Digitally-supported patient-centered asynchronous outpatient follow-up in rheumatoid arthritis - an explorative qualitative study.

OBJECTIVE: A steadily increasing demand and decreasing number of rheumatologists push current rheumatology care to its limits. Long travel times and poor accessibility of rheumatologists present particular challenges for patients. Need-adapted, digitally supported, patient-centered and flexible models of care could contribute to maintaining high-quality patient care. This qualitative study was embedded in a randomized controlled trial (TELERA) investigating a new model of care consisting of the use of a medical app for ePRO (electronic patient-reported outcomes), a self-administered CRP (C-reactive protein) test, and joint self-examination in rheumatoid arthritis (RA) patients. The qualitative study aimed to explore experiences of RA patients and rheumatology staff regarding (1) current care and (2) the new care model. METHODS: The study included qualitative interviews with RA patients (n = 15), a focus group with patient representatives (n = 1), rheumatology nurses (n = 2), ambulatory rheumatologists (n = 2) and hospital-based rheumatologists (n = 3). Data was analyzed by qualitative content analysis. RESULTS: Participants described current follow-up care as burdensome. Patients in remission have to travel long distances. Despite pre-scheduled visits physicians lack questionnaire results and laboratory results to make informed shared decisions during face-to-face visits. Patients reported that using all study components (medical app for ePRO, self-performed CRP test and joint self-examination) was easy and helped them to better assess their disease condition. Parts of the validated questionnaire used in the trial (routine assessment of patient index data 3; RAPID3) seemed outdated or not clear enough for many patients. Patients wanted to be automatically contacted in case of abnormalities or at least have an app feature to request a call-back or chat. Financial and psychological barriers were identified among rheumatologists preventing them to stop automatically scheduling new appointments for patients in remission. Rheumatology nurses pointed to the potential lack of personal contact, which may limit the holistic care of RA-patients. CONCLUSION: The new care model enables more patient autonomy, allowing patients more control and flexibility at the same time. All components were well accepted and easy to carry out for patients. To ensure success, the model needs to be more responsive and allow seamless integration of education material. TRIAL REGISTRATION: The study was prospectively registered on 2021/04/09 at the German Registry for Clinical Trials (DRKS00024928).

An oculometrics-based biofeedback system to impede fatigue development during computer work: A proof-of-concept study.

A biofeedback system may objectively identify fatigue and provide an individualized timing plan for micro-breaks. We developed and implemented a biofeedback system based on oculometrics using continuous recordings of eye movements and pupil dilations to moderate fatigue development in its early stages. Twenty healthy young participants (10 males and 10 females) performed a cyclic computer task for 31-35 min over two sessions: 1) self-triggered micro-breaks (manual sessions), and 2) biofeedback-triggered micro-breaks (automatic sessions). The sessions were held with one-week inter-session interval and in a counterbalanced order across participants. Each session involved 180 cycles of the computer task and after each 20 cycles (a segment), the task paused for 5-s to acquire perceived fatigue using Karolinska Sleepiness Scale (KSS). Following the pause, a 25-s micro-break involving seated exercises was carried out whether it was triggered by the biofeedback system following the detection of fatigue (KSS≥5) in the automatic sessions or by the participants in the manual sessions. National Aeronautics and Space Administration Task Load Index (NASA-TLX) was administered after sessions. The functioning core of the biofeedback system was based on a Decision Tree Ensemble model for fatigue classification, which was developed using an oculometrics dataset previously collected during the same computer task. The biofeedback system identified fatigue with a mean accuracy of approx. 70%. Perceived workload obtained from NASA-TLX was significantly lower in the automatic sessions compared with the manual sessions, p = 0.01 Cohen's dz = 0.89. The results give support to the effectiveness of integrating oculometrics-based biofeedback in timing plan of micro-breaks to impede fatigue development during computer work.

Sensory substitution for balance control using a vestibular-to-tactile device.

Postural control is essential for most activities of daily living. The impairment of this function can be extremely disabling. This work was stimulated by the testimony of a bilateral partial foot amputee who describes his difficulty in maintaining balance while washing his hair in the shower. We postulated that if the postural control system could not rely on accurate and reliable somatosensory inputs from the foot and ankle, as is probably the case following bilateral foot amputation due to the loss of the foot afferents and efferents, the weight of visual and vestibular cues would increase. We therefore assessed if a vestibular-to-tactile sensory substitution device could compensate for this impairment. Two separate experiments were conducted. Experiment 1: The effect of a vestibular-to-tongue tactile biofeedback balance system on the postural stability of this amputee was tested (on a force platform) and compared with a non-amputated, matched control group. The results showed that use of the biofeedback reduced centre of foot (CoP) displacement in all subjects but more spectacularly in the amputee. Experiment 2: The effect of the biofeedback was tested in 16 young healthy adults following a protocol of ankle muscle fatigue (known to alter ankle neuromuscular function and to perturb the control of bipedal posture). The results showed a significant decrease in CoP displacement compared with the control, non-biofeedback condition and a significantly greater effect of the biofeedback in the fatigue than the non-fatigue condition. Taken together, the results of these two studies suggest that an individual with double partial foot amputation was able to improve his balance control thanks to the use of a vestibular-to-tongue tactile biofeedback balance system and that young healthy individuals were able to take advantage of it to reduce the postural destabilisation induced by plantar-flexor muscle fatigue. Further studies are however necessary to confirm this in larger numbers of impaired persons as well as to assess the effectiveness in dynamic situations.

Balance rehabilitation therapy by tongue electrotactile biofeedback in patients with degenerative cerebellar disease.

Few clinical studies have evaluated physiotherapeutic interventions in patients with degenerative cerebellar ataxia. Investigations on the effectiveness of biofeedback-based interventions for training postural control in these patients have not been conducted yet. The aim of the present study was to assess the effectiveness of a 2-week intensive tongue-placed electrotactile biofeedback program for patients with progressive cerebellar ataxia. Subjects were seven adult patients suffering from cerebellar degeneration. Postural control was assessed with static posturography in two sensory conditions eyes open/closed on firm surface. For quantification of postural behavior, we used area, sway path and mean velocity of the centre of foot pressure (CoP). Effects of treatment were determined by comparing Pre, Post and one month follow-up (Retention) experimental sessions. Analysis of measured CoP parameters for tests on firm surface showed a significant main effect of visual condition and no difference across test sessions under open eyes condition. Under eyes closed condition, there were significant differences between Pre versus Post and Pre versus Retention, while the difference Post versus Retention was not significant. Our results suggest that a balance rehabilitation program with postural exercise performed with a head position-based tongue-placed biofeedback system could significantly improve bipedal postural control in patients suffering from degenerative cerebellar ataxia.

Short-term memory effects of an auditory biofeedback on isometric force control: is there a differential effect as a function of transition trials?

The aim of the present study was to investigate memory effects, force accuracy, and variability during constant isometric force at different force levels, using auditory biofeedback. Two types of transition trials were used: a biofeedback-no biofeedback transition trial and a no biofeedback-biofeedback transition trial. The auditory biofeedback produced a low- or high-pitched sound when participants produced an isometric force lower or higher than required, respectively. To achieve this goal, 16 participants were asked to produce and maintain two different isometric forces (30±5% and 90 N±5%) during 25 s. Constant error and standard deviation of the isometric force were calculated. While accuracy and variability of the isometric force varied according to the transition trial, a drift of the force appeared in the no biofeedback condition. This result suggested that the degradation of information about force output in the no biofeedback condition was provided by a leaky memory buffer which was mainly dependent on the sense of effort. Because this drift remained constant whatever the transition used, this memory buffer seemed to be independent of short-term memory processes.

A wireless lingual feedback device to reduce overpressures in seated posture: a feasibility study.

BACKGROUND: Pressure sores are localized injuries to the skin and underlying tissues and are mainly resulting from overpressure. Paraplegic peoples are particularly subjects to pressure sores because of long-time seated postures and sensory deprivation at the lower limbs. METHODOLOGY/PRINCIPAL FINDINGS: Here we report outcomes of a feasibility trial involving a biofeedback system aimed at reducing buttock overpressure whilst an individual is seated. The system consists of (1) pressure sensors, (2) a laptop coupling sensors and actuator (3) a wireless Tongue Display Unit (TDU) consisting of a circuit embedded in a dental retainer with electrodes put in contact with the tongue. The principle consists in (1) detecting overpressures in people who are seated over long periods of time, (2) estimating a postural change that could reduce these overpressures and (3) communicating this change through directional information transmitted by the TDU.Twenty-four healthy subjects voluntarily participated in this study. Twelve healthy subjects initially formed the experimental group (EG) and were seated on a chair with the wireless TDU inside their mouth. They were asked to follow TDU orders that were randomly spread throughout the session. They were evaluated during two experimental sessions during which 20 electro-stimulations were sent. Twelve other subjects, added retrospectively, formed the control group (CG). These subjects participated in one session of the same experiment without any biofeedback.Three dependent variables were computed: (1) the ability of subjects to reach target posture (EG versus CG), (2) high pressure reductions after a biofeedback (EG versus CG) and (3) the level of these reductions relative to their initial values (EG only). Results show (1) that EG reached target postures in 90.2% of the trials, against 5,3% in the CG, (2) a significant reduction in overpressures in the EG compared to the CG and (3), for the EG, that the higher the initial pressures were, the more they were decreased. CONCLUSIONS/SIGNIFICANCE: The findings suggest that, in this trial, subjects were able to use a tongue tactile feedback system to reduce buttock overpressure while seated. Further evaluation of this system on paraplegic subjects remains to be done.

Effectiveness of a tongue-placed electrotactile biofeedback to improve ankle force sense following plantar-flexor muscles fatigue.

To assess the effectiveness of a tongue-placed electrotactile biofeedback system to improve ankle force sense following plantar-flexor muscles fatigue, 11 young healthy adults were asked to perform an isometric contra-lateral force ankle-matching task in two experimental conditions of No fatigue and Fatigue of the plantar-flexor muscles and two conditions of No biofeedback and Biofeedback. The underlying principle of the biofeedback consisted of supplying subjects with supplementary information about the force developed by the plantar-flexor muscles through electrical stimulation of the tongue. Measures of the overall accuracy and the variability of the force ankle-matching performances were determined using the absolute error and the variable error, respectively. Results showed that (1) the Fatigue condition yielded increased absolute and variable errors relative to the No fatigue condition in the No biofeedback condition, whereas (2) no significant difference between the two No fatigue and Fatigue conditions was observed in the Biofeedback condition. These results suggest that subjects were able to integrate augmented sensory information delivered through electrotactile stimulation of the tongue to suppress the adverse effect of plantar-flexor muscles fatigue on ankle force sense.

Massage and mobilization of the feet and ankles in elderly adults: effect on clinical balance performance.

The aim of this study was to evaluate the effects of a session of plantar massage and joint mobilization of the feet and ankles on clinical balance performance in elderly people. A randomized, placebo-controlled, cross-over trial was used to examine the immediate effects of manual massage and mobilization of the feet and ankles. Twenty-eight subjects, aged from 65 to 95 years (78.8+/-8.5 years - mean+/-SD) were recruited from community nursing homes. Main outcome measures were the performances in three tests: One Leg Balance (OLB) test, Timed Up and Go (TUG) test and Lateral Reach (LR) test. Results demonstrated a significant improvement after massage and mobilization compared with placebo for the OLB test (1.1+/-1.7s versus 0.4+/-1.2s, p<0.01) and the TUG test (0.9+/-2.6s versus 0.2+/-1.2s, p<0.05). Conversely, performances in the LR test did not improve significantly. These results emphasise the positive impact of a single session of manual therapy applied to the feet and ankles on balance in elderly subjects.

Sensory supplementation through tongue electrotactile stimulation to preserve head stabilization in space in the absence of vision.

PURPOSE: To investigate the effectiveness of a head position-based, tongue-placed biofeedback system in providing sensory supplementation to preserve head stability in space in the absence of visual information. METHODS: Nine healthy young men with normal vision and no history of previous motor problems, neck injury, vertigo, neurologic disease, or vestibular impairment voluntarily participated in the experiment. They were asked to stand, their feet placed in a semitandem position, as immobile as possible in two conditions of No Vision and Vision and two conditions of No Biofeedback and Biofeedback. In the Biofeedback condition, subjects executed the postural task using a biofeedback system whose principle consisted of supplying them with additional information about their head orientation/motion with respect to gravitational vertical through electrotactile stimulation of the tongue. A system for the analysis of movement was used to record the head displacements. RESULTS: Without the provision of the biofeedback (No Biofeedback condition), the No Vision condition yielded increased head displacements along the mediolateral axis compared with the Vision condition. Conversely, when biofeedback was available (Biofeedback condition), no significant difference between the No Vision and Vision conditions was observed. CONCLUSIONS: These results suggest that healthy young subjects were able to efficiently use head position-based, tongue-placed biofeedback to suppress the head instability induced by the suppression of vision. Hence the present findings demonstrate the effectiveness of a head position-based, tongue-placed biofeedback in providing sensory supplementation to preserve head stability in space in conditions of absent visual information.

Postural effects of the scaled display of visual foot center of pressure feedback under different somatosensory conditions at the foot and the ankle.

OBJECTIVES: To assess the effects of the scaled display of visual foot center of pressure (COP) feedback on upright postural control under different somatosensory conditions at the foot and the ankle. DESIGN: Before and after intervention trials. SETTING: University medical bioengineering laboratory. PARTICIPANTS: Young healthy adults (N=8; mean age, 23+/-2.5 y; mean body weight, 76.8+/-11.2 kg; mean height, 179.8+/-6.8 cm). INTERVENTIONS: Participants were asked to stand upright, as immobile as possible, in 3 visual conditions: a stationary cross feedback (SC-FB) condition and 2 different foot COP feedback (COP-FB) conditions involving increasing scale displays of 2:1 (COP-FB2) and of 10:1 (COP-FB10). These latter conditions correspond to the ratio between the COP displacement on the screen and the actual COP displacement measured by the force platform. This postural task was executed on 2 (firm, foam) support surface conditions. In the foam condition, a 2-cm thick foam support surface was placed under the participants' feet to alter the quality and/or quantity of somatosensory information at the foot and the ankle. MAIN OUTCOME MEASURE: COP displacements were recorded using a force platform. RESULTS: In the firm support surface condition, no significant difference was observed between the COP-FB2 and the SC-FB conditions, whereas the COP-FB10 condition yielded decreased COP displacements relative to the SC-FB condition. In the foam support surface condition, both the COP-FB2 and the COP-FB10 conditions yielded decreased COP displacements relative to the SC-FB condition, with a greater stabilizing effect in the COP-FB10 than COP-FB2 condition. CONCLUSIONS: The postural effects of the scale display of visual COP feedback differed depending on the somatosensory conditions at the foot and the ankle. These findings suggest that increased reliance on augmented sensory information for controlling upright posture in conditions of altered somatosensory input from the foot and ankle could have implications in clinical and rehabilitative areas.

Effectiveness of an electro-tactile vestibular substitution system in improving upright postural control in unilateral vestibular-defective patients.

We investigated the effects of an electro-tactile vestibular substitution system (EVSS) on upright postural control in 12 unilateral vestibular-defective patients. The underlying principle of this system consists in supplying the user with additional information about his/her head orientation/motion with respect to gravitational vertical, normally provided by the vestibular system, through electro-tactile stimulation of his/her tongue. Subjects were asked to stand as immobile as possible with their eyes closed in two No-EVSS and EVSS conditions. Reduced centre-of-foot pressure displacements were observed in the EVSS relative to the No-EVSS condition. These results, demonstrating the effectiveness of the EVSS system in improving upright postural control in unilateral vestibular-defective patients, could have implications in clinical and rehabilitative areas.

Postural destabilization induced by trunk extensor muscles fatigue is suppressed by use of a plantar pressure-based electro-tactile biofeedback.

Separate studies have reported that postural control during quiet standing could be (1) impaired with muscle fatigue localized at the lower back, and (2) improved through the use of plantar pressure-based electro-tactile biofeedback, under normal neuromuscular state. The aim of this experiment was to investigate whether this biofeedback could reduce postural destabilization induced by trunk extensor muscles. Ten healthy adults were asked to stand as immobile as possible in four experimental conditions: (1) no fatigue/no biofeedback, (2) no fatigue/biofeedback, (3) fatigue/no biofeedback and (4) fatigue/biofeedback. Muscular fatigue was achieved by performing trunk repetitive extensions until maximal exhaustion. The underlying principle of the biofeedback consisted of providing supplementary information related to foot sole pressure distribution through electro-tactile stimulation of the tongue. Centre of foot pressure (CoP) displacements were recorded using a force platform. Results showed (1) increased CoP displacements along the antero-posterior axis in the fatigue than no fatigue condition in the absence of biofeedback and (2) no significant difference between the no fatigue and fatigue conditions in the presence of biofeedback. This suggests that subjects were able to efficiently integrate an artificial plantar pressure information delivered through electro-tactile stimulation of the tongue that allowed them to suppress the destabilizing effect induced by trunk extensor muscles fatigue.

Sensory supplementation system based on electrotactile tongue biofeedback of head position for balance control.

The present study aimed at investigating the effects of an artificial head position-based tongue-placed electrotactile biofeedback on postural control during quiet standing under different somatosensory conditions from the support surface. Eight young healthy adults were asked to stand as immobile as possible with their eyes closed on two Firm and Foam support surface conditions executed in two conditions of No-biofeedback and Biofeedback. In the Foam condition, a 6-cm thick foam support surface was placed under the subjects' feet to alter the quality and/or quantity of somatosensory information at the plantar sole and the ankle. The underlying principle of the biofeedback consisted of providing supplementary information about the head orientation with respect to gravitational vertical through electrical stimulation of the tongue. Centre of foot pressure (CoP) displacements were recorded using a force platform. Larger CoP displacements were observed in the Foam than Firm conditions in the two conditions of No-biofeedback and Biofeedback. Interestingly, this destabilizing effect was less accentuated in the Biofeedback than No-biofeedback condition. In accordance with the sensory re-weighting hypothesis for balance control, the present findings evidence that the availability of the central nervous system to integrate an artificial head orientation information delivered through electrical stimulation of the tongue to limit the postural perturbation induced by alteration of somatosensory input from the support surface.

Head position-based electrotactile tongue biofeedback affects postural responses to Achilles tendon vibration in humans.

The purpose of the present experiment was to investigate whether postural responses to ankle proprioceptive perturbation Achilles tendon vibration were affected by the availability of augmented sensory information about head orientation/motion with respect to gravitational vertical, i.e., normally provided by the vestibular system. To achieve this goal, ten standing subjects were exposed to Achilles tendon vibration in two No Biofeedback and Biofeedback conditions. The No Biofeedback condition served as a control condition. In the Biofeedback condition, subjects performed the postural task using a head position-based electrotactile tongue-placed biofeedback system. Center of foot pressure (CoP) displacements were recorded using a force platform. Results showed that (1) Achilles tendon vibration increased CoP displacements in the No Biofeedback condition and (2) this destabilizing effect was less accentuated in the Biofeedback condition. These results are consistent with and discussed in terms of sensory re-weighting mechanisms involved in postural control. In the condition of Achilles tendon vibration, which renders ankle proprioceptive information less reliable for controlling posture, the central nervous system was able to integrate alternatively available augmented sensory information suitable and usable in upright postural control to reduce the destabilizing effect of the ankle proprioceptive perturbation.

Tongue-placed tactile biofeedback suppresses the deleterious effects of muscle fatigue on joint position sense at the ankle.

Whereas the acuity of the position sense at the ankle can be disturbed by muscle fatigue, it recently also has been shown to be improved, under normal ankle neuromuscular state, through the use of an artificial tongue-placed tactile biofeedback. The underlying principle of this biofeedback consisted of supplying individuals with supplementary information about the position of their matching ankle position relative to their reference ankle position through electrotactile stimulation of the tongue. Within this context, the purpose of the present experiment was to investigate whether this biofeedback could mitigate the deleterious effect of muscle fatigue on joint position sense at the ankle. To address this objective, sixteen young healthy university students were asked to perform an active ankle-matching task in two conditions of No-fatigue and Fatigue of the ankle muscles and two conditions of No-biofeedback and Biofeedback. Measures of the overall accuracy and the variability of the positioning were determined using the absolute error and the variable error, respectively. Results showed that the availability of the biofeedback allowed the subjects to suppress the deleterious effects of muscle fatigue on joint position sense at the ankle. In the context of sensory re-weighting process, these findings suggested that the central nervous system was able to integrate and increase the relative contribution of the artificial tongue-placed tactile biofeedback to compensate for a proprioceptive degradation at the ankle.

Inter-individual variability in sensory weighting of a plantar pressure-based, tongue-placed tactile biofeedback for controlling posture.

The purpose of the present experiment was to investigate whether the sensory weighting of a plantar pressure-based, tongue-placed tactile biofeedback for controlling posture could be subject to inter-individual variability. To achieve this goal, 60 young healthy adults were asked to stand as immobile as possible with their eyes closed in two conditions of No-biofeedback and Biofeedback. Centre of foot pressure (CoP) displacements were recorded using a force platform. Overall, results showed reduced CoP displacements in the Biofeedback relative to the No-biofeedback condition, evidencing the ability of the central nervous system to efficiently integrate an artificial plantar-based, tongue-placed tactile biofeedback for controlling posture during quiet standing. Results further showed a significant positive correlation between the CoP displacements measured in the No-biofeedback condition and the decrease in the CoP displacements induced by the use of the biofeedback. In other words, the degree of postural stabilization appeared to depend on each subject's balance control capabilities, the biofeedback yielding a greater stabilizing effect in subjects exhibiting the largest CoP displacements when standing in the No-biofeedback condition. On the whole, by evidencing a significant inter-individual variability in sensory weighting of an additional tactile information related to foot sole pressure distribution for controlling posture, the present findings underscore the need and the necessity to address the issue of inter-individual variability in the field of neuroscience.

How a plantar pressure-based, tongue-placed tactile biofeedback modifies postural control mechanisms during quiet standing.

The purpose of the present study was to determine the effects of a plantar pressure-based, tongue-placed tactile biofeedback on postural control mechanisms during quiet standing. To this aim, 16 young healthy adults were asked to stand as immobile as possible with their eyes closed in two conditions of No-biofeedback and Biofeedback. Centre of foot pressure (CoP) displacements, recorded using a force platform, were used to compute the horizontal displacements of the vertical projection of the centre of gravity (CoG( v )) and those of the difference between the CoP and the vertical projection of the CoG (CoP-CoG( v )). Analysis of the CoP-CoG( v ) displacements showed larger root mean square (RMS) and mean power frequencies (MPF) in the Biofeedback than in the No-biofeedback condition. Stabilogram-diffusion analysis further showed a concomitant increased spatial and reduced temporal transition point co-ordinates at which the corrective processes were initiated and an increased persistent behaviour of the CoP-CoG( v ) displacements over the short-term region. Analysis of the CoG( v ) displacements showed decreased RMS and increased MPF in the Biofeedback relative to the No-biofeedback condition. Stabilogram-diffusion analysis further indicated that these effects mainly stem from reduced spatio-temporal transition point co-ordinates at which the corrective process involving CoG( v ) displacements is initiated and an increased anti-persistent behaviour of the CoG( v ) displacements over the long-term region. Altogether, the present findings suggest that the main way the plantar pressure-based, tongue-placed tactile biofeedback improves postural control during quiet standing is via both a reduction of the correction thresholds and an increased efficiency of the corrective mechanism involving the CoG( v ) displacements.

Improving human ankle joint position sense using an artificial tongue-placed tactile biofeedback.

Proprioception is comprised of sensory input from several sources including muscle spindles, joint capsule, ligaments and skin. The purpose of the present experiment was to investigate whether the central nervous system was able to integrate an artificial biofeedback delivered through electrotactile stimulation of the tongue to improve proprioceptive acuity at the ankle joint. To address this objective, nine young healthy adults were asked to perform an active ankle-matching task with and without biofeedback. The underlying principle of the biofeedback consisted of supplying subjects with supplementary information about the position of their matching ankle position relative to their reference ankle position through a tongue-placed tactile output device (Tongue Display Unit). Measures of the overall accuracy and the variability of the positioning were determined using the absolute error and the variable error, respectively. Results showed more accurate and more consistent matching performances with than without biofeedback, as indicated by decreased absolute and variable errors, respectively. These findings suggested that the central nervous system was able to take advantage of an artificial tongue-placed tactile biofeedback to improve the position sense at the ankle joint.