Telerehabilitation in older adults using information and communication technologies (ICTs) provides therapy, which is potentially equally effective as traditional rehabilitation, yet more accessible. ...This study aimed to analyze the needs and requirements of older adults (OA) and healthcare-professionals (HP) toward ICTs and telerehabilitation in general as well as toward a specific novel exergame-based telerehabilitation system (COCARE system, Dividat).
The COCARE telerehabilitation system enables individual training based on exergames, as well as an assessment system and a digital centralized case management. Six focus groups with in total 34 participants were conducted. A mixed-methods approach was used comprising questionnaires and semi-structured interviews.
Both OA and HP would engage to an exergame-based telerehabilitation program. Major motivating factors are the relevance of such a training for health and the entertainment component of exergames. Main requirements are simplification of the system, variety, a personalized training, a constantly available contact person, and comprehensive instructions for use. Besides, HP praised the system's motivational effect, but remained concerned about risk of falls and social isolation.
ICTs for telerehabilitation are accepted by OA and HP but should be adapted hardware- and software-wise to address OA' age-stemming vulnerabilities (e.g., risk of falls) and low ICT literacy.
The cardinal motor symptoms of Parkinson's disease (PD) have been widely investigated with particular reference to abnormalities of steady-state walking. The great majority of studies, however are ...related to severe forms of PD patients (phases of Hoehn and Yahr scale), where locomotor abnormalities are clearly manifested. Goal of the present study was to quantitatively describe locomotor symptoms in subjects with mild PD. Accordingly, a multitask protocol involving instrumental analysis of steady-state linear walking, initiation of gait, and turning while walking was applied to a group of patients with idiopathic PD in their early clinical stage (phases 1 and 2 of Hoehn and Yahr scale), as well as in age-matched elderly controls. Kinematic, kinetic, and myoelectric measures were obtained by optoelectronic motion analysis, force platform, and telemetric electromyography. Results in PD patients showed a tendency to bradykinetic gait, with reduction of walking speed and cadence. Impairments of gait initiation consisted in reduction of the backward shift of the center of pressure (CoP) and prolongation of the stepping phase. Alterations of the turning task were more consistent and included delayed reorientation of the head toward the new direction, altered head-upper trunk rotational strategy, and adoption of a greater number of steps to complete the turning. It is concluded that patients in the early stage of PD reveal mild alterations of steady-state linear walking and more significant anomalies in the transitional conditions, especially during changes in the travel direction. Quantitative analysis of nonstationary locomotor tasks might be a potentially useful starting point for further studies on the pathophysiology of PD.
Telerehabilitation has gained significance as a tool to deliver and supervise therapy and training as effective as traditional rehabilitation methods yet more accessible and affordable. An ...exergame-based telerehabilitation system has recently been developed within the scope of the international Continuum-of-Care (COCARE) project. The system comprises training devices for use in clinics (Dividat Senso) and at home (Dividat Senso Flex), an assessment system, and a rehabilitation cockpit, and its focus lies on home-based motor-cognitive training, which is remotely managed by health care professionals (HPs).
This study aims to analyze the usability, acceptance, and enjoyment of the COCARE system from the perspective of primary (older adults OAs) and secondary (HPs) end users.
At 3 trial sites (located in Switzerland, Italy, and Cyprus), participants engaged in a single-session trial of the COCARE system, including testing of exergames and assessments. Mixed methods encompassing qualitative approaches (eg, think aloud) and quantitative measures (eg, Exergame Enjoyment Questionnaire EEQ, System Usability Scale SUS, and Unified Theory of Acceptance and Use of Technology UTAUT questionnaire) were used to analyze participants' perceptions of the system and identify potential barriers to its implementation in a home setting. In addition, the associations of performance during gameplay and assessments, demographics, and training motivation (Behavioral Regulation in Exercise Questionnaire-3 BREQ-3) with usability, acceptance, and enjoyment were explored.
A total of 45 OAs and 15 HPs participated in this study. The COCARE system achieved good acceptance ratings (OAs: 83%, range 36%-100% and HPs: 81%, range 63.8%-93.3% of the maximum score), and OAs indicated high enjoyment (mean 73.3, SD 12.7 out of 100 points in the EEQ) during the exergame session. The system's usability, assessed with the SUS, received scores of 68.1 (SD 18.8; OAs) and 70.7 (SD 12.3; HPs) out of 100 points, with substantial differences observed between the trial sites. Several requirements for improvement were identified. Commonly mentioned barriers to adoption included the movement-recognition sensitivity of the Senso Flex, its limited markings, and difficulties in understanding certain instructions for assessments and games. Performance in games and assessments showed the highest significant correlations with the SUS (Spearman ρ=0.35, P=.02 to ρ=0.52, P<.001). The BREQ-3 had significant correlations with all usability measures, thereby even large significant correlations with enjoyment (Spearman ρ=0.58; P<.001). Age had moderately significant correlations with the SUS (Spearman ρ=-0.35; P=.02) and the UTAUT total score (ρ=-0.35; P=.02) but no significant correlation with the EEQ. Concerning sex and years of education, no significant correlations were found.
The study's findings will inform the further development of the COCARE system toward a user-friendly and widely accepted version, enhancing cognitive and physical functions in OAs. Future randomized controlled trials should evaluate the system's feasibility and effectiveness.
Background
Exergame-based motor-cognitive training in older adults has been associated with improvements in physical, cognitive, and psychological functioning. The novel Cocare system (Dividat GmbH), ...developed through a user-centered design process, allows motor-cognitive training in a telerehabilitation setting. It includes (1) a stationary stepping platform for supervised exergame training (Dividat Senso; Dividat GmbH), (2) a home-based version (Dividat Senso Flex, which is a rollable pressure-sensitive mat; Dividat GmbH), (3) an assessment system (including motor-cognitive tests), and (4) a rehabilitation cockpit for remote training supervision and management.
Objective
The aim of this study is to test the feasibility and effectiveness of this novel training system.
Methods
A total of 180 older adults from Switzerland, Italy, and Cyprus aged ≥60 years with a prescription for rehabilitation are randomly allocated to an intervention group or a control group. Both groups continue with their usual care, whereas participants in the intervention group additionally perform a 2-week supervised exergame training program at rehabilitation centers, followed by a 10-week home training program under remote supervision. The assessment system is used to indicate the start level of each participant, and, in both intervention periods, standardized progression rules are applied. The measures of feasibility include adherence, attrition, exergame enjoyment, willingness to perform such a training program, and the number and types of help requests. Effectiveness is assessed in terms of cognitive and physical functioning, balance confidence, and quality of life.
Results
Data collection started in February 2023 and is ongoing. Final measurements are expected to be performed in January 2024.
Conclusions
Owing to the user-centered design approach, the Cocare system is expected to be user-friendly and offers several novel features to cover the whole continuum of care. This pragmatic trial will provide valuable information regarding final necessary adaptations and subsequent implementation efforts.
Trial Registration
ClinicalTrials.gov NCT05751551; https://www.clinicaltrials.gov/study/NCT05751551
International Registered Report Identifier (IRRID)
DERR1-10.2196/49377
Parkinson's disease impacts health-related quality of life (HRQoL), however no studies inquired on predictors of HRQoL changes after rehabilitation. This study assessed the relationship between ...mobility domain of HRQoL measured by Parkinson's Disease Questionnaires-39 (PDQ-39) and clinical-demographic characteristics and developed a model predicting changes after rehabilitation.
Subjects with Parkinson's disease underwent rehabilitation treatment and completed the following predictors: 10-m walking test (10MWT), Timed Up and Go (TUG), Berg Balance scale (BBS), Activities-specific Balance Confidence scales (ABC), Freezing of Gait (FOGQ) and PDQ-39. Two general linear models were calculated to predict the relationship between HRQoL at baseline and to predict HRQoL changes after rehabilitation.
Forty-two subjects (age 74.9 ± 7.3 years, Hoehn&Yahr 2.8 ± 0.6) completed the baseline evaluation. The first model (multiple R
= 0.59, F = 5.86,
< 0.001) showed that ABC (B = - 0.51, CI = - 0.86 to 0.15, R
= 0.41,
= 0.005) and FOGQ (B = 2.38, CI = 1.03 to 3.73, R
= 0.07,
= 0.001) were statistically significant predictors of mobility aspect of HRQoL at baseline. Thirty seven subjects completed the rehabilitation sessions, data were entered in the second model (multiple R
= 0.40, F = 4.24,
< 0.004) showing that gender (B = - 5.12, CI = - 9.86 to - 0.39, R
= 0.23,
= 0.034), Hoehn&Yahr (B = 10.93, CI = + 3.27 to + 18.61, R
= 0.22,
= 0.006) and PDQ-39 mobility at baseline (B = - 0.38, CI = - 0.63 to - 0.14, R
= 0.55,
= 0.002) were statistically significant predictors of changes of the mobility aspect of HRQoL.
Balance confidence and Freezing of Gait are associated with the mobility aspect of HRQoL. Changes in mobility domain of HRQoL (as assessed by PDQ-39) are likely to be greater in males, in people at higher stages of the disease and in people with more severe limitation in mobility domain of HRQoL (as assessed by PDQ-39) before rehabilitation. Results might be different when considering different outcomes or different measures for the same outcome (performance mobility test instead of self-report questionnaires). Further investigations are needed to better understand other components of HRQoL in addition to mobility.
NCT02713971 registered March 8, 2016.
A 48-year-old woman with multiple sclerosis (MS), treated with natalizumab for more than one year without clinical and magnetic resonance imaging (MRI) signs of disease activity, was diagnosed with ...definite progressive multifocal leukoencephalopathy (PML). She presented with subacute motor deficit of the right upper limb (UL), followed by involvement of the homolateral leg and urinary urgency. The patient was treated with steroids and plasma exchange. On follow-up MRI scans, the PML lesion remained stable and no MS rebounds were observed, but the patient complained of a progressive worsening of the right UL motor impairment, becoming dependent in most activities of daily living. A cycle of multidisciplinary rehabilitation (MDR) was then started, including daily sessions of UL robot therapy and occupational therapy. Functional MRI (fMRI) was acquired before and at the end of the MDR cycle using a motor task which consisted of 2 runs: in one run the patient was asked to observe while the second one consisted of hand grasping movements. At the end of the rehabilitation period, both the velocity and the smoothness of arm trajectories during robot-based reaching movements were significantly improved. After MDR, compared with baseline, fMRI showed significantly increased functional activation within the sensory-motor network in the active, motor task, while no significant differences were found in the observational task. MDR in MS, including robot-assisted UL training, seems to be clinically efficacious and to have a significant impact on brain functional reorganization on a short-term, even in the presence of superimposed tissue damage provoked by PML.
The effects of subthalamic nucleus (STN) stimulation on the spatio-temporal organization of locomotor commands directed to lower limb muscles were studied in subjects with idiopathic Parkinson's ...Disease (PD) by recording the EMG activity produced during steady-state walking in representative thigh (rectus femoris, RF, and semimembranosus, SM) and leg (gastrocnemius medialis, GAM, and tibialis anterior, TA) muscles, under four experimental conditions: basal stimulation off, unilateral (right and left) stimulation on, and bilateral stimulation on. Locomotor profiles of all of the muscles tested were found to be substantially affected by STN stimulation, either in terms of restoration/enhancement of the main activity bursts or normalization of recruitment timing thereof. Responses showed relatively higher statistical significance in the distal groups (GAM and TA) and, within them, for the EMG components called into action over the ground-contact (ankle dorsiflexors) and midstance (ankle plantarflexors) phases of the stride cycle. In line with data obtained from clinical rating, unilateral stimulation produced less consistent EMG changes compared with bilateral stimulation. However, at variance with clinical effects, which prevailed on the side of the body contralateral to stimulation, EMG responses to unilateral stimulation were usually symmetrical. Results indicate that the impact of STN stimulation on locomotor activation of lower limb muscles in PD is characterized by: 1) substantial effects exhibiting differential topographical (distal versus proximal) and stride-phase (stance versus swing) consistency and 2) absence of the lateralized actions typically observed for the clinical signs of the disease. Interaction with the activity of functionally different executive systems might account for the observed pattern of responsiveness.
Stair ascent is a challenging daily-life activity highly related to independence. This task is usually assessed with clinical scales suffering from partial subjectivity and limited detail in ...evaluating different task aspects. In this paper, we instrumented the assessment of stair ascent in people with multiple sclerosis (MS), stroke (ST), and Parkinson's disease (PD) to analyze the validity of the proposed quantitative indexes and characterize subjects' performances. Participants climbed 10 steps wearing a magneto-inertial sensor magneto-inertial measurement unit (MIMU) at sternum level. Gait pattern features (step frequency, symmetry, regularity, and harmonic ratios), and upper trunk sway were computed from MIMU signals. Clinical modified dynamic gait index (mDGI) and mDGI-Item 8 "Up stairs" were administered. Significant correlations with clinical scores were found for gait pattern features (r s ≥ 0.536) and trunk pitch sway (r s ≤ -0.367) demonstrating their validity. Instrumental indexes showed alterations in the three pathological groups compared to healthy subjects and significant differences, not clinically detected, among MS, ST, and PD. MS showed the worst performance, with alterations of all gait pattern aspects and larger trunk pitch sway. ST showed worsening in gait pattern features but not in trunk motion. PD showed fewer alterations consisting in reduced step frequency and trunk yaw sway. These results suggest that the use of an MIMU provided valid objective indexes revealing between-group differences in stair ascent not detected by clinical scales. Importantly, the indexes include uppertrunk measures, usually not present in clinical tests, and provide relevant hints for tailored rehabilitation.
In this pilot study, we compared two protocols for robot-based rehabilitation of upper limb in multiple sclerosis (MS): a protocol involving reaching tasks (RT) requiring arm transport only and a ...protocol requiring both objects' reaching and manipulation (RMT). Twenty-two MS subjects were assigned to RT or RMT group. Both protocols consisted of eight sessions. During RT training, subjects moved the handle of a planar robotic manipulandum toward circular targets displayed on a screen. RMT protocol required patients to reach and manipulate real objects, by moving the robotic arm equipped with a handle which left the hand free for distal tasks. In both trainings, the robot generated resistive and perturbing forces. Subjects were evaluated with clinical and instrumental tests. The results confirmed that MS patients maintained the ability to adapt to the robot-generated forces and that the rate of motor learning increased across sessions. Robot-therapy significantly reduced arm tremor and improved arm kinematics and functional ability. Compared to RT, RMT protocol induced a significantly larger improvement in movements involving grasp (improvement in Grasp ARAT sub-score: RMT 77.4%, RT 29.5%, p=0.035) but not precision grip. Future studies are needed to evaluate if longer trainings and the use of robotic handles would significantly improve also fine manipulation.
Step climbing is a demanding task required for personal autonomy in daily living. Anticipatory Postural Adjustments (APAs) preceding gait initiation have been widely investigated revealing to be ...hypometric in Parkinson's disease (PD) with consequences in movement initiation. However, only few studies focused on APAs prior to step climbing. In this work, a novel method based on wearable inertial sensors for the analysis of APAs preceding gait initiation and step climbing was developed to further understand dynamic balance control. Validity and sensitivity of the method have been evaluated.
Eleven PD and 20 healthy subjects were asked to perform two transitional tasks from quiet standing to level walking, and to step climbing respectively. All the participants wore two inertial sensors, placed on the trunk (L2-L4) and laterally on the shank. In addition, a validation group composed of healthy subjects and 5 PD patients performed the tasks on two force platforms. Correlation between parameters from wearable sensors and force platforms was evaluated. Temporal parameters and trunk acceleration from PD and healthy subjects were analyzed.
Significant correlation was found for the validation group between temporal parameters extracted from wearable sensors and force platforms and between medio-lateral component of trunk acceleration and correspondent COP displacement. These results support the validity of the method for evaluating APAs prior to both gait initiation and step climbing. Comparison between PD subjects and a subgroup of healthy controls confirms a reduction in PD of the medio-lateral acceleration of the trunk during the imbalance phase in the gait initiation task and shows similar trends during the imbalance and unloading phase of the step climbing task. Interestingly, PD subjects presented difficulties in adapting the medio-lateral amplitude of the imbalance phase to the specific task needs.
Validity of the method was confirmed by the significant correlation between parameters extracted from wearable sensors and force platforms. Sensitivity was proved by the capability to discriminate PD subjects from healthy controls. Our findings support the applicability of the method to subjects of different age. This method could be a possible valid instrument for a better understanding of feed-forward anticipatory strategies.
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