely efficient in terms of matching with the desired contents.

Purpose

The aim of this study was to develop, and validate versus manual analysis, an automated tool for performing an efficient search through medical scientific literature, according to keywords relevant to the application of specific technologies in the field of cardiology.

Methods

Using this multiplatform tool implemented in Python, PyQt5 library, the user is required to insert a list of keywords, from which all the possible search strings were built by connecting them with logical operators. The algorithm automatically queries the on-line database PubMed (NCBI) and downloads all the resulting abstracts, with titles and keywords. Results related to the field of cardiology are identified counting the occurrences of “marker” words collected in a dedicated dictionary, developed on the base of the Unified Medical Language System (U.S. NLM). Then, a search-specific dictionary is automatically developed according to the statistical distribution of words in the texts of abstracts, titles and keywords and weighting them according to their relative frequency (ratio between occurrences and number of considered papers). Finally, for each paper the occurrences of these “marker” words are counted and a matching-probability score is assigned, providing a sorting of the results according to expected matching with the topic of interest, together with a threshold-based binary classification.

In order to validate the algorithm, three different technologies with potential applications in cardiology were considered: smartphone applications (App), machine learning (ML) and virtual reality (VR). The related dictionaries were developed with the dedicated function embedded in the tool, while, for the validation of the results, a dataset of 461 manually-classified abstracts was considered, and algorithm thresholds were iteratively adjusted on the base of validation results.

Results

The algorithm applied to the validation dataset showed an overall accuracy (acc) of 88.5% (sensitivity (se) 85.78%, specificity (sp) 91.27%) in the identification of cardiology papers, while the results for the three inspected technologies were:

App: acc 90.89% (se 92.16%, sp 90.53%)

ML: acc 82.65% (se 94.06%, sp 79.44%)

VR: acc 91.54% (se 96%, sp 90.3%)

The algorithm can process 5000 abstracts in around 2 hours.

Conclusions

Results of the validation revealed that the proposed approach is highly valuable in speeding-up any search of medical literature focused on a specific technology or application, enabling a quick overview regarding its diffusion and maturity in a specific scientific domain.

Algorithm schema

Funding Acknowledgement

Type of funding source: None

A Tablet App for Handwriting Skill Screening at the Preliteracy Stage: Instrument Validation Study

Background

Difficulties in handwriting, such as dysgraphia, impact several aspects of a child’s everyday life. Current methodologies for the detection of such difficulties in children have the following three main weaknesses: (1) they are prone to subjective evaluation; (2) they can be administered only when handwriting is mastered, thus delaying the diagnosis and the possible adoption of countermeasures; and (3) they are not always easily accessible to the entire community.

Objective

This work aims at developing a solution able to: (1) quantitatively measure handwriting features whose alteration is typically seen in children with dysgraphia; (2) enable their study in a preliteracy population; and (3) leverage a standard consumer technology to increase the accessibility of both early screening and longitudinal monitoring of handwriting difficulties.

Methods

We designed and developed a novel tablet-based app Play Draw Write to assess potential markers of dysgraphia through the quantification of the following three key handwriting laws: isochrony, homothety, and speed-accuracy tradeoff. To extend such an approach to a preliteracy age, the app includes the study of the laws in terms of both word writing and symbol drawing. The app was tested among healthy children with mastered handwriting (third graders) and those at a preliterate age (kindergartners).

Results

App testing in 15 primary school children confirmed that the three laws hold on the tablet surface when both writing words and drawing symbols. We found significant speed modulation according to size (P<.001), no relevant changes to fraction time for 67 out of 70 comparisons, and significant regression between movement time and index of difficulty for 44 out of 45 comparisons (P<.05, R²>0.28, 12 degrees of freedom). Importantly, the three laws were verified on symbols among 19 kindergartners. Results from the speed-accuracy exercise showed a significant evolution with age of the global movement time (circle: P=.003, square: P<.001, word: P=.001), the goodness of fit of the regression between movement time and accuracy constraints (square: P<.001, circle: P=.02), and the index of performance (square: P<.001). Our findings show that homothety, isochrony, and speed-accuracy tradeoff principles are present in children even before handwriting acquisition; however, some handwriting-related skills are partially refined with age.

Conclusions

The designed app represents a promising solution for the screening of handwriting difficulties, since it allows (1) anticipation of the detection of alteration of handwriting principles at a preliteracy age and (2) provision of broader access to the monitoring of handwriting principles. Such a solution potentially enables the selective strengthening of lacking abilities before they exacerbate and affect the child’s whole life.

IoT ink pen for ecological monitoring of daily life handwriting

The analysis of the writing gesture has been successfully investigated in the diagnosis of age-related diseases, but the current technologies and methods still do not allow the ecological daily monitoring of handwriting, mostly because they rely on standardized writing protocols. In this study, we first designed and validated a novel electronic ink pen, equipped with motion and writing force sensing, for the ecological daily-life monitoring of handwriting in uncontrolled environments. We used the pen to acquire writing activities from healthy adults, from which we computed useful handwriting and tremor indicators. We evaluated the reliability of our measurements by computing the intraclass correlation coefficients (ICC) and the minimal detectable changes (MDC). Moderate to excellent reliability were obtained for all the handwriting indicators computed in two different writing tasks. MDC values can be used as reference to discriminate a real change in the handwriting parameters from a measurement error in longitudinal studies. These results pave the way towards the use of the pen for daily life handwriting monitoring.

Supervised Digital Neuropsychological Tests for Cognitive Decline in Older Adults: Usability and Clinical Validity Study

Background

Dementia is a major and growing health problem, and early diagnosis is key to its management.

Objective

With the ultimate goal of providing a monitoring tool that could be used to support the screening for cognitive decline, this study aims to develop a supervised, digitized version of 2 neuropsychological tests: Trail Making Test and Bells Test. The system consists of a web app that implements a tablet-based version of the tests and consists of an innovative vocal assistant that acts as the virtual supervisor for the execution of the test. A replay functionality is added to allow inspection of the user’s performance after test completion.

Methods

To deploy the system in a nonsupervised environment, extensive functional testing of the platform was conducted, together with a validation of the tablet-based tests. Such validation had the two-fold aim of evaluating system usability and acceptance and investigating the concurrent validity of computerized assessment compared with the corresponding paper-and-pencil counterparts.

Results

The results obtained from 83 older adults showed high system acceptance, despite the patients’ low familiarity with technology. The system software was successfully validated. A concurrent validation of the system reported good ability of the digitized tests to retain the same predictive power of the corresponding paper-based tests.

Conclusions

Altogether, the positive results pave the way for the deployment of the system to a nonsupervised environment, thus representing a potential efficacious and ecological solution to support clinicians in the identification of early signs of cognitive decline.

Does cycling induced by functional electrical stimulation enhance motor recovery in the subacute phase after stroke? A systematic review and meta-analysis

OBJECTIVE

To investigate the effects of cycling with functional electrical stimulation on walking, muscle power and tone, balance and activities of daily living in subacute stroke survivors.

DATA SOURCES

Ten electronic databases were searched from inception to February 2020.

REVIEW METHODS

Inclusion criteria were: subacute stroke survivors (<6 months since stroke), an experimental group performing any type of cycling training with electrical stimulation, alone or in addition to usual care, and a control group performing usual care alone. Two reviewers assessed eligibility, extracted data and analyzed the risks of bias. Standardized Mean Difference (SMD) or Mean Difference (MD) with 95% Confidence Intervals (CI) were estimated using fixed- or random-effects models to evaluate the training effect.

RESULTS

Seven randomized controlled trials recruiting a total of 273 stroke survivors were included in the meta-analyses. There was a statistically significant, but not clinically relevant, effect of cycling with electrical stimulation compared to usual care on walking (six studies, SMD [95% CI] = 0.40 [0.13, 0.67]; P = 0.004), capability to maintain a sitting position (three studies, MD [95% CI] = 7.92 [1.01, 14.82]; P = 0.02) and work produced by the paretic leg during pedaling (2 studies, MD [95% CI] = 8.13 [1.03, 15.25]; P = 0.02). No significant between-group differences were found for muscular power, tone, standing balance, and activities of daily living.

CONCLUSIONS

Cycling training with functional electrical stimulation cannot be recommended in terms of being better than usual care in subacute stroke survivors. Further investigations are required to confirm these results, to determine the optimal training parameters and to evaluate long-term effects.

A Tablet-Based App to Discriminate Children at Potential Risk of Handwriting Alterations in a Preliteracy Stage

Failing to master handwriting, as in the case of Dysgraphia, has negative consequences on children's lives. In early stage of development, Dysgraphia diagnosis is delayed and not easily achievable. Thus, the aim of this work is to propose a valid tool to anticipate Dysgraphia screening at a preliteracy age. We developed a tablet application to analyze characteristics altered in dysgraphic handwriting, such as rhythmical laws (isochrony and homothety), or a collection of kinematic and dynamic parameters (smoothness, pressure, frequency contents). To be suitable for the pre-literacy stage, possible alterations are investigated in symbol drawings. The app is tested on 104 preschoolers, both with normal (n=76) and delayed graphical abilities (n=28), reporting excellent acceptance. Some isochrony alterations were reported only for children with delayed graphical abilities. Moreover, kinematic and dynamic parameters are effective in discriminating between risk and norisk conditions. Indeed, the logistic classification adopted resulted in a 0.819 area under the precision-recall curve. These findings pave the way toward an early screening of future handwriting alteration, starting from a pre-literacy age.

Opportunities to improve feasibility, effectiveness and costs associated with a total joint replacements high-volume hospital registry

BACKGROUND

Clinical registries are powerful tools for collecting uniform data longitudinally, thus making it possible to evaluate the outcome of patients affected by a specific pathology. In the context of total joint arthroplasty, registries serve also as post-market surveillance. Adoption of registries is a heavy burden for clinical settings in terms of resources and infrastructures. Excessive workload leads to incomplete data collection which undermines the effectiveness of a registry and consequently the workload needs to be optimised.

METHODS

Starting from the use case of the Istituto Ortopedico Galeazzi, the time and personnel dedicated to the registry was estimated. Analysis of the data collected in the first years enabled us to propose a methodology for workload reduction. Different Machine Learning models were leveraged to predict patients with excellent satisfaction to reduce the number of assessments in their clinical post-operative follow-up. Moreover, feature selection was used to identify any unnecessary clinical scale to collect.

RESULTS

Given an acceptance rate of 3500 patients per year, 22 doctors and 6 non-medical employees were required to adopt a registry properly. Among the tested models, the Naïve Bayes gave the best performance (AUPRC = 0.81) in predicting patient satisfaction at six months. Moreover, we found that the 12-item Short Form was poorly informative in predicting satisfaction at six-months.

CONCLUSIONS

In this study machine learning was leveraged to provide a methodology to reduce workload in the use of pathology registries. Such workload reduction can have a considerable impact at a larger scale, and improve registry feasibility in high-volume hospitals.

Changes in leg cycling muscle synergies after training augmented by functional electrical stimulation in subacute stroke survivors: a pilot study

Background

Muscle synergies analysis can provide a deep understanding of motor impairment after stroke and of changes after rehabilitation. In this study, the neuro-mechanical analysis of leg cycling was used to longitudinally investigate the motor recovery process coupled with cycling training augmented by Functional Electrical Stimulation (FES) in subacute stroke survivors.

Methods

Subjects with ischemic subacute stroke participated in a 3-week training of FES-cycling with visual biofeedback plus usual care. Participants were evaluated before and after the intervention through clinical scales, gait spatio-temporal parameters derived from an instrumented mat, and a voluntary pedaling test. Biomechanical metrics (work produced by the two legs, mechanical effectiveness and symmetry indexes) and bilateral electromyography from 9 leg muscles were acquired during the voluntary pedaling test. To extract muscles synergies, the Weighted Nonnegative Matrix Factorization algorithm was applied to the normalized EMG envelopes. Synergy complexity was measured by the number of synergies required to explain more than 90% of the total variance of the normalized EMG envelopes and variance accounted for by one synergy. Regardless the inter-subject differences in the number of extracted synergies, 4 synergies were extracted from each patient and the cosine-similarity between patients and healthy weight vectors was computed.

Results

Nine patients (median age of 75 years and median time post-stroke of 2 weeks) were recruited. Significant improvements in terms of clinical scales, gait parameters and work produced by the affected leg were obtained after training. Synergy complexity well correlated to the level of motor impairment at baseline, but it did not change after training. We found a significant improvement in the similarity of the synergy responsible of the knee flexion during the pulling phase of the pedaling cycle, which was the mostly compromised at baseline. This improvement may indicate the re-learning of a more physiological motor strategy.

Conclusions

Our findings support the use of the neuro-mechanical analysis of cycling as a method to assess motor recovery after stroke, mainly in an early phase, when gait evaluation is not yet possible. The improvement in the modular coordination of pedaling correlated with the improvement in motor functions and walking ability achieved at the end of the intervention support the role of FES-cycling in enhancing motor re-learning after stroke but need to be confirmed in a controlled study with a larger sample size.

Trial registration

ClinicalTrial.gov, NCT02439515. Registered on May 8, 2015, .

Automatic speech analysis to early detect functional cognitive decline in elderly population

This study aimed at evaluating whether people with a normal cognitive function can be discriminated from subjects with a mild impairment of cognitive function based on a set of acoustic features derived from spontaneous speech. Voice recordings from 90 Italian subjects (age >65 years; group 1: 47 subjects with MMSE>26; group 2: 43 subjects with 20≤ MMSE ≤26) were collected. Voice samples were processed using a MATLAB-based custom software to derive a broad set of known acoustic features. Linear mixed model analyses were performed to select the features able to significantly distinguish between groups. The selected features (% of unvoiced segments, duration of unvoiced segments, % of voice breaks, speech rate, and duration of syllables), alone or in addition to age and years of education, were used to build a learning-based classifier. The leave-one-out cross validation was used for testing and the classifier accuracy was computed. When the voice features were used alone, an overall classification accuracy of 0.73 was achieved. When age and years of education were additionally used, the overall accuracy increased up to 0.80. These performances were lower than the accuracy of 0.86 found in a recent study. However, in that study the classification was based on several tasks, including more cognitive demanding tasks. Our results are encouraging because acoustic features, derived for the first time only from an ecologic continuous speech task, were able to discriminate people with a normal cognitive function from people with a mild cognitive decline. This study poses the basis for the development of a mobile application performing automatic voice analysis on-the-fly during phone calls, which might potentially support the detection of early signs of functional cognitive decline.

Validity and usability of a smart ball-driven serious game to monitor grip strength in independent elderlies

Telemonitoring is one of the most expedient answers to the strong need for preventive care imposed by the rapidly aging society. We propose an innovative solution to the detection of early signs of frailty by presenting a serious game controlled by a smart sensorized soft plastic ball, designed to achieve continuous home-based monitoring of muscle weakness in older adults. Design, development, and testing of the smart ball and of the game interface devised to guide the monitoring procedure are presented. Reliability and concurrent validity of the system in measuring maximal grip strength against the clinical standard Jamar^® were evaluated. Serious game usability and acceptance were investigated on 26 elderlies. Smart ball and Jamar measurements were well correlated (0.76 and 0.80 for dominant and non-dominant hands) and test-retest reliability of pressure measurements was excellent (intraclass correlation coefficient >0.94). The serious game was well accepted by the 96.1 percent of participants, who provided a strongly positive usability score (87.7/100). The smart ball-driven serious game demonstrated excellent reliability and good validity in measuring grip strength. The proposed smart ball-driven serious game can be used for home self-monitoring of grip strength in elderlies.

Is the Brief-BESTest Brief Enough? Suggested Modifications Based on Structural Validity and Internal Consistency

BACKGROUND

The Brief Balance Evaluation Systems Test (Brief-BESTest) could be a useful tool for balance assessment. Although some psychometric characteristics have been examined, others still need to be clarified.

OBJECTIVE

The objective was to assess the structural validity, convergent validity, discriminant validity, and internal consistency of the Brief-BESTest in neurological patients.

DESIGN

This was a cross-sectional study.

METHODS

Data were from 416 patients with neurological disease and related balance disorders. Patients were assessed with the 5-levels Activities-Specific Balance Confidence Scale (ABC 5-levels), Brief-BESTest, and some simple balance tests (ie, 1-leg stance, Timed "Up & Go" test, functional reach, and a fall history questionnaire). Three Brief-BESTest models were examined through confirmatory factor analysis, and the following indexes were calculated: Comparative Fit Index, Tucker-Lewis Index, and root-mean-square error of approximation. Convergent validity was assessed by calculating the correlation between Brief-BESTest and ABC 5-levels total scores. Receiver operating characteristics assessed the ability of each model to differentiate between people with falls and those without falls. Internal consistency was measured with Cronbach α and coefficient ω.

RESULTS

Confirmatory factor analysis showed model 3 (Comparative Fit Index = 0.97; Tucker-Lewis Index = 0.95; root-mean-square error of approximation = 0.05), with item 1 removed and error covariance between items 3 and 4 and between items 5 and 6, to have a significantly better structure than models 1 and 2. The correlation between Brief-BESTest and ABC 5-levels was 0.61 (Spearman ρ) for all 3 models. The area under the curve of the receiver operating characteristics showed an acceptable accuracy (0.72) in distinguishing patients with a history of falls from those without a history of falls (95% confidence interval = 0.66-0.78) for all models and was superior to the areas under the curve of other simple balance tests (1-leg stance, Timed "Up & Go" test, functional reach). Cronbach α was good for Brief-BESTest models 1 (0.92) and 3 (0.92), but ω was greater than 0.80 only for model 3.

LIMITATIONS

The sample was heterogeneous.

CONCLUSIONS

The Brief-BESTest, after some changes, shows good validity and internal consistency in patients affected by different balance disorders.

A multimodal training with visual biofeedback in subacute stroke survivors: a randomized controlled trial

BACKGROUND

Early interventions maximizing patient's involvement are essential to promote gait restoration and motor recovery after stroke.

AIM

The aim of this study is to evaluate the effects of a multimodal biofeedback training involving cycling augmented by functional electrical stimulation (FES) and balance exercises on walking ability and motor recovery.

DESIGN

Randomized controlled trial (NCT02439515).

SETTING

Inpatient rehabilitation facility.

POPULATION

Subacute stroke survivors (less than 6 months from the first event) aged up to 90 years old.

METHODS

Sixty-eight participants were randomly allocated to an experimental group, performing 15 sessions of biofeedback FES-cycling training followed by 15 sessions of biofeedback balance training (20 minutes each) in addition to usual care (70 minutes), and a control group performing 30 sessions (90 minutes) of usual care. Participants were evaluated before training, after 15 sessions, after 30 sessions, and at 6-month follow-up through: gait speed (primary outcome), spatiotemporal gait parameters, Six-Minute Walking Test, Functional Independence Measure, Motricity Index, Trunk Control Test, Berg Balance Scale, and Fall Efficacy Scale.

RESULTS

Both groups significantly improved over time, but no group and interaction effects were found for any outcomes. The 73% of the experimental group achieved a clinically meaningful change in gait speed compared to the 38% of the control group (P=0.048). These percentages were even more unbalanced for patients with a moderate to severe gait impairment at baseline (91% versus 36%; P=0.008).

CONCLUSIONS

The multimodal biofeedback training was not statistically superior to usual care, showing only a positive trend in favor of the experimental group on locomotion recovery. Patients initially not able to walk might be the best candidates for such a training.

CLINICAL REHABILITATION IMPACT

The multimodal biofeedback training is a task-specific, repetitive and intensive training requiring a minimal supervision, which might result in a lower staff to patient ratio if organized in group sessions. Therefore, it can represent a good alternative for early stroke rehabilitation.

Efficacy of two brief cognitive-behavioral rehabilitation programs for chronic neck pain: results of a randomized controlled pilot study

BACKGROUND

Current models of pain behavior suggest that kinesiophobia prevents the reacquisition of normal function, promotes the development of maladaptive coping strategies, and contributes to the disability associated with chronic neck pain (NP).

AIM

Comparing two brief cognitive-behavioral programs aimed at managing kinesiophobia to understand which one induces better short-term improvements in disability, fear of movement, catastrophizing, adaptive coping strategies, quality of life (QoL), and pain intensity of chronic NP.

DESIGN

Pilot, randomized, controlled trial, 3-months follow-up.

SETTING

Outpatients.

POPULATION

Subjects with chronic NP.

METHODS

The population was randomized into two groups: group A (N.=15) underwent four sessions of cognitive-behavioral therapy (CBT) based on the NeckPix© (1-week duration); group B (N.=15) received four sessions of CBT based on the Tampa Scale of Kinesiophobia (TSK) (1-week duration). Afterwards, both groups attended 10 sessions of multimodal exercises (5-week duration). Primary measure: Neck Disability Index (NDI). Secondary measures: NeckPix©, TSK, Pain Catastrophizing Scale, Chronic Pain Coping Inventory, EuroQol-Five Dimensions, and pain intensity Numerical Rating Scale.

STATISTICS

Linear mixed model analyses for repeated measures for each outcome measure to evaluate changes over time and between group.

RESULTS

A significant effect of time was found for all outcomes, while no outcomes showed group and/or interaction effects. No changes were found in terms of NDI at the end of CBT, while a significant improvement of about 13 points was found for both groups at the end of the motor training (P=0.001). Similarly, in terms of quality of life there was no change after the CBT program, and a significant change at the end of the motor training, with a partial loss at follow-up. From CBT sessions to follow-up both groups showed a progressive reduction in kinesiophobia, with each group achieving a bigger change in the specific scale used for the CBT program.

CONCLUSIONS

Two brief cognitive-behavioral rehabilitation programs based on different methodologies of managing fear-avoidance beliefs induced similar short-term improvements in subjects with chronic NP. Clinically significant changes in terms of disability were found in both groups only at the end of a 5-week motor training, regardless of the cognitive-behavioral rehabilitation program previously administrated.

CLINICAL REHABILITATION IMPACT

Treatment of chronic NP requires cognitive modifications closely linked to physical performances in order to achieve mental adjustments and guarantee cognitive-behavioral as well as motor lasting changes.

StimTrack: An open-source software for manual transcranial magnetic stimulation coil positioning

BACKGROUND

During Transcranial Magnetic Stimulation (TMS) experiments researchers often use a neuronavigation system to precisely and accurately maintain coil position and orientation.

NEW METHOD

This study aimed to develop and validate an open-source software for TMS coil navigation. StimTrack uses an optical tracker and an intuitive user interface to facilitate the maintenance of position and orientation of any type of coil within and between sessions. Additionally, online access to navigation data is provided, hereby adding e.g. the ability to start or stop the magnetic stimulator depending on the distance to target or the variation of the orientation angles.

RESULTS

StimTrack allows repeatable repositioning of the coil within 0.7mm for translation and <1° for rotation. Stimulus-response (SR) curves obtained from 19 healthy volunteers were used to demonstrate that StimTrack can be effectively used in a typical experiment. An excellent intra and inter-session reliability (ICC >0.9) was obtained on all parameters computed on SR curves acquired using StimTrack.

COMPARISON WITH EXISTING METHOD

StimTrack showed a target accuracy similar to that of a commercial neuronavigation system (BrainSight, Rogue Research Inc.). Indeed, small differences both in position (∼0.2mm) and orientation (<1°) were found between the systems. These differences are negligible given the human error involved in landmarks registration.

CONCLUSIONS

StimTrack, available as supplementary material, is found to be a good alternative for commercial neuronavigation systems facilitating assessment changes in corticospinal excitability using TMS. StimTrack allows researchers to tailor its functionality to their specific needs, providing added value that benefits experimental procedures and improves data quality.

Intra and inter-session reliability of rapid Transcranial Magnetic Stimulation stimulus-response curves of tibialis anterior muscle in healthy older adults

OBJECTIVE

The clinical use of Transcranial Magnetic Stimulation (TMS) as a technique to assess corticospinal excitability is limited by the time for data acquisition and the measurement variability. This study aimed at evaluating the reliability of Stimulus-Response (SR) curves acquired with a recently proposed rapid protocol on tibialis anterior muscle of healthy older adults.

METHODS

Twenty-four neurologically-intact adults (age:55-75 years) were recruited for this test-retest study. During each session, six SR curves, 3 at rest and 3 during isometric muscle contractions at 5% of maximum voluntary contraction (MVC), were acquired. Motor Evoked Potentials (MEPs) were normalized to the maximum peripherally evoked response; the coil position and orientation were monitored with an optical tracking system. Intra- and inter-session reliability of motor threshold (MT), area under the curve (AURC), MEPmax, stimulation intensity at which the MEP is mid-way between MEPmax and MEPmin (I50), slope in I50, MEP latency, and silent period (SP) were assessed in terms of Standard Error of Measurement (SEM), relative SEM, Minimum Detectable Change (MDC), and Intraclass Correlation Coefficient (ICC).

RESULTS

The relative SEM was ≤10% for MT, I50, latency and SP both at rest and 5%MVC, while it ranged between 11% and 37% for AURC, MEPmax, and slope. MDC values were overall quite large; e.g., MT required a change of 12%MSO at rest and 10%MSO at 5%MVC to be considered a real change. Inter-sessions ICC were >0.6 for all measures but slope at rest and MEPmax and latency at 5%MVC.

CONCLUSIONS

Measures derived from SR curves acquired in <4 minutes are affected by similar measurement errors to those found with long-lasting protocols, suggesting that the rapid method is at least as reliable as the traditional methods. As specifically designed to include older adults, this study provides normative data for future studies involving older neurological patients (e.g. stroke survivors).

Development of the Italian version of the trunk impairment scale in subjects with acute and chronic stroke. Cross-cultural adaptation, reliability, validity and responsiveness

PURPOSE

To cross-culturally adapt and psychometrically analyse the Italian version of the Trunk Impairment Scale on acute (cohort 1) and chronic stroke patients (cohort 2).

METHODS

The Trunk Impairment Scale was culturally adapted in accordance with international standards. The psychometric testing included: internal consistency (Cronbach's alpha), inter- and intra-rater reliability (intraclass correlation coefficient; standard error of measurement and minimal detectable change), construct validity by comparing Trunk Impairment Scale score with Barthel Index, motor subscale of Functional Independence Measure, and Trunk Control Test (Pearson's correlation), and responsiveness (Effect Size, Effect Size with Guyatt approach, standardized response mean, and Receiver Operating Characteristics curves).

RESULTS

The Trunk Impairment Scale was administered to 125 and 116 acute and chronic stroke patients, respectively. Internal consistency was acceptable (α > 0.7), inter- and intra-rater reliability (ICC > 0.9, Minimal Detectable Change for total score < 1.6 in cohort 1 and < 1.1 in cohort 2) were excellent. The construct validity showed acceptable correlations (r > 0.4) with all scales but the motor Functional Independence Measure in cohort 2. Distribution-based methods showed large effects in cohort 1 and moderate to large effects in cohort 2. The Minimal Important Difference was 3.5 both from patient's and therapist's perspective in cohort 1 and 2.5 and 1.5 from patient's and therapist's perspective, respectively, in cohort 2.

CONCLUSION

The Trunk Impairment Scale was successfully translated into Italian and proved to be reliable, valid, and responsive. Its use is recommended for clinical and research purposes. Implications for Rehabilitation Trunk control is an essential part of balance and postural control, constituting an important prerequisite for daily activities and function. The TIS administered in subjects with subacute and chronic stroke was reliable, valid and responsive. The TIS is expected to help clinicians and researchers by identifying key functional processes related to disability in people with subacute and chronic stroke.

How balance task-specific training contributes to improving physical function in older subjects undergoing rehabilitation following hip fracture: a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of a rehabilitation programme including balance task-specific training in improving physical function, pain, activities of daily living (ADL), balance and quality of life in subjects after a hip fracture.

DESIGN

Randomized controlled trial.

SUBJECTS

A total of 52 older subjects selected for internal fixation due to extra-capsular hip fracture were randomized to be included in an experimental ( n = 26) and control group ( n = 26).

INTERVENTIONS

The experimental group underwent a rehabilitation programme based on balance task-specific training. The control group underwent general physiotherapy, including open kinetic chain exercises and walking training. Both groups individually followed programmes of 90-minute sessions five times/week for three weeks.

OUTCOME MEASURES

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), a Pain Numerical Rating Scale, the Berg Balance Scale, the Functional Independence Measure and the 36-item Short-Form Health Survey. The participants were evaluated before and after training, and after 12 months.

RESULTS

Significant effects of time, group and time × group were found for all outcome measures in favour of the experimental group. A clinically important between-group difference of 25 points was achieved after training and at follow-up in terms of the primary outcome (WOMAC function before treatment, after treatment and at follow-up was 84.8 (3.7), 39.8 (4.9) and 35.7 (6.2) for the experimental group and 80.9 (5.7), 65.2 (7.1) and 61.0 (11.1) for the control group).

CONCLUSION

An inpatient rehabilitation programme based on balance task-specific training is useful in improving physical function, pain, ADL and quality of life in older patients after hip fracture.

The combined action of a passive exoskeleton and an EMG-controlled neuroprosthesis for upper limb stroke rehabilitation: First results of the RETRAINER project

The combined use of Functional Electrical Stimulation (FES) and robotic technologies is advocated to improve rehabilitation outcomes after stroke. This work describes an arm rehabilitation system developed within the European project RETRAINER. The system consists of a passive 4-degrees-of-freedom exoskeleton equipped with springs to provide gravity compensation and electromagnetic brakes to hold target positions. FES is integrated in the system to provide additional support to the most impaired muscles. FES is triggered based on the volitional EMG signal of the same stimulated muscle; in order to encourage the active involvement of the patient the volitional EMG is also monitored throughout the task execution and based on it a happy or sad emoji is visualized at the end of each task. The control interface control of the system provides a GUI and multiple software tools to organize rehabilitation exercises and monitor rehabilitation progress. The functionality and the usability of the system was evaluated on four stroke patients. All patients were able to use the system and judged positively its wearability and the provided support. They were able to trigger the stimulation based on their residual muscle activity and provided different levels of active involvement in the exercise, in agreement with their level of impairment. A randomized controlled trial aimed at evaluating the effectiveness of the RETRAINER system to improve arm function after stroke is currently ongoing.

Tuning of Muscle Synergies During Walking Along Rectilinear and Curvilinear Trajectories in Humans

The aim of this study was to develop a methodology based on muscle synergies to investigate whether rectilinear and curvilinear walking shared the same neuro-motor organization, and how this organization was fine-tuned by the walking condition. Thirteen healthy subjects walked on rectilinear and curvilinear paths. Electromyographic data from thirteen back and lower-limb muscles were acquired, together with kinematic data using inertial sensors. Four macroscopically invariant muscle synergies, extracted through non-negative matrix factorization, proved a shared modular organization across conditions. The fine-tuning of muscle synergies was studied through non-negative matrix reconstruction, applied by fixing muscle weights or activation profiles to those of the rectilinear condition. The activation profiles tended to be recruited for a longer period and with a larger amplitude during curvilinear walking. The muscles of the posterior side of the lower limb were those mainly influenced by the fine-tuning, with the muscles inside the rotation path being more active than the outer muscles. This study shows that rectilinear and curvilinear walking share a unique motor command. However, a fine-tuning in muscle synergies is introduced during curvilinear conditions, adapting the kinematic strategy to the new biomechanical needs.

Responsiveness and minimal clinically important changes for the Tampa Scale of Kinesiophobia after lumbar fusion during cognitive behavioral rehabilitation

BACKGROUND

The Tampa Scale of Kinesiophobia (TSK) is a commonly-used measure for the assessment of fear of movement beliefs in chronic complaints, but its responsiveness in subjects after lumbar fusion has been never reported.

AIM

Evaluating the responsiveness and minimal clinically important differences (MCIDs) for the TSK and its subscales after lumbar fusion.

DESIGN

Population-based cohort study.

SETTING

Secondary care rehabilitation hospital.

POPULATION

In-patients undergoing rehabilitation after lumbar fusion.

METHODS

At the beginning and end of a four-week motor and cognitive-behavioral rehabilitation program, 180 patients completed the TSK. After the intervention, the global perceived effect (GPE) was analyzed to produce a dichotomous outcome (improved vs. stable). Responsiveness for the TSK and its subscales were calculated by distribution (effect size [ES], standardized response mean [SRM]) and anchor-based methods (receiver operating characteristics (ROC) curves; correlations between change scores of the TSK and its subscales and GPE). ROC curves were also used to compute MCID values.

RESULTS

The ES ranged from 1.63 to 1.77 and the SRM from 1.25 to 1.39 for TSK and its subscales. The ROC analyses revealed a value of area under the curve (0.999 [95% CI: 0.978; 1.000], 0.998 [95% CI: 0.975; 1.000], 0.990 [95% CI: 0.962; 0.999] for the TSK, Harm and Activity Avoidance subscales, respectively). MCID values greater than 6 (95% CI: >5; >6), 4 (95% CI: >3; >5), and 2 (95% CI: >2; >2) were achieved for the TSK, Harm and Activity Avoidance subscales, respectively. Correlations between change scores of the TSK and its subscales and GPE were high (0.786-0.830).

CONCLUSIONS

The TSK and its subscales were sensitive in detecting clinical changes in subjects undergoing rehabilitation after lumbar fusion.

CLINICAL REHABILITATION IMPACT

The obtained MCID values will help in the design of future randomized controlled trials and in the interpretation of the clinical impact of a rehabilitation program after lumbar fusion.

Artificial neural network EMG classifier for functional hand grasp movements prediction

Objective To design and implement an electromyography (EMG)-based controller for a hand robotic assistive device, which is able to classify the user's motion intention before the effective kinematic movement execution. Methods Multiple degrees-of-freedom hand grasp movements (i.e. pinching, grasp an object, grasping) were predicted by means of surface EMG signals, recorded from 10 bipolar EMG electrodes arranged in a circular configuration around the forearm 2-3 cm from the elbow. Two cascaded artificial neural networks were then exploited to detect the patient's motion intention from the EMG signal window starting from the electrical activity onset to movement onset (i.e. electromechanical delay). Results The proposed approach was tested on eight healthy control subjects (4 females; age range 25-26 years) and it demonstrated a mean ± SD testing performance of 76% ± 14% for correctly predicting healthy users' motion intention. Two post-stroke patients tested the controller and obtained 79% and 100% of correctly classified movements under testing conditions. Conclusion A task-selection controller was developed to estimate the intended movement from the EMG measured during the electromechanical delay.