Multicomponent Support Program for Secondary Prevention of Stroke Using Digital Health Technology: Co-Design Study With People Living With Stroke or Transient Ischemic Attack.

BACKGROUND: Few individuals (<2%) who experience a stroke or transient ischemic attack (TIA) participate in secondary prevention lifestyle programs. Novel approaches that leverage digital health technology may provide a viable alternative to traditional interventions that support secondary prevention in people living with stroke or TIA. To be successful, these strategies should focus on user needs and preferences and be acceptable to clinicians and people living with stroke or TIA. OBJECTIVE: This study aims to co-design, with people with lived experience of stroke or TIA (referred to as consumers) and clinicians, a multicomponent digital technology support program for secondary prevention of stroke. METHODS: A consumer user needs survey (108 items) was distributed through the Australian Stroke Clinical Registry and the Stroke Association of Victoria. An invitation to a user needs survey (135 items) for clinicians was circulated via web-based professional forums and national organizations (eg, the Stroke Telehealth Community of Practice Microsoft Teams Channel) and the authors' research networks using Twitter (subsequently rebranded X, X Corp) and LinkedIn (LinkedIn Corp). Following the surveys, 2 rounds of user experience workshops (design and usability testing workshops) were completed with representatives from each end user group (consumers and clinicians). Feedback gathered after each round informed the final design of the digital health program. RESULTS: Overall, 112 consumers (male individuals: n=63, 56.3%) and 54 clinicians (female individuals: n=43, 80%) responded to the survey; all items were completed by 75.8% (n=85) of consumers and 78% (n=42) of clinicians. Most clinicians (46/49, 94%) indicated the importance of monitoring health and lifestyle measures more frequently than current practice, particularly physical activity, weight, and sleep. Most consumers (87/96, 90%) and clinicians (41/49, 84%) agreed that providing alerts about potential deterioration in an individual's condition were important functions for a digital program. Intention to use a digital program for stroke prevention and discussing the data collected during face-to-face consultations was high (consumers: 79/99, 80%; clinicians 36/42, 86%). In addition, 7 consumers (male individuals: n=5, 71%) and 9 clinicians (female individuals: n=6, 67%) took part in the user experience workshops. Participants endorsed using a digital health program to help consumers manage stroke or TIA and discussed preferred functions and health measures in a digital solution for secondary prevention of stroke. They also noted the need for a mobile app that is easy to use. Clinician feedback highlighted the need for a customizable clinician portal that captures individual consumer goals. CONCLUSIONS: Following an iterative co-design process, supported by evidence from user needs surveys and user experience workshops, a consumer-facing app that integrates wearable activity trackers and a clinician web portal were designed and developed to support secondary prevention of stroke. Feasibility testing is currently in progress to assess acceptability and use.

Informing Personalised Gamification Interventions Through a Novel Gamified Quiz.

Nonadherence to medical interventions and other advice leads to increased care costs and poorer health outcomes across a range of medical fields. An approach to increasing adherence is gamification. To maximize the benefits of gamification, a more structured and informed implementation is required. In this paper, a novel web-based personality determiner has been outlined, the integration of which could provide the personalisation required for an optimized gamification implementation.

Technology-assisted quantification of movement to predict infants at high risk of motor disability: A systematic review.

AIM: To systematically review the scientific literature to determine the predictive validity of technology-assisted measures of observable infant movement in infants less than six months of corrected age (CA) to identify high-risk of motor disability. METHOD: A comprehensive search for randomised and non-randomised controlled trials, cohort studies and cross-comparison trials was performed on five electronic databases up to Feb 2021. Studies were included if they quantified infant movement before 6 months CA using some method of technology-assistance and compared the instrumented measure to a diagnostic clinical measure of neurodevelopment. Studies were excluded if they did not report a technology-assisted measure of infant movement. Methodological quality of the included studies was assessed using the Downs and Black scale. RESULTS: 23 studies met the full inclusion and exclusion criteria. Methodological quality of the included papers ranged from 9 to 24 (out of 26) on the Downs and Black scale. Infant movement assessments included the General Movements Assessment (GMA) and domains of the Hammersmith Infant Neurological Assessment (HINE). Studies used 2D video recordings, RGB-Depth recordings, accelerometry, and electromagnetic motion tracking technologies to quantify movement. Analytical approaches and movement features of interest were individual and varied. Technology assisted quantitative assessments identified cases of later diagnosed CP with sensitivity 44-100 %, specificity 59-95 %, Area under the ROC Curve 82-93 %; and typical development with sensitivity range 30-46 %, specificity 88-95 %, Area under the ROC Curve 68 %. INTERPRETATION: Technology-assisted assessments of movement in infants less than 6 months CA using current technologies are feasible. Validation of measurement tools are limited. Although methods and results appear promising clinical uptake of technology-assisted assessments remains limited.

M♡THer, an mHealth System to Support Women with Gestational Diabetes Mellitus: Feasibility and Acceptability Study.

Background: Gestational diabetes mellitus (GDM) is defined as glucose intolerance first identified during pregnancy. Delays in diagnosis and challenges in management can lead to serious adverse outcomes for the mother and child. As rates of GDM diagnosis increase worldwide, health systems and maternity services have become increasingly strained, especially with new restrictions around in-person care due to the current COVID-19 pandemic. Mobile health (mHealth) has increasingly shown promise for management of chronic disease, driven by smartphone adoption and increased internet connectivity. The aim of this work was to evaluate the adoption and multidisciplinary care coordination of an mHealth platform called M♡THer in a cohort of women with first-time diagnosis of GDM. Methods: The mHealth platform for GDM management was developed incorporating a smartphone application, clinician portal, and secure cloud data storage. Forty participants with a first-time diagnosis of GDM were recruited to use the app during their pregnancy. User attitudes from clinicians and women were captured through post-hoc surveys, and app-usage metrics. Results: Clinicians and women indicated satisfaction and ease of use of the mHealth platform, with some technological challenges around wireless connectivity. Blood glucose reviews and antenatal contact were higher with use of the M♡THer app compared with a matched historical sample. Conclusion: The M♡THer mHealth platform is a new comprehensive tool for health care of women with GDM, and may provide an effective new avenue to enhance multidisciplinary care in the face of COVID-19 disruptions and challenges to traditional care pathways.

Physiological Signal Monitoring for Identification of Emotional Dysregulation in Children.

Children, particularly those with atypical or delayed development, have a reduced ability to self-regulate their emotions and behaviour. After a number of anxiety or stress provoking events, this reduced regulatory ability can result in a meltdown. Extrinsic signals of an impending meltdown are often recognised and acted on by clinicians or parents. These external indications are also accompanied by internal physiological changes, such as increase in heart rate, skin electrodermal activity, and skin temperature. These physiological signals may be used to predict impending meltdown events and facilitate earlier and effective carer intervention, especially in complex management cases. We present a preliminary study using a wearable sensor system for continuous monitoring of physiological signals to measure and predict emotional changes in school-aged children. Our models are able to correctly classify the behavioural state of a child with 68% mean global model accuracy and up to 85% for person-dependent models. Prediction of emotion and identification of impending meltdowns will potentially assist parents, carers, teachers and clinicians to manage stress and problem behaviours before they escalate, and support self-management strategies throughout the variety of normal daily life.

A motor-driven adjustable prosthetic socket operated using a mobile phone app: A technical note.

Sockets that allow incremental size adjustment during ambulation may help prosthesis users improve management of their changes in limb volume and the quality of their prosthetic fit. A platform system was developed that allowed people with trans-tibial limb loss to adjust the radial positions of socket panels during ambulation in small increments via a motor mounted beneath the socket. The motor altered the length of a cable running through the socket panels according to commands communicated from a mobile phone. A proportional-integral-derivative controller adjusted the voltage applied to the motor via pulse-width modulation to achieve target settings. Bench test results showed that when the system was subjected to loads comparable to those expected during clinical use, maximum absolute steady state error was 0.036 mm. Treadmill testing on 16 people with trans-tibial limb amputation demonstrated that the range of cable lengths over which participants deemed fit clinically acceptable varied between 24 mm and 114 mm depending on the user. In field testing 11 of 13 participants were comfortable making socket size adjustments while walking. The developed system achieves incremental socket size adjustments appropriate for research and development of ambulatory adjustable sockets.

Socket size adjustments in people with transtibial amputation: Effects on residual limb fluid volume and limb-socket distance.

BACKGROUND: Small intermittent adjustments of socket size using adjustable sockets may be a means for people with transtibial amputation to better maintain residual limb fluid volume and limb position while using a prosthesis. METHODS: Socket size, limb fluid volume, and distance from the limb to the socket, termed "sensed distance," were recorded while participants with transtibial amputation walked on a treadmill wearing a motor-driven, cabled-panel, adjustable socket. Researchers made frequent socket size adjustments using a mobile phone app to identify participants' acceptable socket size range. Limb fluid volume and sensed distance were then monitored as incremental adjustments were made to the socket. FINDINGS: Prosthesis users in this study (n = 10) accepted socket sizes between -5% and +5% of their neutral socket volume. There was a rapid increase in limb fluid volume and sensed distance upon socket enlargement, and a rapid decrease upon reduction. Subsequently, there were gradual changes in fluid volume and sensed distance. While visually monitoring limb fluid volume data in real time, researchers were able to adjust socket size to maintain consistent limb fluid volume within a -0.7% to +0.9% volume change for 24 min. INTERPRETATION: Participant residual limbs compensated to socket size adjustment. Using socket-mounted sensors to monitor limb-socket mechanics, an automatic adjustable socket that maintains limb fluid volume may be possible and may improve socket fit in instances where fit deteriorates during use.

Health-e Minds: a Participatory Personalised and Gamified mHealth Platform to Support Healthy Living Behaviours for People with Mental Illness.

This paper presents the development of an innovative platform (Health-e Minds) to support persons with diagnosed serious mental illness (SMI) in their self-management, but also to enhance multidisciplinary care provision. It comprises of a smartphone app and an interactive internet-based clinician web portal. The smartphone app accompanies and guides persons with SMI through their recovery journey by monitoring health measures, delivering simple interactive questionnaires and providing educational and motivational multimedia content. The web-portal enables clinical care providers to view their client's progress and provide individualized feedback and/or early care intervention dependent on the advice of the clinical review. A unique feature of the platform is an inbuilt gaming component which encourages patients to adhere to the goals set in consultation with their clinicians. Rewards are attained by comparison of activities achieved, measured against individualized goals, set through the clinical portal. A feasibility study is underway among 40 patients with SMI at the Sunshine Coast University Hospital, in order to ascertain levels of program efficacy and successful health-related outcomes.

Development of a Wearable Sensor Network for Quantification of Infant General Movements for the Diagnosis of Cerebral Palsy.

Qualitative assessments of infant spontaneous movements can be performed to measure neurodevelopmental status and provide early insight into the presence of any abnormalities. Clinical assessments of infant movements at 12 weeks post term age are up to 98% predictive of the eventual development of Cerebral Palsy, but their reach is often limited to infants already identified as high-risk within the traditional healthcare system. We present the development of a network of wearable sensors designed to noninvasively measure spontaneous movements in infants from 12-20 weeks post-term- age both within the clinic and for future home use. Pilot data on a single healthy term infant is presented to demonstrate clinical functionality towards future validation studies in infants at high-risk of Cerebral Palsy. Using this system for tele- delivered assessments in the home could enhance screening of neurodevelopmental disorders for infants and families in rural and remote areas, a population with reduced health services.

Effects of activity intensity, time, and intermittent doffing on daily limb fluid volume change in people with transtibial amputation.

BACKGROUND:: The volume of a prosthesis user's residual limb changes during the day and may affect the fit of the prosthesis. These changes must be managed by the user to prevent discomfort, skin breakdown, and falls. OBJECTIVES:: The objectives were to test how activity, time of day, and intermittent doffing affected residual limb fluid volume in people with transtibial amputation. STUDY DESIGN:: Standardized, repeated measure (A-B-A) out-of-laboratory protocol. METHODS:: Participants with transtibial amputation completed three 6-h test sessions. Two sessions served as controls (A protocol) during which participants left their prosthesis donned, and one session was an intervention (B protocol) where participants doffed their prosthesis twice for 20 min during the 6 h of testing. Within-socket fluid volume was measured using a custom portable bioimpedance analysis system. RESULTS:: A total of 13 participants completed the study. The rate of limb fluid volume loss was higher early in the session compared with late in the session. Participants experienced less fluid volume loss during high activity than low activity. Socket users with pin suspension experienced less posterior fluid volume loss when they intermittently doffed their prosthesis. Intermittent doffing did not benefit limb fluid volume of mechanical vacuum and suction suspension users. CONCLUSION:: High activity may reduce fluid volume loss compared with low activity. Intermittent doffing may provide volume accommodation for transtibial prosthesis users with pin suspension. CLINICAL RELEVANCE: Prosthetists should query their patients about the intensity of activity they conduct when advising them on limb volume management. Patients using sockets with pin suspension may be able to offset limb fluid volume loss by periodically doffing the prosthesis.

Increasing Health Care Adherence Through Gamification, Video Feedback, and Real-World Rewards.

Treatment non-adherence poses a sizeable and persistent challenge to health professionals. In the US alone, it is estimated that at least $100 billion per year is spent on avoidable health care costs with an additional $230 billion per year forfeited due to lost productivity. Efforts to increase adherence have yielded mixed results. We present an adaptable, theoretical framework that uses established gamification methods coupled with a means of motivating patients using real-world rewards. The framework presented herein is implemented via user interface modifications to a clinically validated health tracking app, as well as a means of delivering video feedback for viewing a variety of potential reward outcomes.

Residual limb fluid volume change and volume accommodation: Relationships to activity and self-report outcomes in people with trans-tibial amputation.

BACKGROUND: Fluctuations in limb volume degrade prosthesis fit and require users to accommodate changes using management strategies, such as donning and doffing prosthetic socks. OBJECTIVES: To examine how activities and self-report outcomes relate to daily changes in residual limb fluid volume and volume accommodation. STUDY DESIGN: Standardized, two-part laboratory protocol with an interim observational period. METHODS: Participants were classified as "accommodators" or "non-accommodators," based on self-report prosthetic sock use. Participants' residual limb fluid volume change was measured using a custom bioimpedance analyzer and a standardized in-laboratory activity protocol. Self-report health outcomes were assessed with the Socket Comfort Score and Prosthesis Evaluation Questionnaire. Activity was monitored while participants left the laboratory for at least 3 h. They then returned to repeat the bioimpedance test protocol. RESULTS: Twenty-nine people were enrolled. Morning-to-afternoon percent limb fluid volume change per hour was not strongly correlated to percent time weight-bearing or to self-report outcomes. As a group, non-accommodators ( n = 15) spent more time with their prosthesis doffed and reported better outcomes than accommodators. CONCLUSION: Factors other than time weight-bearing may contribute to morning-to-afternoon limb fluid volume changes and reported satisfaction with the prosthesis among trans-tibial prosthesis users. Temporary doffing may be a more effective and satisfying accommodation method than sock addition. Clinical relevance Practitioners should be mindful that daily limb fluid volume change and prosthesis satisfaction are not dictated exclusively by activity. Temporarily doffing the prosthesis may slow daily limb fluid volume loss and should be investigated as an alternative strategy to sock addition.

Instrumented socket inserts for sensing interaction at the limb-socket interface.

The objective of this research was to investigate a strategy for designing and fabricating computer-manufactured socket inserts that were embedded with sensors for field monitoring of limb-socket interactions of prosthetic users. An instrumented insert was fabricated for a single trans-tibial prosthesis user that contained three sensor types (proximity sensor, force sensing resistor, and inductive sensor), and the system was evaluated through a sequence of laboratory clinical tests and two days of field use. During in-lab tests 3 proximity sensors accurately distinguish between don and doff states; 3 of 4 force sensing resistors measured gradual pressure increases as weight-bearing increased; and the inductive sensor indicated that as prosthetic socks were added the limb moved farther out of the socket and pistoning amplitude decreased. Multiple sensor types were necessary in analysis of field collected data to interpret how sock changes affected limb-socket interactions. Instrumented socket inserts, with sensors selected to match clinical questions of interest, have the potential to provide important insights to improve patient care.

Effects of socket size on metrics of socket fit in trans-tibial prosthesis users.

The purpose of this research was to conduct a preliminary effort to identify quantitative metrics to distinguish a good socket from an oversized socket in people with trans-tibial amputation. Results could be used to inform clinical practices related to socket replacement. A cross-over study was conducted on community ambulators (K-level 3 or 4) with good residual limb sensation. Participants were each provided with two sockets, a duplicate of their as-prescribed socket and a modified socket that was enlarged or reduced by 1.8mm (∼6% of the socket volume) based on the fit quality of the as-prescribed socket. The two sockets were termed a larger socket and a smaller socket. Activity was monitored while participants wore each socket for 4 weeks. Participants' gait; self-reported satisfaction, quality of fit, and performance; socket comfort; and morning-to-afternoon limb fluid volume changes were assessed. Visual analysis of plots and estimated effect sizes (measured as mean difference divided by standard deviation) showed largest effects for step time asymmetry, step width asymmetry, anterior and anterior-distal morning-to-afternoon fluid volume change, socket comfort score, and self-reported utility. These variables may be viable metrics for early detection of deterioration in socket fit, and should be tested in a larger clinical study.

A Bioimpedance Analysis Platform for Amputee Residual Limb Assessment.

OBJECTIVE: The objective of this research was to develop a bioimpedance platform for monitoring fluid volume in residual limbs of people with trans-tibial limb loss using prostheses. METHODS: A customized multifrequency current stimulus profile was sent to thin flat electrodes positioned on the thigh and distal residual limb. The applied current signal and sensed voltage signals from four pairs of electrodes located on the anterior and posterior surfaces were demodulated into resistive and reactive components. An established electrical model (Cole) and segmental limb geometry model were used to convert results to extracellular and intracellular fluid volumes. Bench tests and testing on amputee participants were conducted to optimize the stimulus profile and electrode design and layout. RESULTS: The proximal current injection electrode needed to be at least 25 cm from the proximal voltage sensing electrode. A thin layer of hydrogel needed to be present during testing to ensure good electrical coupling. Using a burst duration of 2.0 ms, intermission interval of 100 µs, and sampling delay of 10 µs at each of 24 frequencies except 5 kHz, which required a 200-µs sampling delay, the system achieved a sampling rate of 19.7 Hz. CONCLUSION: The designed bioimpedance platform allowed system settings and electrode layouts and positions to be optimized for amputee limb fluid volume measurement. SIGNIFICANCE: The system will be useful toward identifying and ranking prosthetic design features and participant characteristics that impact residual limb fluid volume.

Preliminary evaluation of a novel bladder-liner for facilitating residual limb fluid volume recovery without doffing.

For people who wear a prosthetic limb, residual-limb fluid volume loss during the day may be problematic and detrimentally affect socket fit. The purpose of this research was to test the capability of a novel liner with adjustable bladders positioned within its wall to mitigate volume loss and facilitate limb fluid volume recovery and retention. Bioimpedance analysis was used to monitor fluid volume changes in the anterior and posterior residual limb of participants with transtibial amputation. Participants underwent six cycles of sitting for 90 s, standing for 90 s, and walking for 5 min with liquid within the bladder-liners. Between the third and fourth cycles, participants sat for 10 min with liquid left within the bladders (Liquid-In) or removed (Liquid-Out). Results showed that participants recovered more fluid volume during the 10 min of sitting with Liquid-Out than Liquid-In (p = 0.09 for anterior and p = 0.04 for posterior). However, those fluid volume recoveries were not well retained in the short term (after the fourth cycle) or the long term (after the sixth cycle). Physiologic differences between sessions, reflected in the rates of fluid volume change at the outset of the session, and excessive stiffness of the bladder-liners may have affected fluid volume retentions.

Liquid cooling system for the vibro-tactile threshold device.

Vibrotactile threshold testing has been used to investigate activation of human somatosensory pathways. A portable vibrotactile threshold testing device called the Vibrotactile Threshold Evaluator for the Workplace (VTEW) was designed for screening of carpal tunnel syndrome in the workplace, and initially contained a small fan for cooling. During subject testing, the device is operated intermittently, which causes the linear actuator to warm the tactile probe. The probe causes discomfort for some subjects. During testing, the probe heated to 42 °C within 90 seconds of continuous operation. A liquid cooling system was implemented to dissipate heat from the probe. The liquid cooling system maintains a steady state temperature of 36 °C for continuous actuation of the probe. The liquid cooling system is capable of maintaining a safe operating temperature, without adding erroneous vibrations to the device. However, the cooling system deters the portability of the device. Further research will investigate how to make the liquid cooling system portable and implements vibrotactile threshold testing in the workplace to quickly evaluate whether or not a person has early symptoms of carpal tunnel syndrome.

A wireless sensory feedback system for real-time gait modification.

Current rehabilitation technology and techniques have proven effective at modifying and correcting gait abnormalities. They are however limited to laboratory and clinical settings, under the supervision of a specialist. Conventional techniques for quantifying gait asymmetries can be combined with sensory feedback methods to provide an intuitive and inexpensive feedback system for extra-clinical rehabilitation. A wireless feedback system has been designed to collect gait information, process it in real-time, and provide corrective feedback to the user. The corrective feedback can be presented through visual, audible, or vibrotactile methods, or a combination thereof. Initial results have led to improvement in the sensory interface of the device to maximize the corrective influence on inexperienced subjects. These preliminary findings suggest that the wireless feedback device can influence the gait of the user, and effectively adapt to their personal feedback preferences.