Rehabilitation activities with tablet (REACT) in Parkinson's disease.

INTRODUCTION: There is evidence to demonstrate that plasticity is "use-dependent" and that intensive practice may be necessary to modify neural organization. PURPOSE: The main aim of this work is to investigate the REACT usability, an innovative app, to assist People with Parkinson Disease (PwPD) at home. METHODS: A pilot study has been conducted enrolling 20 consecutive PwPD. Before home rehabilitation activities started, each patient received training on the REACT app and how to use the device and the services in daily practice. Motor and cognitive evaluations were administered to assign personalized exercises, tailored to patients' needs and potential. PwPD carried out REACT home program for 1 month, four times a week. The app included motor exercise and tutorial of activities of daily living (ADL) and functional cognitive stimulation. REACT-app usability was evaluated with the System Usability Scale (SUS). RESULTS: The results from SUS questionnaire were, on average, above the threshold of "good usability" (SUS score > 68), as reported in the literature. The 47% of PwPD that used the app rated the usability of the solution as "excellent." Almost all SUS items reached the reference benchmark (except items 4, 5, and 7). No adverse events occurred. CONCLUSIONS: REACT can be considered a useful and safe tool to support the continuity of care and treatment at home, in PwPD. Larger-scale trials are needed to validate the good acceptance and efficacy of home rehabilitation through technology applications.

Effects of gait rehabilitation on motor coordination in stroke survivors: an UCM-based approach.

Post-stroke locomotion is usually characterized by asymmetrical gait patterns, compensatory movements of trunk and nonparetic limb, altered motor coordination, and wide inter-stride variability. This pilot study was designed to test a twofold hypothesis: post-stroke survivors can exploit the redundancy of the segmental angles to stabilize the 3D footpath trajectory during the swing phase, in accordance with the Uncontrolled Manifold (UCM) theory; an intense rehabilitative treatment improves both motor performance and outcomes of the UCM analysis. Ten stroke survivors underwent two evaluation sessions, before and after a conventional multidisciplinary intensive rehabilitation program, encompassing clinical tests and gait analysis, both overground and on treadmill. In addition, the UCM analysis was implemented to investigate whether variance of segmental angles is structured to minimize the inter-stride variability of the 3D footpath during the swing phase of treadmill locomotion. Both clinical and spatio-temporal parameters improved after the treatment, even if the statistical significance was reached for a limited set of them. The UCM analysis suggested that post-stroke survivors exploit the redundancy of lower limbs segmental angles mainly during the late swing, without significant differences between affected and unaffected sides. Thereafter, the main significant effects of the rehabilitative treatment consisted in strengthening the synergistic organization of the redundant segmental angles involving a more accurate control of the 3D footpath. Concluding, the UCM theory can be a promising tool to appraise the effects of a specific rehabilitative protocol on motor coordination in post-stroke survivors.

Evaluation of an Automatic Speech Recognition Platform for Dysarthric Speech.

INTRODUCTION: The use of commercially available automatic speech recognition (ASR) software is challenged when dysarthria accompanies a physical disability. To overcome this issue, a mobile and personal speech assistant (mPASS) platform was developed, using a speaker-dependent ASR software. OBJECTIVE: The aim of this study was to evaluate the performance of the proposed platform and to compare mPASS recognition accuracy to a commercial speaker-independent ASR software. In addition, secondary aims were to investigate the relationship between severity of dysarthria and accuracy and to explore people with dysarthria perceptions on the proposed platform. METHODS: Fifteen individuals with dysarthric speech and 20 individuals with nondysarthric speech recorded 24 words and 5 sentences in a clinical environment. Differences in recognition accuracy between the two systems were evaluated. In addition, mPASS usability was assessed with a technology acceptance model (TAM) questionnaire. RESULTS: In both groups, mean accuracy rates were significantly higher with mPASS compared to the commercial ASR for words and for sentences. mPASS reached good levels of usefulness and ease of use according to the TAM questionnaire. CONCLUSIONS: Practical applicability of this technology is realistic: the mPASS platform is accurate, and it could be easily used by individuals with dysarthria.

Rehabilitation, the Great Absentee of Virtual Coaching in Medical Care: Scoping Review.

BACKGROUND: In the last few years, several studies have focused on describing and understanding how virtual coaches (ie, coaching program or smart device aiming to provide coaching support through a variety of application contexts) could be key drivers for health promotion in home care settings. As there has been enormous technological progress in the field of artificial intelligence and data processing in the past decade, the use of virtual coaches gains an augmented attention in the considerations of medical innovations. OBJECTIVE: This scoping review aimed at providing an overview of the applications of a virtual coach in the clinical field. In particular, the review focused on the papers that provide tangible information for coaching activities with an active implication for engaging and guiding patients who have an ongoing plan of care. METHODS: We aimed to investigate the use of the term virtual coach in the clinical field performing a methodical review of the relevant literature indexed on PubMed, Scopus, and Embase databases to find virtual coach papers focused on specific activities dealing with clinical or medical contexts, excluding those aimed at surgical settings or electronic learning purposes. RESULTS: After a careful revision of the inclusion and exclusion criteria, 46 records were selected for the full-text review. Most of the identified articles directly or indirectly addressed the topic of physical activity. Some papers were focused on the use of virtual coaching (VC) to manage overweight or nutritional issues. Other papers dealt with technological interfaces to facilitate interactions with patients suffering from different chronic clinical conditions such as heart failure, chronic obstructive pulmonary disease, depression, and chronic pain. CONCLUSIONS: Although physical activity is a healthy practice that is most encouraged by a virtual coach system, in the current scenario, rehabilitation is the great absentee. This paper gives an overview of the tangible applications of this tool in the medical field and may inspire new ideas for future research on VC.

Aging does not affect the intralimb coordination elicited by slip-like perturbation of different intensities.

This study was aimed at verifying whether aging modifies intralimb coordination strategy during corrective responses elicited by unexpected slip-like perturbations delivered during steady walking on a treadmill. To this end, 10 young and 10 elderly subjects were asked to manage unexpected slippages of different intensities. We analyzed the planar covariation law of the lower limb segments, using the principal component analysis, to verify whether elevation angles of older subjects covaried along a plan before and after the perturbation. Results showed that segments related to the perturbed limbs of both younger and older people do not covary after all perturbations. Conversely, the planar covariation law of the unperturbed limb was systematically held for younger and older subjects. These results occurred despite differences in spatio-temporal and kinematic parameters being observed among groups and perturbation intensities. Overall, our analysis revealed that aging does not affect intralimb coordination during corrective responses induced by slip-like perturbation, suggesting that both younger and older subjects adopt this control strategy while managing sudden and unexpected postural transitions of increasing intensities. Accordingly, results corroborate the hypothesis that balance control emerges from a governing set of biomechanical invariants, that is, suitable control schemes (e.g., planar covariation law) shared across voluntary and corrective motor behaviors, and across different sensory contexts due to different perturbation intensities, in both younger and older subjects. In this respect, our findings provide further support to investigate the effects of specific task training programs to counteract the risk of fall.NEW & NOTEWORTHY This study was aimed at investigating how aging affects the intralimb coordination of lower limb segments, described by the planar covariation law, during unexpected slip-like perturbations of increasing intensity. Results revealed that neither the aging nor the perturbation intensity affects this coordination strategy. Accordingly, we proposed that the balance control emerges from an invariant set of control schemes shared across different sensory motor contexts and despite age-related neuromuscular adaptations.

Model-based variables for the kinematic assessment of upper-extremity impairments in post-stroke patients.

BACKGROUND: Common scales for clinical evaluation of post-stroke upper-limb motor recovery are often complemented with kinematic parameters extracted from movement trajectories. However, there is no a general consensus on which parameters to use. Moreover, the selected variables may be redundant and highly correlated or, conversely, may incompletely sample the kinematic information from the trajectories. Here we sought to identify a set of clinically useful variables for an exhaustive but yet economical kinematic characterization of upper limb movements performed by post-stroke hemiparetic subjects. METHODS: For this purpose, we pursued a top-down model-driven approach, seeking which kinematic parameters were pivotal for a computational model to generate trajectories of point-to-point planar movements similar to those made by post-stroke subjects at different levels of impairment. RESULTS: The set of kinematic variables used in the model allowed for the generation of trajectories significantly similar to those of either sub-acute or chronic post-stroke patients at different time points during the therapy. Simulated trajectories also correctly reproduced many kinematic features of real movements, as assessed by an extensive set of kinematic metrics computed on both real and simulated curves. When inspected for redundancy, we found that variations in the variables used in the model were explained by three different underlying and unobserved factors related to movement efficiency, speed, and accuracy, possibly revealing different working mechanisms of recovery. CONCLUSION: This study identified a set of measures capable of extensively characterizing the kinematics of upper limb movements performed by post-stroke subjects and of tracking changes of different motor improvement aspects throughout the rehabilitation process.

The effect of arm weight support on upper limb muscle synergies during reaching movements.

BACKGROUND: Compensating for the effect of gravity by providing arm-weight support (WS) is a technique often utilized in the rehabilitation of patients with neurological conditions such as stroke to facilitate the performance of arm movements during therapy. Although it has been shown that, in healthy subjects as well as in stroke survivors, the use of arm WS during the performance of reaching movements leads to a general reduction, as expected, in the level of activation of upper limb muscles, the effects of different levels of WS on the characteristics of the kinematics of motion and of the activity of upper limb muscles have not been thoroughly investigated before. METHODS: In this study, we systematically assessed the characteristics of the kinematics of motion and of the activity of 14 upper limb muscles in a group of 9 healthy subjects who performed 3-D arm reaching movements while provided with different levels of arm WS. We studied the hand trajectory and the trunk, shoulder, and elbow joint angular displacement trajectories for different levels of arm WS. Besides, we analyzed the amplitude of the surface electromyographic (EMG) data collected from upper limb muscles and investigated patterns of coordination via the analysis of muscle synergies. RESULTS: The characteristics of the kinematics of motion varied across WS conditions but did not show distinct trends with the level of arm WS. The level of activation of upper limb muscles generally decreased, as expected, with the increase in arm WS. The same eight muscle synergies were identified in all WS conditions. Their level of activation depended on the provided level of arm WS. CONCLUSIONS: The analysis of muscle synergies allowed us to identify a modular organization underlying the generation of arm reaching movements that appears to be invariant to the level of arm WS. The results of this study provide a normative dataset for the assessment of the effects of the level of arm WS on muscle synergies in stroke survivors and other patients who could benefit from upper limb rehabilitation with arm WS.

Virtual Coaching for Home Rehabilitation - Evidence of an Empirical Study.

Older individuals often face disabilities or diseases that lower their quality of life (QoL). While inpatient rehabilitation can initially enhance QoL, there is often a lack of continuation at home. Virtual coaches (VCs) as specific embodied conversational agents promise appropriate support for home rehabilitation. They emerge as complementary digital aids to ensure care continuity. This paper presents the results of implementing a full-featured VC for older patients' home rehabilitation in a multi-stage study, summarizing the main results regarding QoL outcomes and user experience tests. The study confirms the intervention as an engaging means for rehabilitation (mostly above user experience thresholds) and improvements of QoL (>10% between experimental and control groups).

EMG-based pattern recognition approach in post stroke robot-aided rehabilitation: a feasibility study.

BACKGROUND: Several studies investigating the use of electromyographic (EMG) signals in robot-based stroke neuro-rehabilitation to enhance functional recovery. Here we explored whether a classical EMG-based patterns recognition approach could be employed to predict patients' intentions while attempting to generate goal-directed movements in the horizontal plane. METHODS: Nine right-handed healthy subjects and seven right-handed stroke survivors performed reaching movements in the horizontal plane. EMG signals were recorded and used to identify the intended motion direction of the subjects. To this aim, a standard pattern recognition algorithm (i.e., Support Vector Machine, SVM) was used. Different tests were carried out to understand the role of the inter- and intra-subjects' variability in affecting classifier accuracy. Abnormal muscular spatial patterns generating misclassification were evaluated by means of an assessment index calculated from the results achieved with the PCA, i.e., the so-called Coefficient of Expressiveness (CoE). RESULTS: Processing the EMG signals of the healthy subjects, in most of the cases we were able to build a static functional map of the EMG activation patterns for point-to-point reaching movements on the horizontal plane. On the contrary, when processing the EMG signals of the pathological subjects a good classification was not possible. In particular, patients' aimed movement direction was not predictable with sufficient accuracy either when using the general map extracted from data of normal subjects and when tuning the classifier on the EMG signals recorded from each patient. CONCLUSIONS: The experimental findings herein reported show that the use of EMG patterns recognition approach might not be practical to decode movement intention in subjects with neurological injury such as stroke. Rather than estimate motion from EMGs, future scenarios should encourage the utilization of these signals to detect and interpret the normal and abnormal muscle patterns and provide feedback on their correct recruitment.

Effects of early and intensive neuro-rehabilitative treatment on muscle synergies in acute post-stroke patients: a pilot study.

BACKGROUND: After a stroke, patients show significant modifications of neural control of movement, such as abnormal muscle co-activation, and reduced selectivity and modulation of muscle activity. Nonetheless, results reported in literature do not allow to unequivocally explain whether and, in case, how a cerebrovascular accident affects muscle synergies underlying the control of the upper limb. These discrepancies suggest that a complete understanding of the modular re-organization of muscle activity due to a stroke is still lacking. This pilot study aimed at investigating the effects of the conjunction between the natural ongoing of the pathology and the intense robot-mediated treatment on muscle synergies of the paretic upper limb of subacute post-stroke patients. METHODS: Six subacute patients, homogenous with respect to the age and the time elapsed from the trauma, and ten healthy age-matched subjects were enrolled. The protocol consisted in achieving planar movement of the upper limb while handling the end-effector of a robotic platform. Patients underwent 6 weeks long treatment while clinical scores, kinematics of the end-effector and muscle activity were recorded. Then we verified whether muscle coordination underlying the motor task was significantly affected by the cerebrovascular accident and how muscle synergies were modified along the treatment. RESULTS: Results show that although muscle synergies in subacute stroke patients were qualitatively comparable to those of healthy subjects, those underlying the movement of the shoulder can reflect the functional deficit induced by the pathology. Moreover, the improvement of motor performance due to the treatment was achieved in conjunction with slight modifications of muscle synergies. In this regard, modifications of muscle synergies appeared to be influenced by the different recovering mechanisms across patients presumably due to the heterogeneity of lesions, sides and location of the accident. CONCLUSIONS: The results support the hypothesis that muscle synergies reflect the injury of the cerebrovascular accident and could document the effects of the functional recovery due to a suitable and customized treatment. Therefore, they open up new possibilities for the development of more effective neuro-rehabilitation protocols.

Pay attention: you can fall! The Mini-BESTest scale and the turning duration of the TUG test provide valid balance measures in neurological patients: a prospective study with falls as the balance criterion.

Background: Balance, i.e., the ability not to fall, is often poor in neurological patients and this impairment increases their risk of falling. The Mini-Balance Evaluation System Test (Mini-BESTest), a rating scale, the Timed Up and Go (TUG) test, and gait measures are commonly used to quantify balance. This study assesses the criterion validity of these measures as balance measures. Methods: The probability of being a faller within nine months was used as the balance criterion. The Mini-BESTest, TUG (instrumented with inertial sensors), and walking test were administered before and after inpatient rehabilitation. Multiple and LASSO logistic regressions were used for the analysis. The diagnostic accuracy of the model was assessed with the area under the curve (AUC) of the receiver operating characteristic curve. Mobility measure validity was compared with the Akaike Information Criterion (AIC). Results: Two hundred and fourteen neurological patients (stroke, peripheral neuropathy, or parkinsonism) were recruited. In total, 82 patients fell at least once in the nine-month follow-up. The Mini-BESTest (AUC = 0.69; 95%CI: 0.62-0.76), the duration of the TUG turning phase (AUC = 0.69; 0.62-0.76), and other TUG measures were significant faller predictors in regression models. However, only the turning duration (AIC = 274.0) and Mini-BESTest (AIC = 276.1) substantially improved the prediction of a baseline model, which only included fall risk factors from the medical history (AIC = 281.7). The LASSO procedure selected gender, disease chronicity, urinary incontinence, the Mini-BESTest, and turning duration as optimal faller predictors. Conclusion: The TUG turning duration and the Mini-BESTest predict the chance of being a faller. Their criterion validity as balance measures in neurological patients is substantial.

Differential Item Functioning of the Mini-BESTest Balance Measure: A Rasch Analysis Study.

The Mini-Balance Evaluation Systems Test (Mini-BESTest), a 14-item scale, has high content validity for balance assessment. This study further examines the construct validity of the Mini-BESTest with an emphasis on its measurement invariance. The Mini-BESTest was administered to 292 neurological patients in two sessions (before and after rehabilitation) and evaluated with the Rasch analysis (Many-Facet Rating Scale Model: persons, items, sessions). Categories' order and fit to the model were assessed. Next, maps, dimensionality, and differential item functioning (DIF) were examined for construct validity evaluation. DIF was inspected for several clinically important variables, including session, diagnosis, and assistive devices. Mini-BESTest items had ordered categories and fitted the Rasch model. The item map did not flag severe construct underrepresentation. The dimensionality analysis showed that another variable extraneous to balance affected the score of a few items. However, this multidimensionality had only a modest impact on measures. Session did not cause DIF. DIF for assistive devices affected six items and caused a severe measurement artefact. The measurement artefact caused by DIF for diagnosis was negligible. The Mini-BESTest returns interval measures with robust construct validity and measurement invariance. However, caution should be used when comparing Mini-BESTest measures obtained with and without assistive devices.

Personalized Integrated Care Promoting Quality of Life for Older People: Protocol for a Multicenter Randomized Controlled Trial.

BACKGROUND: Alzheimer disease (AD) and Parkinson disease (PD) are the 2 most common neurodegenerative diseases affecting millions of people worldwide. The Personalized Integrated Care Promoting Quality of Life for Older People (PC4L) project proposes an integrated, scalable, and interactive care ecosystem that can be easily adapted to the needs of several neurodegenerative and chronic diseases, care institutions, and end user requirements. OBJECTIVE: The study protocol developed within the framework of the PC4L project aims to iteratively test the integrated platform and its modules, and focuses primarily on assessing the impact of the proposed solution (ie, the PC4L platform) on patients' quality of life, as well as its usability and feasibility on a large-scale sample size in 3 different scenarios (home, neurorehabilitation, and day care centers). METHODS: A prospective multicenter clinical study is conducted in 5 European countries (Germany, Italy, Portugal, Romania, and Spain) at 6 different pilot centers, for 3 months, in patients with PD, Parkinsonism, AD, and other dementias (ODs). Patients were randomized in a ratio of 1:1 to the intervention group (use of the PC4L system) or the control group (no intervention). The PC4L system consists mainly of a wristband for monitoring parameters such as steps and levels of physical activity, and the PC4L app, which includes different engaging functionalities. Both groups are assessed through baseline and end-of-study clinical evaluations, including assessment of quality of life through the EQ-5D-3L scale. RESULTS: The study protocol is part of a project approved and funded by the European Commission Horizon 2020 (grant agreement number 875221). The ethics committees of all involved centers reviewed and approved the study protocol. The study began with the recruitment phase in September 2022, and enrollment ended in February 2023. Recruitment is now closed (April 2023). The results of this study are expected to be published in summer 2023. A total of 558 patients, 279 per study group, were recruited. The results will allow to clarify the impact of PC4L on quality of life, will assess the empowerment of patients and the medical resources use, as well as the usability of the final version of the PC4L system. It will also provide information on the support of the system as a tool to facilitate the decision-making process. CONCLUSIONS: The PC4L project intends to test a technology-based, integrated, scalable, and interactive care platform on patients with neurodegenerative diseases and proposes a good coordinated care model between all involved actors. Future developments of the PC4L solution may involve caregivers and socio-health professionals in the decision-making process in order to facilitate efficient communication between all stakeholders and ensure reliable and protected access to data within Europe. TRIAL REGISTRATION: ClinicalTrials.gov NCT05538455; https://clinicaltrials.gov/study/NCT05538455. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/47916.

Action Observation Treatment for Upper Limb Rehabilitation in Patients With Stroke: Protocol for a Multicenter Randomized Controlled Trial.

BACKGROUND: In the last few years, new noninvasive strategies have emerged as rehabilitative treatments for patients with stroke. Action observation treatment (AOT) is a rehabilitation approach based on the properties of the mirror neuron system with a positive impact on modifying cortical activation patterns and improving the upper limb kinematics. AOT involves the dynamic process of observing purposeful actions with the intention of imitating and then practicing those actions. In recent years, several clinical studies suggested the effectiveness of AOT in patients with stroke to improve motor recovery and autonomy in activities of daily living. However, a deeper knowledge of the behavior of the sensorimotor cortex during AOT seems to be essential. OBJECTIVE: The aim of this clinical trial, conducted in 2 neurorehabilitation centers and in patients' homes, is to investigate the effectiveness of AOT in patients with stroke, confirming the translational power of a tailored treatment. Particular emphasis will be placed on the predictive value of neurophysiological biomarkers. In addition, the feasibility and impact of a home-based AOT program will be investigated. METHODS: A 3-arm, assessor-blinded, randomized controlled trial will be performed by enrolling patients with stroke in the chronic stage. A total of 60 participants will be randomly allocated to receive 15 sessions of AOT with different protocols (AOT at the hospital, AOT at home, and sham AOT), 3 sessions per week. The primary outcome will be assessed using the Fugl-Meyer Assessment-Upper Extremity scores. Secondary outcomes will be clinical, biomechanical, and neurophysiological assessment. RESULTS: The study protocol is part of a project (project code GR-2016-02361678) approved and funded by the Italian Ministry of Health. The study began with the recruitment phase in January 2022, and enrollment was expected to end in October 2022. Recruitment is now closed (December 2022). The results of this study are expected to be published in spring 2023. Upon completion of the analyses, we will examine the preliminary effectiveness of the intervention and neurophysiological outcomes. CONCLUSIONS: This study will be used to evaluate the effectiveness of 2 different AOT scenarios (ie, AOT at the hospital and AOT at home) in patients with chronic stroke and to assess the predictive value of neurophysiological biomarkers. Specifically, we will attempt to induce the functional modification of the cortical components by exploiting the features of the mirror neuron system, demonstrating relevant clinical, kinematic, and neurophysiological changes after AOT. With our study, we also want to provide, for the first time in Italy, the AOT home-based program while assessing its feasibility and impact. TRIAL REGISTRATION: ClinicalTrials.gov NCT04047134; https://clinicaltrials.gov/ct2/show/NCT04047134. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42094.

End Users' and Other Stakeholders' Needs and Requirements in the Development of a Personalized Integrated Care Platform (PROCare4Life) for Older People With Dementia or Parkinson Disease: Mixed Methods Study.

BACKGROUND: With what has been known as the "triple-win effect", introducing information and communication technologies (ICTs) in the health care of neurodegenerative diseases is beneficial in delaying the need for institutional care, reducing the associated health care costs, reducing the caregiving burden, and improving individuals' quality of life. Nevertheless, the mismatch between the users' expectations and their actual needs remains one of the main challenges that can reduce the usability of technology solutions. Therefore, the European project Personalized Integrated Care Promoting Quality of Life for Older People (PROCare4Life), which aimed to develop an ICT-based platform for all parties involved in the health care of neurodegenerative diseases, adopted a user-centered design approach, where all users are involved from the inception and throughout the platform development and implementation to integrate their needs and requirements in the proposed platform. OBJECTIVE: This paper presents the results of a study on the needs and requirements of the potential end users (older people with neurodegenerative diseases, caregivers, and health care professionals) and other key stakeholders in the development of the PROCare4Life platform. METHODS: A mixed qualitative and quantitative study design was used, including 2 web-based surveys, 40 interviews, and 4 workshops. The study was conducted between April and September 2020 in 5 European countries: Germany, Italy, Portugal, Romania, and Spain. Both data types were analyzed separately and then merged and interpreted, with greater priority placed on qualitative research. RESULTS: A total of 217 participants were recruited; 157 (72.4%) of them completed the web-based surveys (n=85, 54.1% patients and n=72, 45.9% caregivers), and 60 (27.6%) individuals participated in the qualitative research (20/60, 33% health care professionals; 5/60, 8% patients; 5/60, 8% caregivers; and 30/60, 50% key stakeholders). We identified 3 main themes (T): (T1) experiences associated with illness, (T2) thoughts about the platform technology, and (T3) desired properties. Alerts for adverse events, communication tools, reminders, and monitoring are constantly needed functionalities, whereas ease of use, personalization, and user-friendliness are foreseen as necessary features. CONCLUSIONS: This paper identified the key personal, social, and health factors that influence the daily lives of the potential end users and reflected on their needs and expectations regarding the design of the proposed PROCare4Life platform. The collected data were useful for the development of the PROCare4Life platform. Although the combination and collection of features for diverse user groups are typical for integrated care platforms, it results in exponential complexity for designers, developers, and users. Contradicting opinions and several concerns in this study demonstrate that an ICT-integrated care platform should not promise too much for too many. Instead, selection, focus, and, sometimes, restriction to essentials are necessary. Users and other stakeholders should be involved in these decisions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/22463.

AGREE: an upper-limb robotic platform for personalized rehabilitation, concept and clinical study design.

Rehabilitation exoskeletons can supplement therapist-based training allowing post-stroke patients to perform functional, high-dosage, repetitive exercises. The use of robotic devices allows providing intense rehabilitation sessions and permits clinicians to personalize the therapy according to the patient's need. In this work, we propose an upper-limb rehabilitation system developed within the AGREE project. The platform relies on a four degrees-of-freedom arm exoskeleton, capable of assisting state-of-the-art rehabilitation exercises under different training modalities while behaving transparently to user-generated and therapist-applied forces. The system is provided with a LEDs-matrix mat to guide patients during reaching tasks with visual feedback, an EMG reader to evaluate the patient's involvement during the therapy, and several software tools to help clinicians customize the treatment and monitor the patient's progress. A randomized controlled pilot study aimed at evaluating the usability and the effectiveness of the AGREE rehabilitation platform to improve arm impairment after stroke is currently ongoing.

The Reaching Phase of Feeding and Self-Care Actions Optimizes Action Observation Effects in Chronic Stroke Subjects.

BACKGROUND: The Action Observation Therapy (AOT) is a well-established post-stroke rehabilitation treatment based on the theoretical framework of the Mirror Neuron System (MNS) activation. However, AOT protocols are still heterogeneous in terms of video contents of observed actions. OBJECTIVE: The aim of this study was to analyze electroencephalographic (EEG) recordings in stroke patients during the observation of different videos of task-specific upper limb movements, and to define which category of actions can elicit a stronger cortical activation in the observer's brain. METHODS: Signals were analyzed from 19 chronic stroke subjects observing customized videos that represented 3 different categories of upper limb actions: Finalized Actions, Non-Finalized Actions, and Control Videos. The Event-Related Desynchronization in the µ and ß bands was chosen to identify the involvement of the cerebral cortex: the area of the normalized power spectral density was calculated for each category and, deepening, for the reaching and completion sub-phases of Finalized Actions. For descriptive purposes, the time course of averaged signal power was described. The Kruskal-Wallis test (P < .05) was applied. RESULTS: The analysis showed a greater desynchronization when subjects observed Finalized Actions with respect to Non-Finalized in all recorded areas; Control videos provoked a synchronization in the same areas and frequency bands. The reaching phase of feeding and self-care actions evoked a greater suppression both in µ and ß bands. CONCLUSIONS: The observation of finalized arm movements seems to elicit the strongest activation of the MNS in chronic stroke patients. This finding may help the clinicians to design future AOT-based stroke rehabilitation protocols. CLINICAL TRIAL REGISTRATION: Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT04047134.

Investigating Users' and Other Stakeholders' Needs in the Development of a Personalized Integrated Care Platform (PROCare4Life) for Older People with Dementia or Parkinson Disease: Protocol for a Mixed Methods Study.

BACKGROUND: Dementias-including Alzheimer disease-and Parkinson disease profoundly impact the quality of life of older population members and their families. PROCare4Life (Personalized Integrated Care Promoting Quality of Life for Older Adults) is a European project that recognizes the benefit of technology-based integrated care models in improving the care coordination and the quality of life of these target groups. This project proposes an integrated, scalable, and interactive care platform targeting older people suffering from neurodegenerative diseases, their caregivers, and socio-health professionals. PROCare4Life adopts a user-centered design approach from the early stage and throughout platform development and implementation, during which the platform is designed and adapted to the needs and requirements of all the involved users. OBJECTIVE: This paper presents the study protocol for investigating users' needs and requirements regarding the design of the proposed PROCare4Life platform. METHODS: A mixed qualitative and quantitative study design is utilized, including online surveys, interviews, and workshops. The study aimed to recruit approximately 200 participants, including patients diagnosed with dementia or Parkinson disease, caregivers, socio-health professionals, and other stakeholders, from five different European countries: Germany, Italy, Portugal, Romania, and Spain. RESULTS: The study took place between April and September 2020. Recruitment is now closed, and all the data have been collected and analyzed in order to be used in shaping the large-scale pilot phase of the PROCare4Life project. Results of the study are expected to be published in spring 2021. CONCLUSIONS: This paper charts the protocol for a user-centered design approach at the early stage of the PROCare4Life project in order to shape and influence an integrated health platform suitable for its intended target group and purpose. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/22463.

Virtual Coaching for Rehabilitation: The Participatory Design Experience of the vCare Project.

End-user involvement constitutes an essential goal during the development of innovative solution, not only for the evaluation, but also in codesign, following a user-centered strategy. Indeed, it is a great asset of research to base the work in a user-centered approach, because it allows to build a platform that will respond to the real needs of users. The aims of this work are to present the methodology adopted to involve end-users (i.e., neurological patients, healthy elderly, and health professionals) in the evaluation of a novel virtual coaching system based on the personalized clinical pathways and to present the results obtained from these preliminary activities. Specific activities involving end-users were planned along the development phases and are referred to as participatory design. The user experience of participatory design is constituted by the two different phases: the "end-user's perspective" phase where the user involvement in experiential activities is from an observational point of view, whereas the "field study" phase is the direct participation in these activities. Evaluation tools (i.e., scales, questionnaires, and interviews) were planned to assess different aspects of the system. Thirty patients [14 with poststroke condition and 16 with Parkinson's disease (PD)], 13 healthy elderly, and six health professionals were enrolled from two clinical centers during the two phases of participatory design. Results from "end-user's perspective" phase showed globally a positive preliminary perception of the service. Overall, a positive evaluation (i.e., UEQ median score > 1) was obtained for each domain of the scale in both groups of patients and healthy subjects. The evaluation of the vCare system during the "field study" phase was assessed as excellent (>80 points) from the point of view of both patients and health professionals. According to the majority of patients, the rehabilitation service through the solution was reported to be interesting, engaging, entertaining, challenging and useful for improving impaired motor functions, and making patients aware of their cognitive abilities. Once refined and fine-tuned in the aspects highlighted in the this work, the system will be clinically tested at user's home to measure the real impact of the rehabilitative coaching services.

Muscle function impairment in cancer patients in pre-cachexia stage.

Cancer cachexia has been reported to be directly responsible for at least 20% of cancer deaths. Management of muscle wasting in cancer-associated cachexia appears to be of pivotal importance for survival of patients. In this regard, it would be interesting to identify before its patent appearance eventual functional markers of muscle damage, to plan specific exercise protocols to counteract cachexia. The muscle function of 13 oncologic patients and 15 controls was analyzed through: i) analysis of the oxidative metabolism, indirectly evaluated trough dosage of blood lactate levels before and after a submaximal incremental exercise on a treadmill; ii) analysis of strength and, iii) endurance, in both lower and upper limbs muscles, employing an isokinetic dynamometer. Statistical analyses were carried out to compare the muscle activities between groups. Analysis of oxidative metabolism during the incremental exercise on a treadmill showed that patients performed a shorter exercise than controls. Lactate levels were significantly higher in patients both at baseline and after the task. Muscle strength analysis in patients group showed a reduction of Maximum Voluntary Contraction during the isometric contraction and, a tendency to fatigue during endurance task. Data emerging from this study highlight an impairment of muscle oxidative metabolism in subjects affected by a pre-cachexia stage of cancer. A trend of precocious fatigability and an impairment of muscle strength production were also observed. This evidence underlines the relevance of assessing muscle function in order to develop novel rehabilitative approaches able to counteract motor impairment and eventually to prevent cachexia in these patients.