Missing Data Statistics Provide Causal Insights into Data Loss in Diabetes Health Monitoring by Wearable Sensors.

BACKGROUND: Data loss in wearable sensors is an inevitable problem that leads to misrepresentation during diabetes health monitoring. We systematically investigated missing wearable sensors data to get causal insight into the mechanisms leading to missing data. METHODS: Two-week-long data from a continuous glucose monitor and a Fitbit activity tracker recording heart rate (HR) and step count in free-living patients with type 2 diabetes mellitus were used. The gap size distribution was fitted with a Planck distribution to test for missing not at random (MNAR) and a difference between distributions was tested with a Chi-squared test. Significant missing data dispersion over time was tested with the Kruskal-Wallis test and Dunn post hoc analysis. RESULTS: Data from 77 subjects resulted in 73 cleaned glucose, 70 HR and 68 step count recordings. The glucose gap sizes followed a Planck distribution. HR and step count gap frequency differed significantly (p < 0.001), and the missing data were therefore MNAR. In glucose, more missing data were found in the night (23:00-01:00), and in step count, more at measurement days 6 and 7 (p < 0.001). In both cases, missing data were caused by insufficient frequency of data synchronization. CONCLUSIONS: Our novel approach of investigating missing data statistics revealed the mechanisms for missing data in Fitbit and CGM data.

Early Warning Scores to Support Continuous Wireless Vital Sign Monitoring for Complication Prediction in Patients on Surgical Wards: Retrospective Observational Study.

BACKGROUND: Wireless vital sign sensors are increasingly being used to monitor patients on surgical wards. Although early warning scores (EWSs) are the current standard for the identification of patient deterioration in a ward setting, their usefulness for continuous monitoring is unknown. OBJECTIVE: This study aimed to explore the usability and predictive value of high-rate EWSs obtained from continuous vital sign recordings for early identification of postoperative complications and compares the performance of a sensor-based EWS alarm system with manual intermittent EWS measurements and threshold alarms applied to individual vital sign recordings (single-parameter alarms). METHODS: Continuous vital sign measurements (heart rate, respiratory rate, blood oxygen saturation, and axillary temperature) collected with wireless sensors in patients on surgical wards were used for retrospective simulation of EWSs (sensor EWSs) for different time windows (1-240 min), adopting criteria similar to EWSs based on manual vital signs measurements (nurse EWSs). Hourly sensor EWS measurements were compared between patients with (event group: 14/46, 30%) and without (control group: 32/46, 70%) postoperative complications. In addition, alarms were simulated for the sensor EWSs using a range of alarm thresholds (1-9) and compared with alarms based on nurse EWSs and single-parameter alarms. Alarm performance was evaluated using the sensitivity to predict complications within 24 hours, daily alarm rate, and false discovery rate (FDR). RESULTS: The hourly sensor EWSs of the event group (median 3.4, IQR 3.1-4.1) was significantly higher (P<.004) compared with the control group (median 2.8, IQR 2.4-3.2). The alarm sensitivity of the hourly sensor EWSs was the highest (80%-67%) for thresholds of 3 to 5, which was associated with alarm rates of 2 (FDR=85%) to 1.2 (FDR=83%) alarms per patient per day respectively. The sensitivity of sensor EWS-based alarms was higher than that of nurse EWS-based alarms (maximum=40%) but lower than that of single-parameter alarms (87%) for all thresholds. In contrast, the (false) alarm rates of sensor EWS-based alarms were higher than that of nurse EWS-based alarms (maximum=0.6 alarm/patient/d; FDR=80%) but lower than that of single-parameter alarms (2 alarms/patient/d; FDR=84%) for most thresholds. Alarm rates for sensor EWSs increased for shorter time windows, reaching 70 alarms per patient per day when calculated every minute. CONCLUSIONS: EWSs obtained using wireless vital sign sensors may contribute to the early recognition of postoperative complications in a ward setting, with higher alarm sensitivity compared with manual EWS measurements. Although hourly sensor EWSs provide fewer alarms compared with single-parameter alarms, high false alarm rates can be expected when calculated over shorter time spans. Further studies are recommended to optimize care escalation criteria for continuous monitoring of vital signs in a ward setting and to evaluate the effects on patient outcomes.

Missing data imputation techniques for wireless continuous vital signs monitoring.

Wireless vital signs sensors are increasingly used for remote patient monitoring, but data analysis is often challenged by missing data periods. This study explored the performance of various imputation techniques for continuous vital signs measurements. Wireless vital signs measurements (heart rate, respiratory rate, blood oxygen saturation, axillary temperature) from surgical ward patients were used for repeated random simulation of missing data periods (gaps) of 5-60 min in two-hour windows. Gaps were imputed using linear interpolation, spline interpolation, last observation- and mean carried forwards technique, and cluster-based prognosis. Imputation performance was evaluated using the mean absolute error (MAE) between original and imputed gap samples. Besides, effects on signal features (window's slope, mean) and early warning scores (EWS) were explored. Gaps were simulated in 1743 data windows, obtained from 52 patients. Although MAE ranges overlapped, median MAE was structurally lowest for linear interpolation (heart rate: 0.9-2.6 beats/min, respiratory rate: 0.8-1.8 breaths/min, temperature: 0.04-0.17 °C, oxygen saturation: 0.3-0.7% for 5-60 min gaps) but up to twice as high for other techniques. Three techniques resulted in larger ranges of signal feature bias compared to no imputation. Imputation led to EWS misclassification in 1-8% of all simulations. Imputation error ranges vary between imputation techniques and increase with gap length. Imputation may result in larger signal feature bias compared to performing no imputation, and can affect patient risk assessment as illustrated by the EWS. Accordingly, careful implementation and selection of imputation techniques is warranted.

Determining the Reliable Measurement Period for Preoperative Baseline Values With Telemonitoring Before Major Abdominal Surgery: Pilot Cohort Study.

BACKGROUND: Preoperative telemonitoring of vital signs, physical activity, and well-being might be able to optimize prehabilitation of the patient's physical and mental condition prior to surgery, support setting alarms during in-hospital monitoring, and allow personalization of the postoperative recovery process. OBJECTIVE: The primary aim of this study was to evaluate when and how long patients awaiting major abdominal surgery should be monitored to get reliable preoperative individual baseline values of heart rate (HR), daily step count, and patient-reported outcome measures (PROMs). The secondary aim was to describe the perioperative course of these measurements at home. METHODS: In this observational single-center cohort study, patients used a wearable sensor during waking hours and reported PROMs (pain, anxiety, fatigue, nausea) on a tablet twice a day. Intraclass correlation coefficients (ICCs) were used to evaluate the reliability of mean values on 2 specific preoperative days (the first day of telemonitoring and the day before hospital admission) and randomly selected preoperative periods compared to individual reference values. Mean values of HR, step count, and PROMs per day were visualized in a boxplot from 14 days before hospital admission until 30 days after surgery. RESULTS: A total of 16 patients were included in the data analyses. The ICCs of mean values on the first day of telemonitoring were 0.91 for HR, 0.71 for steps, and at least 0.86 for PROMs. The day before hospital admission showed reliability coefficients of 0.76 for HR, 0.71 for steps, and 0.92-0.99 for PROMs. ICC values of randomly selected measurement periods increased over the continuous period of time from 0.68 to 0.99 for HR and daily step counts. A lower bound of the 95% CI of at least 0.75 was determined after 3 days of measurements. The ICCs of randomly selected PROM measurements were 0.89-0.94. Visualization of mean values per day mainly showed variable preoperative daily step counts (median 2409, IQR 1735-4661 steps/day) and lower postoperative daily step counts (median 884, IQR 474-1605 steps/day). In addition, pain was visually reduced until 30 days after surgery at home. CONCLUSIONS: In this prospective pilot study, for patients awaiting major abdominal surgery, baseline values for HR and daily step count could be measured reliably by a wearable sensor worn for at least 3 consecutive days and PROMs during any preoperative day. No clear conclusions were drawn from the description of the perioperative course by showing mean values of HR, daily step count, and PROM values over time in the home situation.

Feasibility and patient's experiences of perioperative telemonitoring in major abdominal surgery: an observational pilot study.

BACKGROUND: Telemonitoring during the perioperative trajectory may improve patient outcomes and self-management. The aim of this study is to assess the feasibility of and patient's experiences with telemonitoring before and after major abdominal surgery to inform future study design. METHODS: Patients planned for elective major abdominal surgery wore a sensor and answered well-being questions on a tablet daily for at least 2 weeks preoperatively up to 30-days postoperatively. Feasibility was assessed by participation and completion rate, compliance per day, weekly satisfaction scores, and reasons for nonscheduled contact. RESULTS: Twenty-three patients were included (participation rate of 54.5%) with a completion rate of 69.6%. Median compliance with the wearable sensor and well-being questions was respectively: 94.7% and 83.3% preoperatively at home; 100% and 66.7% postoperatively in-hospital; and 95.4% and 85.8% postoperatively at home. Median weekly satisfaction scores for both wearing the sensor and well-being questions were 5 (IQR, 4-5). Contact moments were related to absence of sensor data and technological issues (76.0%) or patient discomfort and insecurity (24.0%). CONCLUSIONS: In this study, telemonitoring showed high satisfaction and compliance during the perioperative trajectory. Future trial design regarding the effectiveness of telemonitoring requires embedding in clinical practice and support for patients, relatives, and healthcare personnel.

Game not over: Explaining older adults' use and intention to continue using a gamified eHealth service.

BACKGROUND: Gamification within eHealth services can increase eHealth adoption. However, little is known about factors affecting adoption of gamified eHealth among older adults. In this study, we sought to explain the (continued) use of a gamified eHealth service among older adults (55+). METHODS: Participants used a gamified eHealth service, focusing on falls prevention, for 4 weeks and completed a post-test questionnaire based on the Technology Acceptance Model. We used Partial Least Squares Structural Equation Modeling to analyse our data. RESULTS: Seventy-two older adults participated with a mean age of 65.1 years (SD = 7.0). Our results show that first, perceived ease of use affected use of the service (use duration: ß = 0.303, R2 = 0.130, and use frequency: ß = 0.304, R2 = 0.107). Second, perceived usefulness affected the intention to continue using the service (ß = 0.754, R2 = 0.640). Third, use of the service did not predict the intention to continue using it. Furthermore, enjoyment affected perceived usefulness (ß = 0.783, R2 = 0.563) and aesthetics affected perceived ease of use (ß = 0.634, R2 = 0.652). CONCLUSIONS: This study refutes the expected relation between use and intention to continue use a gamified eHealth service. Additionally, we learned that using theoretical approaches focusing on technology acceptance, are not suitable for explaining (continued) use of gamified eHealth services.

Evaluation of a virtual coaching system eHealth intervention: A mixed methods observational cohort study in the Netherlands.

BACKGROUND: With the rise in human life expectancy, the prevalence of chronic disease has increased significantly. Adopting a healthy lifestyle can decrease the risk of chronic disease. Virtual coaching systems can help older adults adopt a healthy lifestyle.AimThe primary objective of this study was to assess the use, user experience and potential health effects of a conversational agent-based eHealth platform (Council of Coaches) implemented in a real-world setting among older adults. METHODS: An observational cohort study was conducted with older adults aged 55 years or older in the Netherlands. Participants were enrolled for 5-9 weeks during which they had access to Council of Coaches. They completed three questionnaires: pre-test, post-test, and at follow-up. After five weeks, an interview was conducted, and participants chose whether they wanted to use the eHealth intervention for another four weeks during the facultative phase. RESULTS: The study population consisted of 51 older adults (70.6% female) with a mean age of 65.3 years (SD = 7.4). Of these, 94.1% started interacting with Council of Coaches, and most participants interacted once per week. During the facultative phase, 21 participants were still interacting with Council of Coaches. Minimal clinical important differences in quality of life were found among the study population after interacting with Council of Coaches. CONCLUSION: Our results demonstrate that eHealth interventions with virtual coaching can be used among older adults. This may increase quality of life for older adults, and decrease their healthcare needs. Future research into such eHealth interventions should take into account the inclusion of sufficient personalised content and the use of a mixed methods study for assessing the eHealth intervention.

Continuous Monitoring of Vital Signs With Wearable Sensors During Daily Life Activities: Validation Study.

BACKGROUND: Continuous telemonitoring of vital signs in a clinical or home setting may lead to improved knowledge of patients' baseline vital signs and earlier detection of patient deterioration, and it may also facilitate the migration of care toward home. Little is known about the performance of available wearable sensors, especially during daily life activities, although accurate technology is critical for clinical decision-making. OBJECTIVE: The aim of this study is to assess the data availability, accuracy, and concurrent validity of vital sign data measured with wearable sensors in volunteers during various daily life activities in a simulated free-living environment. METHODS: Volunteers were equipped with 4 wearable sensors (Everion placed on the left and right arms, VitalPatch, and Fitbit Charge 3) and 2 reference devices (Oxycon Mobile and iButton) to obtain continuous measurements of heart rate (HR), respiratory rate (RR), oxygen saturation (SpO2), and temperature. Participants performed standardized activities, including resting, walking, metronome breathing, chores, stationary cycling, and recovery afterward. Data availability was measured as the percentage of missing data. Accuracy was evaluated by the median absolute percentage error (MAPE) and concurrent validity using the Bland-Altman plot with mean difference and 95% limits of agreement (LoA). RESULTS: A total of 20 volunteers (median age 64 years, range 20-74 years) were included. Data availability was high for all vital signs measured by VitalPatch and for HR and temperature measured by Everion. Data availability for HR was the lowest for Fitbit (4807/13,680, 35.14% missing data points). For SpO2 measured by Everion, median percentages of missing data of up to 100% were noted. The overall accuracy of HR was high for all wearable sensors, except during walking. For RR, an overall MAPE of 8.6% was noted for VitalPatch and that of 18.9% for Everion, with a higher MAPE noted during physical activity (up to 27.1%) for both sensors. The accuracy of temperature was high for VitalPatch (MAPE up to 1.7%), and it decreased for Everion (MAPE from 6.3% to 9%). Bland-Altman analyses showed small mean differences of VitalPatch for HR (0.1 beats/min [bpm]), RR (-0.1 breaths/min), and temperature (0.5 °C). Everion and Fitbit underestimated HR up to 5.3 (LoA of -39.0 to 28.3) bpm and 11.4 (LoA of -53.8 to 30.9) bpm, respectively. Everion had a small mean difference with large LoA (-10.8 to 10.4 breaths/min) for RR, underestimated SpO2 (>1%), and overestimated temperature up to 2.9 °C. CONCLUSIONS: Data availability, accuracy, and concurrent validity of the studied wearable sensors varied and differed according to activity. In this study, the accuracy of all sensors decreased with physical activity. Of the tested sensors, VitalPatch was found to be the most accurate and valid for vital signs monitoring.

Adaptive threshold-based alarm strategies for continuous vital signs monitoring.

Continuous vital signs monitoring in post-surgical ward patients may support early detection of clinical deterioration, but novel alarm approaches are required to ensure timely notification of abnormalities and prevent alarm-fatigue. The current study explored the performance of classical and various adaptive threshold-based alarm strategies to warn for vital sign abnormalities observed during development of an adverse event. A classical threshold-based alarm strategy used for continuous vital signs monitoring in surgical ward patients was evaluated retrospectively. Next, (combinations of) six methods to adapt alarm thresholds to personal or situational factors were simulated in the same dataset. Alarm performance was assessed using the overall alarm rate and sensitivity to detect adverse events. Using a wireless patch-based monitoring system, 3999 h of vital signs data was obtained in 39 patients. The clinically used classical alarm system produced 0.49 alarms/patient/day, and alarms were generated for 11 out of 18 observed adverse events. Each of the tested adaptive strategies either increased sensitivity to detect adverse events or reduced overall alarm rate. Combining specific strategies improved overall performance most and resulted in earlier presentation of alarms in case of adverse events. Strategies that adapt vital sign alarm thresholds to personal or situational factors may improve early detection of adverse events or reduce alarm rates as compared to classical alarm strategies. Accordingly, further investigation of the potential of adaptive alarms for continuous vital signs monitoring in ward patients is warranted.

Continuous monitoring of vital signs with the Everion biosensor on the surgical ward: a clinical validation study.

BACKGROUND: Wearable sensors enable continuous vital sign monitoring, although information about their performance on nursing wards is scarce. Vital signs measured by telemonitoring and nurse measurements on a surgical ward were compared to assess validity and reliability. METHODS: In a prospective observational study, surgical patients wore a wearable sensor (Everion, Biovotion AG, Zürich, Switzerland) that continuously measured heart rate (HR), respiratory rate (RR), oxygen saturation (SpO2), and temperature during their admittance on the ward. Validity was evaluated using repeated-measures correlation and reliability using Bland-Altman plots, mean difference, and 95% limits of agreement (LoA). RESULTS: Validity analyses of 19 patients (median age, 68; interquartile range, 62.5-72.5 years) showed a moderate relationship between telemonitoring and nurse measurements for HR (r = 0.53; 95% confidence interval, 0.44-0.61) and a poor relationship for RR, SpO2, and temperature. Reliability analyses showed that Everion measured HR close to nurse measurements (mean difference, 1 bpm; LoA, -16.7 to 18.7 bpm). Everion overestimated RR at higher values, whereas SpO2 and temperature were underestimated. CONCLUSIONS: A moderate relationship was determined between Everion and nurse measurements at a surgical ward in this study. Validity and reliability of telemonitoring should also be assessed with gold standard devices in future clinical trials.

Genetic Algorithm for Feature Selection in Lower Limb Pattern Recognition.

Choosing the right features is important to optimize lower limb pattern recognition, such as in prosthetic control. EMG signals are noisy in nature, which makes it more challenging to extract useful information. Many features are used in the literature, which raises the question which features are most suited for use in lower limb myoelectric control. Therefore, it is important to find combinations of best performing features. One way to achieve this is by using a genetic algorithm, a meta-heuristic capable of searching vast feature spaces. The goal of this research is to demonstrate the capabilities of a genetic algorithm and come up with a feature set that has a better performance than the state-of-the-art feature set. In this study, we collected a dataset containing ten able-bodied subjects who performed various gait-related activities while measuring EMG and kinematics. The genetic algorithm selected features based on the performance on the training partition of this dataset. The selected feature sets were evaluated on the remaining test set and on the online benchmark dataset ENABL3S, against a state-of-the-art feature set. The results show that a feature set based on the selected features of a genetic algorithm outperforms the state-of-the-art set. The overall error decreased up to 0.54% and the transitional error by 2.44%, which represent a relative decrease in overall errors up to 11.6% and transitional errors up to 14.1%, although these results were not significant. This study showed that a genetic algorithm is capable of searching a large feature space and that systematic feature selection shows promising results for lower limb myoelectric control.

Effectiveness of current perioperative telemonitoring on postoperative outcome in patients undergoing major abdominal surgery: A systematic review of controlled trials.

BACKGROUND: Perioperative telemonitoring of patients undergoing major surgery might lead to improved postoperative outcomes. The aim of this systematic review is to evaluate the effectiveness of current perioperative telemonitoring interventions on postoperative clinical, patient-reported, and financial outcome measures in patients undergoing major surgery. METHODS: For this systematic review, PubMed, CINAHL, and Embase databases were searched for eligible articles published between January 1, 2009 and March 15, 2021. Studies were eligible as they described: (P) patients aged 18 years or older who underwent major abdominal surgery, (I) perioperative telemonitoring as intervention, (C) a control group receiving usual care, (O) any type of postoperative clinical, patient-reported, or financial outcome measures, and (S) an interventional study design. RESULTS: The search identified 2958 articles of which 10 were eligible for analysis, describing nine controlled trials of 2438 patients. Perioperative telemonitoring comprised wearable biosensors (n = 3), websites (n = 3), e-mail (n = 1), and mobile applications (n = 2). Outcome measures were clinical (n = 8), patient-reported (n = 5), and financial (n = 2). Results show significant improvement of recovery time, stoma self-efficacy and pain in the early postoperative phase in patients receiving telemonitoring. Other outcome measures were not significantly different between the groups. CONCLUSION: Evidence for the effectiveness of perioperative telemonitoring in major surgery is scarce. There is a need for good quality studies with sufficient patients while ensuring that the quality and usability of the technology and the adoption in care processes are optimal.

Can the Childhood Physical Activity Questionnaire Be Used to Identify Physical Activity Levels in Children With Asthma?

Objective: Children with asthma who are physically active have a better quality of life, emphasizing the importance of activity monitoring and promotion in daily life. The validity of self-reported activity measurements has been questioned in pediatric populations. In this study, we aim to compare the Physical Activity Questionnaire for Children (PAQ-C) with objectively measured PA using accelerometry. Design: In this comparison study, the pooled dataset of two cross-sectional studies was used, which prospectively home-monitored PA using the alternative self-report PAQ-C questionnaire as well as with the criterion standard accelerometry (Actigraph wGT3X-BT and GT1M). Participants:Ninety children with pediatrician-diagnosed asthma participated in the study. Main Outcome Measures:Correlation coefficients were calculated to determine the relation between the PAQ-C and accelerometer data. The predictive value of the PAQ-C in differentiating between achieving and failing the recommended daily level of moderate-to-vigorous activity (MVPA) was evaluated with receiver operator characteristic (ROC) analysis. Results: The results showed weak to moderate correlations of the PAQ-C with the accelerometer data (r = 0.29-0.47). A PAQ-C cutoff of 3.09 showed the best performance on predicting whether the recommended level of MVPA was achieved. With this cutoff, 21 of the 39 children that did achieve their daily MVPA level (53.8% sensitivity) and 33 of the 46 children that did fail their daily MVPA level (71.7% specificity) were correctly classified. A PAQ-C score of 3.5 revealed a negative predictive value of 100% for assessing physical inactivity. Conclusion: This study revealed a weak relation between the PAQ-C and PA assessed with accelerometry. However, a PAQ-C score of 3.5 or higher might be used as a low-cost and easy-to-use PA screening tool for ruling out physical inactivity in a portion of the pediatric asthma population. Clinical Trial Registration: Netherlands Trial Register: Trial NL6087.

Acceptance and Potential Impact of the eWALL Platform for Health Monitoring and Promotion in Persons with a Chronic Disease or Age-Related Impairment.

Pervasive health technologies can increase the effectiveness of personal health monitoring and training, but more user studies are necessary to understand the interest for these technologies, and how they should be designed and implemented. In the present study, we evaluated eWALL, a user-centered pervasive health technology consisting of a platform that monitors users' physical and cognitive behavior, providing feedback and motivation via an easy-to-use, touch-based user interface. The eWALL was placed for one month in the home of 48 subjects with a chronic condition (chronic obstructive pulmonary disease-COPD or mild cognitive impairment-MCI) or with an age-related impairment. User acceptance, platform use, and potential clinical effects were evaluated using surveys, data logs, and clinical scales. Although some features of the platform need to be improved before reaching technical maturity and making a difference in patients' lives, the real-life evaluation of eWALL has shown how some features may influence patients' intention to use this promising technology. Furthermore, this study made it clear how the free use of different health apps is modulated by the real needs of the patient and by their usefulness in the context of the patient's clinical status.

Sensory Interactive Table (SIT)-Development of a Measurement Instrument to Support Healthy Eating in a Social Dining Setting.

This paper presents the Sensory Interactive Table (SIT): an instrumented, interactive dining table. Through the use of load cells and LEDs that are embedded in the table surface, SIT allows us to study: (1) the eating behaviors of people in a social setting, (2) the social interactions around the eating behaviors of people in a social setting, and (3) the continuous cycle of feedback through LEDs on people's eating behavior and their response to this feedback in real time, to ultimately create an effective dietary support system. This paper presents the hard- and software specifications of the system, and it shows the potential of the system to capture mass-related dimensions in real time and with high accuracy and spatial resolution.

Inconsistent descriptions of lumbar multifidus morphology: A scoping review.

BACKGROUND: Lumbar multifidus (LM) is regarded as the major stabilizing muscle of the spine. The effects of exercise therapy in low back pain (LBP) are attributed to this muscle. A current literature review is warranted, however, given the complexity of LM morphology and the inconsistency of anatomical descriptions in the literature. METHODS: Scoping review of studies on LM morphology including major anatomy atlases. All relevant studies were searched in PubMed (Medline) and EMBASE until June 2019. Anatomy atlases were retrieved from multiple university libraries and online. All studies and atlases were screened for the following LM parameters: location, imaging methods, spine levels, muscle trajectory, muscle thickness, cross-sectional area, and diameter. The quality of the studies and atlases was also assessed using a five-item evaluation system. RESULTS: In all, 303 studies and 19 anatomy atlases were included in this review. In most studies, LM morphology was determined by MRI, ultrasound imaging, or drawings - particularly for levels L4-S1. In 153 studies, LM is described as a superficial muscle only, in 72 studies as a deep muscle only, and in 35 studies as both superficial and deep. Anatomy atlases predominantly depict LM as a deep muscle covered by the erector spinae and thoracolumbar fascia. About 42% of the studies had high quality scores, with 39% having moderate scores and 19% having low scores. The quality of figures in anatomy atlases was ranked as high in one atlas, moderate in 15 atlases, and low in 3 atlases. DISCUSSION: Anatomical studies of LM exhibit inconsistent findings, describing its location as superficial (50%), deep (25%), or both (12%). This is in sharp contrast to anatomy atlases, which depict LM predominantly as deep muscle. Within the limitations of the self-developed quality-assessment tool, high-quality scores were identified in a majority of studies (42%), but in only one anatomy atlas. CONCLUSIONS: We identified a lack of standardization in the depiction and description of LM morphology. This could affect the precise understanding of its role in background and therapy in LBP patients. Standardization of research methodology on LM morphology is recommended. Anatomy atlases should be updated on LM morphology.

User Experience and Potential Health Effects of a Conversational Agent-Based Electronic Health Intervention: Protocol for an Observational Cohort Study.

BACKGROUND: While the average human life expectancy has increased remarkably, the length of life with chronic conditions has also increased. To limit the occurrence of chronic conditions and comorbidities, it is important to adopt a healthy lifestyle. Within the European project "Council of Coaches," a personalized coaching platform was developed that supports developing and maintaining a healthy lifestyle. OBJECTIVE: The primary aim of this study is to assess the user experience with and the use and potential health effects of a fully working Council of Coaches system implemented in a real-world setting among the target population, specifically older adults or adults with type 2 diabetes mellitus or chronic pain. METHODS: An observational cohort study with a pretest-posttest design will be conducted. The study population will be a dynamic cohort consisting of older adults, aged ≥55 years, as well as adults aged ≥18 years with type 2 diabetes mellitus or chronic pain. Each participant will interact in a fully automated manner with Council of Coaches for 5 to 9 weeks. The primary outcomes are user experience, use of the program, and potential effects (health-related factors). Secondary outcomes include demographics, applicability of the virtual coaches, and user interaction with the virtual coaches. RESULTS: Recruitment started in December 2019 and is conducted through mass mailing, snowball sampling, and advertisements in newspapers and social media. This study is expected to conclude in August 2020. CONCLUSIONS: The results of this study will either confirm or reject the hypothesis that a group of virtual embodied conversational coaches can keep users engaged over several weeks of interaction and contribute to positive health outcomes. TRIAL REGISTRATION: The Netherlands Trial Register: NL7911; https://www.trialregister.nl/trial/7911. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/16641.

Pattern measures of sedentary behaviour in adults: A literature review.

OBJECTIVE: With sensors, we are increasingly able to assess sitting behaviour during the day. However, there is no consensus among researchers on the best outcome measures for representing the accumulation of sedentary time during the day. METHODS: We analysed the pattern measures of sedentary behaviour. Articles reporting patterns measures in adults, in which behaviour data was collected with a sensor were included. We discuss the strengths and weaknesses of the pattern measures of sedentary behaviour and provide recommendations for choosing objective measures of sedentary behaviour. RESULTS: Most studies report the number of sitting bouts during the day. Others focus on the number of breaks and/or periods of physical activity. Simple measures of sedentary behaviour were most popular. More complex pattern measures, such as the Gini index or the half-life bout duration, that capture the distribution of lengths of sitting periods in a single number, were reported sparsely. The sedentary patterns that were reported in the various studies were difficult to compare, due to the differences among measurement devices, data analysis protocols and a lack of basic outcome parameters such as total wear-time and total sedentary time. CONCLUSIONS: Objective sedentary measures can be grouped into simple and complex measures of sedentary time accumulation during the day. These measures serve different goals. The answer to the question as to which measures are most suitable to report, is strongly dependent on the research question. We have shown that the reported measures were dependent on (a) the sensing method, (b) the classification method, (c) the experimental and data cleaning protocol and (d) the applied definitions of bouts and breaks. We recommend that studies should always report total wear-time, total sedentary time, number of bouts and at least one measure describing the diversity of bout lengths in the sedentary behaviour such as the half-life bout duration. Additionally, we recommend reporting the measurement conditions and data processing steps.

Telemedicine in patients with peripheral arterial disease: is it worth the effort?

Introduction: For patients with peripheral arterial disease (PAD), the various components of telemedicine, such as telemonitoring, telecoaching, and teleconsultation, could be valuable in daily management. The objective of this review was to give an overview of the current use of telemedicine interventions in PAD. Areas covered: A literature search was performed for studies that evaluated patients with PAD of the aorto-pedal trajectory, who were monitored by telemedicine and acted upon accordingly. The primary outcome was health-related outcomes. The studies that were found focused mainly on wearable activity monitoring and telecoaching in PAD (n = 4) or wound monitoring after vascular surgery (n = 2). Main results indicate that telemedicine interventions are able to detect (post-operative) complications early, improve functional capacity and claudication onset time, and improve PAD patients' quality of life. Expert opinion: The use of telemedicine in PAD patients is still an under-explored area. Studies investigating the use of telemedicine in PAD are very limited and show varying results. Owing to its high potential in improving physical ability, lifestyle coaching, and timely detection of deterioration, future research should focus on proper implementation of telemedicine in PAD patients, including clinical and feasibility outcomes, effect on workload of nurses, and cost-efficiency.

The effect of ankle-foot orthoses on fall/near fall incidence in patients with (sub-)acute stroke: A randomized controlled trial.

Falls are commonly reported post-stroke. Ankle-foot orthoses (AFOs) are often provided to improve safety and walking, but the effect of their use in the reduction of falls after stroke is unknown. A randomized controlled trial (RCT) on the effects of AFO-provision after stroke was performed. Effects on clinical scales, 3D-gait kinematics and muscle-activity were previously reported. This paper aims to study the effects of AFO-provision on occurrence and circumstances of falls/near falls. The RCT included unilateral hemiparetic stroke patients. AFOs were provided either early (study week 1) or delayed (study week 9). Both groups were compared in the first eight weeks of the study and diaries were used to register falls/near falls and their circumstances. Follow-up measurements were performed in week 9-52, in which both groups were provided with AFOs. Functional Ambulation Categories and Berg Balance Scale were assessed to determine walking independence and balance, respectively. Last known scores were noted in case of an incident. Thirty-three subjects were included (16 early, 17 delayed). In week 1-8, the early group, who were provided with AFOs, fell significantly more frequently compared with the delayed group, 11 versus 4 times, respectively (Incidence Rate Ratio = 2.9, p = 0.039). Out of the falls recorded in the early group, 63.6% occurred without wearing AFOs. Most of these falls occurred during transfers (36.4%) and standing (27.3%), and notably it were the subjects who did not have independent walking ability. No differences were found for near falls in week 1-8, or for falls/near falls in week 9-52. Six severe consequences (including fractures) were reported from a fall. To conclude, the subjects provided with AFOs early after stroke reported a higher number of falls, compared to the subjects that had not yet been provided with AFOs. However, in the subjects provided with AFOs, 63.6% of the falls occurred whilst without wearing the AFO. Furthermore, the majority of these incidents took place whilst subjects had no independent walking ability. This raises an interesting question of the importance of careful instructions to patients and their relatives, and the influence of potential cognitive impairments on the ability of the subjects to take on these instructions.