Virgílio F. Bento

A Rehabilitation Tool Designed for Intensive Web-Based Cognitive Training: Description and Usability Study

Background Cognitive deficits are among the most disabling of neurological diseases and have a serious impact on the quality of life of patients and families. Cognitive training has been proven successful in improving or compensating for neuropsychological deficits after acute brain injury, but its efficacy highly depends on the intensity of treatment over an extended period of time. Therefore, cognitive training indicates expensive human resources and renders the rehabilitation process vulnerable to physical and economic barriers for the majority of patients. Objective The aim of this study was to develop and test a new Web-based rehabilitation tool that provides intensive cognitive training at home under clinical prescription and monitoring, at affordable costs. Methods From a pool of 60 original exercises, designed and used over the past 10 years for cognitive training at our center, we developed 27 exercises on a computer game format, with automatic increase or decrease of difficulty levels. These exercises were assembled in a clean, user-friendly design and covered various cognitive domains such as attention (n=4), memory (n=11), language (n=3), calculus (n=3), praxis (n=2), and executive functions (n=3). A Web 2.0 platform was also designed to provide medical prescription of cognitive training sessions, performed at the patient’s home. These sessions included continuous monitoring of compliance, performance, and evolution; algorithms for automatic adjustment and long-term learning through use, and database recording of all activities. The end-user interaction test included 80 patients from our memory clinic from several groups including subjective memory complaints (n=20), traumatic brain injury (n=20), stroke and other static brain lesions (n=20), and mild Alzheimer’s disease (n=20). During a 1-hour session, patients and their relatives were taught to use the system and allowed to practice using it. At the end of the session, they were asked to complete a questionnaire. Results A total of 48/80 patients (60%) attended the training session. The mean age of the patients was 60 years (SD 13.3, range 41-78), and the mean level of formal education was 6 years (range 4-16). Of all the participants, 32/48 patients (66%) have previously used a computer. All patients and their relatives made a positive evaluation of the cognitive training tool. Only 2/48 patients (4%) were not interested in performing the exercises at home; 19/48 patients (39%) mentioned the need for further coaching from a relative or health care professional. The patients who mentioned difficulties in performing the exercises have not used the computer earlier. Conclusions This new Web-based system was very well accepted by patients and their relatives, who showed high levels of motivation to use it on a daily basis at home. The simplicity of its use and comfort were especially outlined. This tool will have an important effect on human resource management, in increasing the patient access to specialized health care and improving the quality and national health system costs of rehabilitation programs.

Web-based cognitive training: patient adherence and intensity of treatment in an outpatient memory clinic.

Background Cognitive training has been playing an increasing role in the treatment of patients with cognitive deficits. This type of intervention, namely its intensity, can be optimized by incorporating information technology-based systems. Objective The intent of the study was to determine the treatment intensity and patient adherence to home-based cognitive training strategies (Web-based cognitive training). Methods A cohort of 45 patients with neurologic and psychiatric diseases attending an outpatient memory clinic (average age 50.7 years, SD 17.0; average education 7.8 years, SD 4.9) was followed over 18 months. Participants were challenged to use a Web-based cognitive training system, “COGWEB”, on a daily basis, and fulfilled at least four weeks of training supervised remotely. Additionally, 11 patients attended face-to-face sessions. Results The average duration of continuous cognitive training was 18.8 weeks (SD 18.9). Each patient performed on average 363.5 minutes/week (SD 136.6). At 6-month follow-up, 82.8% complied with their treatment plan. The average proportion of complete weeks was 0.75 (SD 0.22). Patients with dementia trained more intensively (444.6 minutes/week), followed by patients with static brain lesion (414.5 minutes/week; P=.01). The group that held face-to-face sessions performed more training overall (481.4 vs 366.9 minutes/week), achieving a stronger expression and statistical significance in the last week of training (652.6 versus 354.9 minutes/week, P=.027). Conclusions Overall, the weekly training intensity was high. Patients with dementia and static lesions performed more cognitive training. Face-to-face sessions were associated with higher intensities. The combination of classical methods with information technology systems seems to ensure greater training intensity.

Towards a movement quantification system capable of automatic evaluation of upper limb motor function after neurological injury

The paper proposes an integrated system to automatically assess motor function after neurological injury. A portable motion capture system was developed in order to obtain all the relevant three dimensional kinematics of the upper limb movement. These kinematics were analyzed by means of a decision tree classifier which features where inferred from the Functional Ability Score (FAS) of the Wolf Motor Function Test (WMFT). In addition, the system is able to correctly quantify the performance time of each selected task of the WMFT. In terms of the FAS the system and the clinician show coherent results for 3 out of 5 patients in the first task tested and 4 out of 5 for the second task tested. Regarding performance time, the mean error between the system and the clinician was of 0.216 s for the 25 trials performed (5 patients, 5 tasks each). These results represent an important proof of concept towards a system capable of precisely evaluate upper limb motor function after neurological injury.

Movement quantification in epileptic seizures: A feasibility study for a new 3D approach

Movement quantification of the human body is presently used for analyzing deficits resulting from Central Nervous System (CNS) pathologies or exploring the insights of the human motor system behaviour. Following our previous work on 2D movement quantification of epileptic seizures, we now present a feasibility study for a newly developed 3D technique. In order to validate this new 3D approach we made a comparison with the previous method. Both techniques were tested in two different datasets: a simple motor execution performed by a volunteer and a complex motor motion induced by a real epileptic seizure. The results obtained showed, as expected, the superior robustness and precision of the 3D approach but also confirmed the validity of the 2D method, given certain constraints. We conclude that the newly developed 3D system will highly improve our capacity of pursuing the clinical research on quantitative characterization of seizure semiology to support epilepsy diagnosis.

The vibratory stimulus as a neurorehabilitation tool for stroke patients: Proof of concept and tolerability test

INTRODUCTION Current scientific knowledge reinforces that successful reorganization of surviving nervous tissue supports cognitive and motor recovery after stroke. The development of new neurorehabilitation tools to modulate this physiologic process is needed. In this context, vibratory stimuli are a noninvasive form of proprioceptive stimulation of the nervous system and are freely available and easy to use at a low cost. OBJECTIVES To access the feasibility and tolerability of targeted vibratory stimuli delivered through a wearable device in an early post-stroke setting. PATIENTS AND METHODS Five stroke patients were recruited from a stroke unit setting having a first ever medial cerebral artery ischemic stroke with motor deficit. The stimulation device developed delivered external vibratory stimuli to major joints at preprogrammed arrays of intensity, duration and interval of actuation. The tolerability test was set for five-hour duration and during that period data on vital parameters, cognitive, motor and sensitive performance as well as anxiety scores were recorded. RESULTS The device remained in place throughout and none of the patients or relatives asked to interrupt the tolerability test. There were no major complications during the trial or the ensuing days. Attention to the affected side during stimulation was increased in four patients, and two were reported as clearly more awake during the test. DISCUSSION This is the first tolerability test focused on the use of targeted vibratory stimulus as a neurorehabilitation tool in stroke patients. There were no hazards to report and most interestingly the majority of patients showed increased awareness to the affected side of the body. These findings will be further analyzed under functional MRI control and on long-term ambulatory use trials.

Development of a self-administered web-based test for longitudinal cognitive assessment.

Sequential testing with brief cognitive tools has been recommended to improve cognitive screening and monitoring, however the few available tools still depend on an external evaluator and periodic visits. We developed a self-administered computerized test intended for longitudinal cognitive testing (Brain on Track). The test can be performed from a home computer and is composed of several subtests, expected to evaluate different cognitive domains, all including random elements to minimize learning effects. An initial (A) and a refined version of the test (B) were applied to patients with mild cognitive impairment or early dementia (n = 88) and age and education-matched controls. A subsample of a population-based cohort (n = 113) performed the test at home every three months to evaluate test-retest reliability. The test’s final version Cronbach’s alpha was 0.90, test scores were significantly different between patients and controls (p = 0.001), the area under the receiver operating characteristic curve was 0.75 and the smallest real difference (43.04) was lower than the clinical relevant difference (56.82). In the test-retest reliability analysis 9/10 subtests showed two-way mixed single intraclass consistency correlation coefficient >0.70. These results imply good internal consistency, discriminative ability and reliability when performed at home, encouraging further longitudinal clinical and population-based studies.

A novel system for automatic classification of upper limb motor function after stroke: An exploratory study

In the early post-stroke phase, when clinicians attempt to evaluate interventions and accurately measure motor performance, reliable tools are needed. Therefore, the development of a system capable of independent, repeated and automatic assessment of motor function is of increased importance. This manuscript explores the potential of a newly designed device for automatic assessment of motor impairment after stroke. A portable motion capture system was developed to acquire three-dimensional kinematics data of upper limb movements. These were then computed through an automatic decision tree classifier, with features inferred from the Functional Ability Score (FAS) of the Wolf Motor Function Test (WMFT). Five stroke patients were tested on both sides across five selected tasks. The system was compared against a trained clinician, operating simultaneously and blinded. Regarding performance time, the mean difference (system vs clinician) was 0.17s (sd=0.14s). For FAS evaluation, there was agreement in 4 out of 5 patients in the two tasks evaluated. The prototype tested was able to automatically classify upper limb movement, according to a widely used functional motor scale (WMFT) in a relevant clinical setting. These results represent an important step towards a system capable of precise and independent motor evaluation after stroke. The portability and low-cost design will contribute for its usability in ambulatory clinical settings and research trials.

Motor task performance under vibratory feedback early poststroke: single center, randomized, cross-over, controled clinical trial

Stroke rehabilitation is far from meeting patient needs in terms of timing, intensity and quality. This study evaluates the efficacy and safety of an innovative technological tool, combining 3D motion analysis with targeted vibratory feedback, on upper-limb task performance early poststroke (<4 weeks). The study design was a two-sequence, two-period, randomized, crossover trial (NCT01967290) in 44 patients with upper-limb motor deficit (non-plegic) after medial cerebral artery ischemia. Participants were randomly assigned to receive either the experimental session (repetitive motor task under vibratory feedback and 3D motor characterization) or the active comparator (3D motor characterization only). The primary outcome was the number of correct movements per minute on a hand-to-mouth task measured independently. Vibratory feedback was able to modulate motor training, increasing the number of correct movements by an average of 7.2/min (95%CI [4.9;9.4]; P < 0.001) and reducing the probability of performing an error from 1:3 to 1:9. This strategy may improve the efficacy of training on motor re-learning processes after stroke, and its clinical relevance deserves further study in longer duration trials.

The potential of motion quantification systems in the automatic evaluation of motor function after stroke.

The assessment of motor performance is of major importance for correct decision making in neurorehabilitation, especially early after stroke (1). The need for more reliable and valid tools of motor assessment is common to both clinical and research settings. In addition, everyday clinical practice is usually disturbed by scarcity of specialized human resources, which limits the time dedicated to motor assessment and the number of possible motor tests performed. In this context, a wearable system capable of automatic assessment of motor function is of increased importance. It could allow clinicians to easily document motor performance and would represent a significant upgrade in the management of future rehabilitation plans and clinical trials (2). To achieve this goal, we developed a portable motion capture system based on magnetic, angular rate, and gravity sensors to acquire all the relevant threedimensional kinematics of upper limb movements (3). These data were then computed through an automatic decision tree classifier, whose features were inferred from the Functional Ability Score (FAS) of the Wolf Motor Function Test. Features comprised the analysis of synergic movements with the shoulder, smoothness, and motor executions out of the plane of action. Five stroke patients were enrolled and tested on both sides in five selected tasks. The system was compared against a trained clinician, operating simultaneously and blinded. Results showed, in terms of performance time, a mean difference between the system and the clinician of 0·17 s (standard deviation = 0·14 s) for all trials performed (3). The systematic delay of the clinician’ assessments were probably due to human error, when indicating task conclusion time. For FAS evaluation, the system and the clinician showed agreement in four out of five patients for two motor tasks evaluated (3). These results represent an important step toward a system capable of a precise and independent motor evaluation after stroke. Virgílio F. Bento, Vítor T. Cruz*, David D. Ribeiro, Catarina Branco, and Paula Coutinho

Home-based Rehabilitation With A Novel Digital Biofeedback System versus Conventional In-person Rehabilitation after Total Knee Replacement: a feasibility study

In-person home-based rehabilitation and telerehabilitation can be as effective as clinic-based rehabilitation after total knee arthroplasty (TKA), but require heavy logistics and are highly dependent on human supervision. New technologies that allow independent home-based rehabilitation without constant human supervision may help solve this problem. This was a single-center, feasibility study comparing a digital biofeedback system that meets these needs against conventional in-person home-based rehabilitation after TKA over an 8-week program. Primary outcome was the change in the Timed Up and Go score between the end of the program and baseline. Fifty-nine patients completed the study (30 experimental group; 29 conventional rehabilitation). The study demonstrated a superiority of the experimental group for all outcomes. Adverse events were similar in both groups. This is the first study to demonstrate that a digital rehabilitation solution can achieve better outcomes than conventional in-person rehabilitation, while less demanding in terms of human resources.