Designing a mHealth clinical decision support system for Parkinson's disease: a theoretically grounded user needs approach.

BACKGROUND: Despite the established evidence and theoretical advances explaining human judgments under uncertainty, developments of mobile health (mHealth) Clinical Decision Support Systems (CDSS) have not explicitly applied the psychology of decision making to the study of user needs. We report on a user needs approach to develop a prototype of a mHealth CDSS for Parkinson's disease (PD), which is theoretically grounded in the psychological literature about expert decision making and judgement under uncertainty. METHODS: A suite of user needs studies was conducted in 4 European countries (Greece, Italy, Slovenia, the UK) prior to the development of PD_Manager, a mHealth-based CDSS designed for Parkinson's disease, using wireless technology. Study 1 undertook Hierarchical Task Analysis (HTA) including elicitation of user needs, cognitive demands and perceived risks/benefits (ethical considerations) associated with the proposed CDSS, through structured interviews of prescribing clinicians (N = 47). Study 2 carried out computational modelling of prescribing clinicians' (N = 12) decision strategies based on social judgment theory. Study 3 was a vignette study of prescribing clinicians' (N = 18) willingness to change treatment based on either self-reported symptoms data, devices-generated symptoms data or combinations of both. RESULTS: Study 1 indicated that system development should move away from the traditional silos of 'motor' and 'non-motor' symptom evaluations and suggest that presenting data on symptoms according to goal-based domains would be the most beneficial approach, the most important being patients' overall Quality of Life (QoL). The computational modelling in Study 2 extrapolated different factor combinations when making judgements about different questions. Study 3 indicated that the clinicians were equally likely to change the care plan based on information about the change in the patient's condition from the patient's self-report and the wearable devices. CONCLUSIONS: Based on our approach, we could formulate the following principles of mHealth design: 1) enabling shared decision making between the clinician, patient and the carer; 2) flexibility that accounts for diagnostic and treatment variation among clinicians; 3) monitoring of information integration from multiple sources. Our approach highlighted the central importance of the patient-clinician relationship in clinical decision making and the relevance of theoretical as opposed to algorithm (technology)-based modelling of human judgment.

Gait changes following robot-assisted gait training in children with cerebral palsy.

This study investigated changes of gait pattern induced by a 4-week robot-assisted gait training (RAGT) in twelve ambulatory spastic diparesis children with cerebral palsy (CP) aged 10.4+/-3.2 years old by using computerized gait analysis (CGA). Pre-post intervention CGA data of children with CP was contrasted to the normative data of typically developing children by using cross-correlation and statistically evaluated by a Wilcoxon test. Significant pre-post intervention changes (p<0.01) include: decreased muscle activity of biceps femoris, rectus femoris, and tibialis anterior; a decrease in range of internal hip joint rotation, higher cadence, step length, and increased stride time. This study suggests that RAGT can be used in muscle reeducation and improved hip joint motion range in ambulatory children with CP.

Efficient FES triggering applying Kalman filter during sensory supported treadmill walking.

In this paper an algorithm for a functional electrical stimulation (FES) gait re-education system for incomplete spinal cord injured persons, providing efficient stimulation triggering, is presented. During neurological impaired gait FES was provided as motor augmentation support. Simultaneously the gait kinematics were recorded using the proposed sensory system, which is equipped with a dual-axial accelerometer and a gyroscope. The sensory device was placed at the shank of the paretic leg. The data assessed were input into a mathematical algorithm applied for shank angle estimation. The algorithm is based on the Kalman filter, estimating the angle error and correcting the actual measurement. Furthermore the information was combined with other kinematic data for the purpose of efficient and reliable stimulation triggering. The algorithm was tested with preliminary measurements on several neurologically intact persons during even terrain and treadmill walking. Trial measurements were verified with a contactless optical measurement system, with FES only simulated on controller output. Later on a treadmill training in combination with FES triggering was carried out. The outcome of the measurements shows that the use of sensory integration may successfully solve the problem of data assessment in dynamic movement where an inclinometer does not provide sufficient information for efficient control of FES.

Use of telekinesthetic feedback in walking assisted by functional electrical stimulation.

A telekinesthetic feedback implemented into functional electrical stimulation (FES) orthosis is described. Single channel FES is used to provoke ankle dorsiflexion during walking. FES is controlled manually by a special lever, built into the handle of the crutch. The angular position of the lever defines the intensity of stimulation and thus the magnitude of the ankle dorsiflexion. The measured joint angle provides the feedback information about the ankle joint position, which is presented to the user as a force feedback applied to the control lever. As the first step in the development of a complex micromechatronic device, a simulated testing environment was prepared. A computer model, comprising dynamic foot characteristics, as well as agonistic and antagonistic muscle groups, substitutes the ankle joint. The model also includes fatiguing of the electrically stimulated muscles. For experimental purposes an actuated control lever was built. The efficacy of the telekinesthetic feedback was evaluated in a group of six healthy persons.

Biomechanics of walking with silicone prosthesis after midtarsal (Chopart) disarticulation.

BACKGROUND: Currently accepted understanding is that silicone foot prostheses have little influence on biomechanics of walking; however clinical observations suggest several beneficial effects. The objective of this study was to characterize biomechanics of gait in a group of subjects with disarticulation through the talonavicular (T-N) and calcaneocuboid (C-C) (midtarsal) joints wearing two different prosthetic solutions: silicone prostheses and conventional prostheses. METHODS: Four subjects that underwent Chopart partial foot amputation were included in the study. Silicone prosthesis was custom manufactured for each individual subject. Instrumented gait analysis was performed in each subject in four experimental conditions: barefooted, barefooted and wearing silicon prosthesis, wearing footwear with conventional prosthesis and wearing footwear with silicon prosthesis. Comparisons and statistical analysis were made between both barefooted conditions and both foot-wearing conditions. FINDINGS: Our results show that silicone prosthesis without reinforced sole increases gait velocity, improves generation of ankle plantarflexion moment throughout the stance phase and enables greater power generation at push-off. The most important changes, however, occur in the frontal plane, where improved hip adduction angles and higher hip abduction moment in the stance enable more normal pelvic movement and consequently also less trunk inclination toward amputated side. INTERPRETATION: We conclude that silicone prostheses are not solely for cosmetic reasons but may be also biomechanically superior over other prosthetic solutions, especially for walking barefoot.

The influence of boot stiffness on gait kinematics and kinetics during stance phase.

In the study, the influence of different boot prototype stiffness on gait kinematics and kinetics was investigated. The boot stiffness was determined by force-deformation measurement while pressing the foot model inserted into the boot by a custom-made robot. Gait analysis was carried out in nine neurologically intact subjects during walking while wearing two different boots with and without carrying a backpack, and differences were statistically tested using ANOVA. The results indicated distinctions in the boot shaft and vamp stiffness. The boot with a softer boot shaft enabled a wider range of motion in the ankle joint leading to more power generation in the ankle joint during the push-off, increased step length and gait velocity. The backpack mostly influenced the pelvis and trunk kinematics. The study has demonstrated the influence of boot shaft stiffness on biomechanical gait parameters and its importance for push-off that manufacturers should take into consideration when optimizing the footwear performance.

Dermatome electrical stimulation as a therapeutic ambulatory aid for incomplete spinal cord injured patients.

Electrical stimulation of the L-3,4 dermatome during treadmill walking is proposed as a gait training modality in incomplete spinal cord injured patients. The dermatome stimulation proved to be efficient in diminishing the extensor tone occurring after loading of the paralyzed limb during the stance phase of walking and resulting in improved flexion of the leg during the swing phase.

FES Rehabilitative Systems for Re-Education of Walking in Incomplete Spinal Cord Injured Persons.

Objective. The aim of the paper is to present various relatively simple functional electrical stimulation (FES) systems that affect neural circuits and reflex behavior by providing necessary peripheral input to the lower extremities of incomplete spinal cord injured (SCI) persons. Methods. The proposed FES re-education walking systems make use of feedback information that is transmitted from the paralyzed limb to the nonparalyzed part of the patient's body. A single gait variable can be analogously transmitted to the walking subject in a form of sensory stimulation. The information about several gait variables can be first integrated and afterwards delivered to the walking subject as a single command. Conclusions. Significant improvements in the duration of the double support phase, metabolic energy expenditure, and physiologic cost index were observed when using FES-assisted training of walking in incomplete SCI persons.