Using digital tools in clinical, health and social care research: a mixed-methods study of UK stakeholders.

OBJECTIVE: The COVID-19 pandemic accelerated changes to clinical research methodology, with clinical studies being carried out via online/remote means. This mixed-methods study aimed to identify which digital tools are currently used across all stages of clinical research by stakeholders in clinical, health and social care research and investigate their experience using digital tools. DESIGN: Two online surveys followed by semistructured interviews were conducted. Interviews were audiorecorded, transcribed and analysed thematically. SETTING, PARTICIPANTS: To explore the digital tools used since the pandemic, survey participants (researchers and related staff (n=41), research and development staff (n=25)), needed to have worked on clinical, health or social care research studies over the past 2 years (2020-2022) in an employing organisation based in the West Midlands region of England (due to funding from a regional clinical research network (CRN)). Survey participants had the opportunity to participate in an online qualitative interview to explore their experiences of digital tools in greater depth (n=8). RESULTS: Six themes were identified in the qualitative interviews: 'definition of a digital tool in clinical research'; 'impact of the COVID-19 pandemic'; 'perceived benefits/drawbacks of digital tools'; 'selection of a digital tool'; 'barriers and overcoming barriers' and 'future digital tool use'. The context of each theme is discussed, based on the interview results. CONCLUSIONS: Findings demonstrate how digital tools are becoming embedded in clinical research, as well as the breadth of tools used across different research stages. The majority of participants viewed the tools positively, noting their ability to enhance research efficiency. Several considerations were highlighted; concerns about digital exclusion; need for collaboration with digital expertise/clinical staff, research on tool effectiveness and recommendations to aid future tool selection. There is a need for the development of resources to help optimise the selection and use of appropriate digital tools for clinical research staff and participants.

How Do Drivers Perceive Risks During Automated Driving Scenarios? An fNIRS Neuroimaging Study.

OBJECTIVE: Using brain haemodynamic responses to measure perceived risk from traffic complexity during automated driving. BACKGROUND: Although well-established during manual driving, the effects of driver risk perception during automated driving remain unknown. The use of fNIRS in this paper for assessing drivers' states posits it could become a novel method for measuring risk perception. METHODS: Twenty-three volunteers participated in an empirical driving simulator experiment with automated driving capability. Driving conditions involved suburban and urban scenarios with varying levels of traffic complexity, culminating in an unexpected hazardous event. Perceived risk was measured via fNIRS within the prefrontal cortical haemoglobin oxygenation and from self-reports. RESULTS: Prefrontal cortical haemoglobin oxygenation levels significantly increased, following self-reported perceived risk and traffic complexity, particularly during the hazardous scenario. CONCLUSION: This paper has demonstrated that fNIRS is a valuable research tool for measuring variations in perceived risk from traffic complexity during highly automated driving. Even though the responsibility over the driving task is delegated to the automated system and dispositional trust is high, drivers perceive moderate risk when traffic complexity builds up gradually, reflected in a corresponding significant increase in blood oxygenation levels, with both subjective (self-reports) and objective (fNIRS) increasing further during the hazardous scenario. APPLICATION: Little is known regarding the effects of drivers' risk perception with automated driving. Building upon our experimental findings, future work can use fNIRS to investigate the mental processes for risk assessment and the effects of perceived risk on driving behaviours to promote the safe adoption of automated driving technology.

Data sharing across osteoarthritis research groups and disciplines: Opportunities and challenges.

Background: Osteoarthritis is a heterogeneous condition characterised by a wide variety of factors and represents a worldwide healthcare challenge. There are multiple clinical and research specialisms involved in the diagnosis, prognosis and treatment of osteoarthritis, and there may be opportunities to share or pool data which are currently not being utilised. However, there are challenges to doing so which require carefully structured solutions and partnership working. Methods: Interviews were conducted with nine experts from various fields within osteoarthritis research. A semi-structured approach was used, and thematic analysis applied to the results. Results: Generally, osteoarthritis researchers were supportive of data sharing, provided it is done responsibly and without impacting data integrity. Benefits identified included increasing typically low-powered data, the potential for machine learning opportunities, and the potential for improved patient outcomes. However, a number of challenges were identified, relating to: data security, data harmonisation, storage costs, ethical considerations and governance. Conclusions: There is clear support for increased data sharing and partnership working in osteoarthritis research. Further investigation will be required to navigate the complex issues identified; however, it is clear that collaborative opportunities should be better facilitated and there may be innovative ways to do this. It is also clear that nomenclature within different disciplines could be better streamlined, to improve existing opportunities to harmonise data.

Stay home and stay active? The impact of stay-at-home restrictions on physical activity routines in the UK during the COVID-19 pandemic.

We investigated which population groups were impacted most in terms of physical activity levels during the restrictions applied during the COVID-19 pandemic. We surveyed UK residents, sampled through users of a rewards-for-exercise app (Sweatcoin; n = 749) and an online panel (Prolific; n = 907). Of the app users, n = 487 further provided daily step-count data collected by the app, prior to, and during the periods of restrictions in the UK between March-June 2020. Regression models were used to investigate factors associated with self-reported change in physical activity and change in daily step-count during the periods of restrictions. Significant factors associated with self-reported change in physical activity included rural residents (positive, b = 0.87, p < 0.001), relative to urban dwellers, people classed as obese (negative, b = -0.51, p = 0.008, relative to healthy weight) and gym users (negative, b = -1.10, p < 0.001, relative to walkers). All groups had reduced step counts during restrictions, with Black, Asian and minority ethnic groups showing greater reductions compared to White British ethnicity (negative, b = -0.18, p = 0.008). Targeted interventions are required to ensure that physical and mental health impacts of sedentary behaviour are not exacerbated over the long-term by significant reductions in physical activity identified in these groups particularly those who are also more vulnerable to COVID-19.

Repeatability of Inertial Measurement Units for Measuring Pelvic Mobility in Patients Undergoing Total Hip Arthroplasty.

Consideration of pelvic mobility when positioning implants for total hip arthroplasty (THA) has been shown to reduce the risk of complications such as dislocation, squeaking and excessive wear. We aim to test the repeatability of pelvic tilt measurements taken between three positions (standing, flexed-seated and step-up) by an inertial measurement unit (IMU) and hence, evaluate their reliability in screening for high pelvic mobility in patients undergoing THA. The repeated IMU measurements of pelvic tilt were analysed for consistency and compared with measures taken by x-ray analysis. Our study showed greater variation in measures taken by the IMU particularly in the flexed-seated position. The patient's pelvic tilt in this position negatively correlated with their mid-back angle, suggesting the posture of the patient is a source of variation in the flexed-seated position if not kept consistent during assessments. IMUs were overall able to produce accurate and reliable measurements of pelvic tilt; however, protocols will need to be adjusted to factor in a patient's mid-back angle when taking future readings.

Can a 'rewards-for-exercise app' increase physical activity, subjective well-being and sleep quality? An open-label single-arm trial among university staff with low to moderate physical activity levels.

BACKGROUND: This study examined the impact of a 'rewards-for-exercise' mobile application on physical activity, subjective well-being and sleep quality among 148 employees in a UK university with low to moderate physical activity levels. METHODS: A three-month open-label single-arm trial with a one-year follow-up after the end of the trial. Participants used the Sweatcoin application which converted their outdoor steps into a virtual currency used for the purchase of products available at the university campus' outlets, using an in-app marketplace. The primary outcome measure was self-reported physical activity. Secondary measures included device-measured physical activity, subjective well-being (i.e., life satisfaction, positive affect, negative affect), and self-reported sleep quality. RESULTS: The findings show an increase in self-reported physical activity (d = 0.34), life satisfaction (d = 0.31), positive affect (d = 0.29), and sleep quality (d = 0.22) during the three-month trial period. CONCLUSION: The study suggests that mobile incentives-for-exercise applications might increase physical activity levels, positive affect, and sleep quality, at least in the short term. The observed changes were not sustained 12 months after the end of the trial.

A Sensor-Based Screening Tool for Identifying High Pelvic Mobility in Patients Due to Undergo Total Hip Arthroplasty.

There is increasing evidence that pelvic mobility is a critical factor to consider in implant alignment during total hip arthroplasty (THA). Here, we test the feasibility of using an inertial sensor fitted across the sacrum to measure change in pelvic tilt, and hence screen for patients with high pelvic mobility. Patients (n = 32, mean age: 57.4 years) due to receive THA surgery participated in the study. Measures of pelvic tilt were captured simultaneously using the device and radiograph in three functional positions: Standing, flexed-seated, and step-up. We found a strong correlation between the device and radiograph measures for the change in pelvic tilt measure from standing to flexed-seated position (R2 = 0.911); 75% of absolute errors were under 5 degrees. We demonstrated that the device can be used as a screening tool to rapidly identify patients who would benefit from more detailed surgical planning of implant positioning to reduce future risks of impingement and dislocation.

Timing and correction of stepping movements with a virtual reality avatar.

Research into the ability to coordinate one's movements with external cues has focussed on the use of simple rhythmic, auditory and visual stimuli, or interpersonal coordination with another person. Coordinating movements with a virtual avatar has not been explored, in the context of responses to temporal cues. To determine whether cueing of movements using a virtual avatar is effective, people's ability to accurately coordinate with the stimuli needs to be investigated. Here we focus on temporal cues, as we know from timing studies that visual cues can be difficult to follow in the timing context. Real stepping movements were mapped onto an avatar using motion capture data. Healthy participants were then motion captured whilst stepping in time with the avatar's movements, as viewed through a virtual reality headset. The timing of one of the avatar step cycles was accelerated or decelerated by 15% to create a temporal perturbation, for which participants would need to correct to, in order to remain in time. Step onset times of participants relative to the corresponding step-onsets of the avatar were used to measure the timing errors (asynchronies) between them. Participants completed either a visual-only condition, or auditory-visual with footstep sounds included, at two stepping tempo conditions (Fast: 400ms interval, Slow: 800ms interval). Participants' asynchronies exhibited slow drift in the Visual-Only condition, but became stable in the Auditory-Visual condition. Moreover, we observed a clear corrective response to the phase perturbation in both the fast and slow tempo auditory-visual conditions. We conclude that an avatar's movements can be used to influence a person's own motion, but should include relevant auditory cues congruent with the movement to ensure a suitable level of entrainment is achieved. This approach has applications in physiotherapy, where virtual avatars present an opportunity to provide the guidance to assist patients in adhering to prescribed exercises.

Bone-to-Bone and Implant-to-Bone Impingement: A Novel Graphical Representation for Hip Replacement Planning.

Bone-to-bone impingement (BTBI) and implant-to-bone impingement (ITBI) risk assessment is generally performed intra-operatively by surgeons, which is entirely subjective and qualitative, and therefore, lead to sub-optimal results and recurrent dislocation in some cases. Therefore, a method was developed for identifying subject-specific BTBI and ITBI, and subsequently, visualising the impingement area on native bone anatomy to highlight where prominent bone should be resected. Activity definitions and subject-specific bone geometries, with planned implants were used as inputs for the method. The ITBI and BTBI boundary and area were automatically identified using ray intersection and region growing algorithm respectively to retain the same 'conical clearance angle' obtained to avoid prosthetic impingement (PI). The ITBI and BTBI area was then presented with different colours to highlight the risk of impingement, and importance of resection. A clinical study with five patients after 2 years of THA was performed to validate the method. The results supported the study hypothesis, in that the predicted highest risk area (red coloured zone) was completely/majorly resected during the surgery. Therefore, this method could potentially be used to examine the effect of different pre-operative plans and hip motions on BTBI, ITBI, and PI, and to guide bony resection during THA surgery.

Engagement with MyFitnessPal in eating disorders: Qualitative insights from online forums.

OBJECTIVE: Using calorie-counting and fitness-tracking technologies is concerning in relation to eating disorders. While studies in this area typically assess one aspect of use (e.g., frequency), engagement with a device or application is more complex. Consequently, important relationships between the use of these technologies and the eating disorder symptomatology might remain undetected. The current study therefore used comments from online eating disorder-related forums to generate comprehensive qualitative insights into engagement with a popular calorie-counting and fitness-tracking application, MyFitnessPal. METHOD: First, we extracted every comment mentioning MyFitnessPal made on three eating disorder-related forums between May 2015 and January 2018 (1,695 comments from 920 commenters). Then, we conducted an inductive thematic analysis using these comments to identify important aspects of engagement with MyFitnessPal. RESULTS: The analyses resulted in three themes: Preventing misuse, describing ways in which MyFitnessPal attempts to prevent pathological use and actions taken by users to circumvent its interventions; Accuracy, outlining distrust of MyFitnessPal's accuracy and ways in which perceived inaccuracy is reduced or compensated for; and Psychosocial factors, comprising cognitive, behavioral, and social factors that influence, or are influenced by, engagement with MyFitnessPal. DISCUSSION: The qualitative insights provide a detailed overview of how people with high levels of eating disorder symptomatology likely engage with MyFitnessPal. The insights can be used as a basis to develop valid, quantitative assessment of pathological patterns of engagement with calorie-counting and fitness-tracking technologies. The findings can also provide clinicians with insight into how their patients likely engage with, and are affected by, these devices and applications.

Profiling Commenters on Mental Health-Related Online Forums: A Methodological Example Focusing on Eating Disorder-Related Commenters.

BACKGROUND: Understanding the characteristics of commenters on mental health-related online forums is vital for the development of effective psychological interventions in these communities. The way in which commenters interact can enhance our understanding of their characteristics. OBJECTIVE: Using eating disorder-related (EDR) forums as an example, this study detailed a methodology that aimed to determine subtypes of mental health-related forums and profile their commenters based on the other forums to which they contributed. METHODS: The researchers identified all public EDR forums (with ≥500 contributing commenters between March 2017 and February 2018) on a large Web-based discussion platform (Reddit). A mixed-methods approach comprising network analysis with community detection, text mining, and manual review identified subtypes of EDR forums. For each subtype, another network analysis with community detection was conducted using the EDR forum commenter overlap between 50 forums on which the commenters also commented. The topics of forums in each detected community were then manually reviewed to identify the shared interests of each subtype of EDR forum commenters. RESULTS: Six subtypes of EDR forums were identified, to which 14,024 commenters had contributed. The results focus on 2 subtypes-proeating disorder and thinspiration-and communities of commenters within both subtypes. Within the proeating disorder subtype, 3 communities of commenters were detected that related to the body and eating, mental health, and women, appearance, and mixed topics. With regard to the thinspiration group, 78.17% (849/1086) of commenters had also commented on pornographic forums and 16.66% (181/1086) had contributed to proeating disorder forums. CONCLUSIONS: The article exemplifies a methodology that provides insight into subtypes of mental health-related forums and the characteristics of their commenters. The findings have implications for future research and Web-based psychological interventions. With the publicly available data and code provided, researchers can easily reproduce the analyses or utilize the methodology to investigate other mental health-related forums.

Text-mining as a methodology to assess eating disorder-relevant factors: Comparing mentions of fitness tracking technology across online communities.

OBJECTIVE: Text-mining offers a technique to identify and extract information from a large corpus of textual data. As an example, this study presents the application of text-mining to assess and compare interest in fitness tracking technology across eating disorder and health-related online communities. METHOD: A list of fitness tracking technology terms was developed, and communities (i.e., 'subreddits') on a large online discussion platform (Reddit) were compared regarding the frequency with which these terms occurred. The corpus used in this study comprised all comments posted between May 2015 and January 2018 (inclusive) on six subreddits-three eating disorder-related, and three relating to either fitness, weight-management, or nutrition. All comments relating to the same 'thread' (i.e., conversation) were concatenated, and formed the cases used in this study (N = 377,276). RESULTS: Within the eating disorder-related subreddits, the findings indicated that a 'pro-eating disorder' subreddit, which is less recovery focused than the other eating disorder subreddits, had the highest frequency of fitness tracker terms. Across all subreddits, the weight-management subreddit had the highest frequency of the fitness tracker terms' occurrence, and MyFitnessPal was the most frequently mentioned fitness tracker. DISCUSSION: The technique exemplified here can potentially be used to assess group differences to identify at-risk populations, generate and explore clinically relevant research questions in populations who are difficult to recruit, and scope an area for which there is little extant literature. The technique also facilitates methodological triangulation of research findings obtained through more 'traditional' techniques, such as surveys or interviews.

Cue properties change timing strategies in group movement synchronisation.

To maintain synchrony in group activities, each individual within the group must continuously correct their movements to remain in time with the temporal cues available. Cues might originate from one or more members of the group. Current research suggests that when synchronising movements, individuals optimise their performance in terms of minimising variability of timing errors (asynchronies) between external cues and their own movements. However, the cost of this is an increase in the timing variability of their own movements. Here we investigate whether an individual's timing strategy changes according to the task, in a group scenario. To investigate this, we employed a novel paradigm that positioned six individuals to form two chains with common origin and termination on the circumference of a circle. We found that participants with access to timing cues from only one other member used a strategy to minimise their asynchrony variance. In contrast, the participant at the common termination of the two chains, who was required to integrate timing cues from two members, used a strategy that minimised movement variability. We conclude that humans are able to flexibly switch timekeeping strategies to maintain task demands and thus optimise the temporal performance of their movements.

Corrigendum: Stepping to phase-perturbed metronome cues: multisensory advantage in movement synchrony but not correction.

[This corrects the article on p. 724 in vol. 8, PMID: 25309397.].

Early, but not late visual distractors affect movement synchronization to a temporal-spatial visual cue.

The ease of synchronizing movements to a rhythmic cue is dependent on the modality of the cue presentation: timing accuracy is much higher when synchronizing with discrete auditory rhythms than an equivalent visual stimulus presented through flashes. However, timing accuracy is improved if the visual cue presents spatial as well as temporal information (e.g., a dot following an oscillatory trajectory). Similarly, when synchronizing with an auditory target metronome in the presence of a second visual distracting metronome, the distraction is stronger when the visual cue contains spatial-temporal information rather than temporal only. The present study investigates individuals' ability to synchronize movements to a temporal-spatial visual cue in the presence of same-modality temporal-spatial distractors. Moreover, we investigated how increasing the number of distractor stimuli impacted on maintaining synchrony with the target cue. Participants made oscillatory vertical arm movements in time with a vertically oscillating white target dot centered on a large projection screen. The target dot was surrounded by 2, 8, or 14 distractor dots, which had an identical trajectory to the target but at a phase lead or lag of 0, 100, or 200 ms. We found participants' timing performance was only affected in the phase-lead conditions and when there were large numbers of distractors present (8 and 14). This asymmetry suggests participants still rely on salient events in the stimulus trajectory to synchronize movements. Subsequently, distractions occurring in the window of attention surrounding those events have the maximum impact on timing performance.

Interaction between interpersonal and postural coordination during frequency scaled rhythmic sway: the role of dance expertise.

Light fingertip touch between partners swaying rhythmically side by side evokes interpersonal synchrony. In non-dancers and dancers swaying to a metronome, we examined the effects of frequency scaling and touch between the partners on both postural (ankle-hip) and inter-personal coordination. In both groups, touch did not interfere with the ankle-hip coordination. In non-dancers but not dancers, increasing frequency resulted in a loss of the ankle-hip coupling that was accompanied by a reduction of the touch mediated interpersonal synchrony. It is suggested that the effect of touch on interpersonal synchrony depends on the reliability of the haptic information sensed at the fingertip and assumes an in phase ankle-hip coupling. These findings have implications in clinical practice when using touch to help balance impaired individuals.

Stepping to phase-perturbed metronome cues: multisensory advantage in movement synchrony but not correction.

Humans can synchronize movements with auditory beats or rhythms without apparent effort. This ability to entrain to the beat is considered automatic, such that any perturbations are corrected for, even if the perturbation was not consciously noted. Temporal correction of upper limb (e.g., finger tapping) and lower limb (e.g., stepping) movements to a phase perturbed auditory beat usually results in individuals being back in phase after just a few beats. When a metronome is presented in more than one sensory modality, a multisensory advantage is observed, with reduced temporal variability in finger tapping movements compared to unimodal conditions. Here, we investigate synchronization of lower limb movements (stepping in place) to auditory, visual and combined auditory-visual (AV) metronome cues. In addition, we compare movement corrections to phase advance and phase delay perturbations in the metronome for the three sensory modality conditions. We hypothesized that, as with upper limb movements, there would be a multisensory advantage, with stepping variability being lowest in the bimodal condition. As such, we further expected correction to the phase perturbation to be quickest in the bimodal condition. Our results revealed lower variability in the asynchronies between foot strikes and the metronome beats in the bimodal condition, compared to unimodal conditions. However, while participants corrected substantially quicker to perturbations in auditory compared to visual metronomes, there was no multisensory advantage in the phase correction task-correction under the bimodal condition was almost identical to the auditory-only (AO) condition. On the whole, we noted that corrections in the stepping task were smaller than those previously reported for finger tapping studies. We conclude that temporal corrections are not only affected by the reliability of the sensory information, but also the complexity of the movement itself.

Can dancers suppress the haptically mediated interpersonal entrainment during rhythmic sway?

Interpersonal entrainment emerges spontaneously when partners performing rhythmic movements together exchange sensory feedback about the other's movements. In this study, we asked whether couples of expert dancers, non-dancers and mixed couples can suppress the spontaneous haptically mediated inter-personal entrainment when their rhythmic sway is paced by differing metronome tempos. Fifty-four young participants formed three types of couples: nine dancer couples, consisting of individuals with at least eight years systematic practice in traditional Greek dance; nine non-dancer couples, consisting of individuals with no prior experience in dance and nine mixed couples, consisting of one dancer and one novice partner. Partners swayed rhythmically for 60 s, at different pacing frequencies (one at 0.25 Hz and the other at 0.35 Hz) under three haptic contact conditions: no contact between them; light fingertip touch established in the 2nd trial segment (30 s); and light fingertip touch released in the 2nd trial segment (30 s). Spectral analysis of the antero-posterior center of pressure displacement revealed that light touch increased the deviation of the dominant from the target (pacing) sway frequency, decreased the proportion of the signal's power at the target frequency and increased the coherence between the partners' sway signals (inter-personal coherence). These effects were specific to the mixed group whereas touch interference was weaker in non-dancers and absent in dancers. In addition, the coherence between the trial segments (intra-personal coherence) significantly decreased with touch only for the non-dancer while it remained unchanged for the dancer partner of the mixed group suggesting that the dancer was leading the non-dancer partner. It is concluded that systematic practice with traditional dance can modulate the spontaneous tendency towards haptically mediated interpersonal entrainment.

Moving in time: Bayesian causal inference explains movement coordination to auditory beats.

Many everyday skilled actions depend on moving in time with signals that are embedded in complex auditory streams (e.g. musical performance, dancing or simply holding a conversation). Such behaviour is apparently effortless; however, it is not known how humans combine auditory signals to support movement production and coordination. Here, we test how participants synchronize their movements when there are potentially conflicting auditory targets to guide their actions. Participants tapped their fingers in time with two simultaneously presented metronomes of equal tempo, but differing in phase and temporal regularity. Synchronization therefore depended on integrating the two timing cues into a single-event estimate or treating the cues as independent and thereby selecting one signal over the other. We show that a Bayesian inference process explains the situations in which participants choose to integrate or separate signals, and predicts motor timing errors. Simulations of this causal inference process demonstrate that this model provides a better description of the data than other plausible models. Our findings suggest that humans exploit a Bayesian inference process to control movement timing in situations where the origin of auditory signals needs to be resolved.