A wearable biofeedback device to improve motor symptoms in Parkinson’s disease

Dissertação de mestrado em Engenharia BiomédicaThis dissertation presents the work done during the fifth year of the course Integrated Master’s in Biomedical Engineering, in Medical Electronics. This work was carried out in the Biomedical & Bioinspired Robotic Devices Lab (BiRD Lab) at the MicroElectroMechanics Center (CMEMS) established at the University of Minho. For validation purposes and data acquisition, it was developed a collaboration with the Clinical Academic Center (2CA), located at Braga Hospital. The knowledge acquired in the development of this master thesis is linked to the motor rehabilitation and assistance of abnormal gait caused by a neurological disease. Indeed, this dissertation has two main goals: (1) validate a wearable biofeedback system (WBS) used for Parkinson's disease patients (PD); and (2) develop a digital biomarker of PD based on kinematic-driven data acquired with the WBS. The first goal aims to study the effects of vibrotactile biofeedback to play an augmentative role to help PD patients mitigate gait-associated impairments, while the second goal seeks to bring a step advance in the use of front-end algorithms to develop a biomarker of PD based on inertial data acquired with wearable devices. Indeed, a WBS is intended to provide motor rehabilitation & assistance, but also to be used as a clinical decision support tool for the classification of the motor disability level. This system provides vibrotactile feedback to PD patients, so that they can integrate it into their normal physiological gait system, allowing them to overcome their gait difficulties related to the level/degree of the disease. The system is based on a user- centered design, considering the end-user driven, multitasking and less cognitive effort concepts. This manuscript presents all steps taken along this dissertation regarding: the literature review and respective critical analysis; implemented tech-based procedures; validation outcomes complemented with results discussion; and main conclusions and future challenges.Esta dissertação apresenta o trabalho realizado durante o quinto ano do curso Mestrado Integrado em Engenharia Biomédica, em Eletrónica Médica. Este trabalho foi realizado no Biomedical & Bioinspired Robotic Devices Lab (BiRD Lab) no MicroElectroMechanics Center (CMEMS) estabelecido na Universidade do Minho. Para efeitos de validação e aquisição de dados, foi desenvolvida uma colaboração com Clinical Academic Center (2CA), localizado no Hospital de Braga. Os conhecimentos adquiridos no desenvolvimento desta tese de mestrado estão ligados à reabilitação motora e assistência de marcha anormal causada por uma doença neurológica. De facto, esta dissertação tem dois objetivos principais: (1) validar um sistema de biofeedback vestível (WBS) utilizado por doentes com doença de Parkinson (DP); e (2) desenvolver um biomarcador digital de PD baseado em dados cinemáticos adquiridos com o WBS. O primeiro objetivo visa o estudo dos efeitos do biofeedback vibrotáctil para desempenhar um papel de reforço para ajudar os pacientes com PD a mitigar as deficiências associadas à marcha, enquanto o segundo objetivo procura trazer um avanço na utilização de algoritmos front-end para biomarcar PD baseado em dados inerciais adquiridos com o dispositivos vestível. De facto, a partir de um WBS pretende-se fornecer reabilitação motora e assistência, mas também utilizá-lo como ferramenta de apoio à decisão clínica para a classificação do nível de deficiência motora. Este sistema fornece feedback vibrotáctil aos pacientes com PD, para que possam integrá-lo no seu sistema de marcha fisiológica normal, permitindo-lhes ultrapassar as suas dificuldades de marcha relacionadas com o nível/grau da doença. O sistema baseia-se numa conceção centrada no utilizador, considerando o utilizador final, multitarefas e conceitos de esforço menos cognitivo. Portanto, este manuscrito apresenta todos os passos dados ao longo desta dissertação relativamente a: revisão da literatura e respetiva análise crítica; procedimentos de base tecnológica implementados; resultados de validação complementados com discussão de resultados; e principais conclusões e desafios futuros

The Influence of Plantar Cutaneous Stimulation on a Functional Test of Gait in Parkinson’s Disease

Although possible deficits in proprioception have been implicated as a cause of gait impairments in individuals with Parkinson’s disease (PD), little research has been done to investigate improving this possible deficit as a method to influence mobility. The overall purpose of the current thesis was to investigate the influence of increased plantar stimulation on stability and gait impairments. This study also investigated the contribution of attention to locomotion in PD. The two studies comprising this thesis addressed the possible influence of the ribbed insoles in the initial response of PD participants as well as the long-term use of the insole. The first study focused on developing a task to assess the influence of the facilitatory insoles on gait for individuals with PD compared to healthy control participants. For the purpose of evaluating the facilitatory insoles in a functionally relevant task participants performed a modified “Timed Up and Go” task with an additional secondary motor task. The secondary task of carrying a tray with glasses demonstrated that attention plays a large role in the production and maintenance of gait as gait deficits became more pronounced. However, the facilitatory insoles also influenced gait parameters which demonstrated that the possible deficits in proprioception contribute to the gait impairments in PD. The initial response to the insoles, in the first study, did not improve gait parameters, which suggests that PD participants may need more time to adjust to the increased plantar stimulation. The second study investigated the influence of the facilitatory insoles when they are worn for a longer period of time. Participants wore either the facilitatory insoles or blank insoles while completing the PD Sensory Attention Focussed Exercise (PD SAFEx) rehabilitation program. Results demonstrated that when the facilitatory insoles are worn long-term, they can benefit the turning and straight-line walking in individuals with PD. PD participants became more confident in their ability to turn as they exerted less control over their centre of mass. Participants also displayed a decreased base of support and time spent in double limb support without negatively affecting lateral stability. These improvements suggest that the facilitatory insoles, when worn long-term, allow for a more normalized pattern of gait for individuals with PD. The TUG task used in this thesis proved to be a good measure to evaluate changes in stability and gait parameters in PD participants. Long-term use of the facilitatory insoles demonstrated improvements in stability and gait deficits during difficult aspects of gait such as turning. This suggests that the facilitatory insoles would be a simple and effective intervention to use, however further investigation should occur to ensure that the improvements will continue when facilitatory insoles are used on a daily basis. As well, investigation into the long-term use of other types of cutaneous stimulation such as vibratory insoles would be beneficial for the PD population

Efficacy of Rhythmic Acquisition on Gait Performance Among Individuals with Parkinson’s Disease

The purpose of this study was to identify the ability of individuals with Parkinson’s disease (PD) to acquire different rhythmic complexity levels through individual home-based Improvised Active Music Therapy (IAMT) sessions. The study aimed to identify whether higher acquisition of rhythmic complexity levels improved gait performance, as well as beat perception and production abilities. In this single subject multiple baseline design, the study measured the ability of four right-handed participants with PD to acquire greater density of syncopation, as a measure of rhythmic complexity levels, while playing uninterrupted improvised music on a simplified electronic drum-set. An accredited music therapist led each session with an acoustic guitar. The study described how higher density of syncopation levels presented in participants’ playing related to not only gait performance, and beat perception and production abilities, but also to other music measurements. The participants’ music content was transformed into digital music data in real time using Musical Instrument Digital Interface (MIDI). MIDI data was analyzed to determine density of syncopation, note count, velocity, and asynchrony during baseline and treatment IAMT intervention. Results from visual analyses and Pearson correlations indicated partial evidence for the ability of individuals with PD to acquire different rhythmic complexity levels through IAMT. Partial evidence was also found to support the overall effectiveness of IAMT sessions in increasing participant’s mean gait velocity and stride length, and reducing step time and stride length variability. The findings of the current study indicate that IAMT sessions could be an effective strategy to increase physical mobility among individuals with PD. Using MIDI in the IAMT approach can yield data to evaluate treatment effectiveness and assess patient progress, providing daily measures and analysis of data using statistical analyses alongside visual analysis. This method has the potential to lead to new evidence-based interventions modeled in music therapy

Diagnosis and Treatment of Parkinson's Disease

Parkinson's disease is diagnosed by history and physical examination and there are no laboratory investigations available to aid the diagnosis of Parkinson's disease. Confirmation of diagnosis of Parkinson's disease thus remains a difficulty. This book brings forth an update of most recent developments made in terms of biomarkers and various imaging techniques with potential use for diagnosing Parkinson's disease. A detailed discussion about the differential diagnosis of Parkinson's disease also follows as Parkinson's disease may be difficult to differentiate from other mimicking conditions at times. As Parkinson's disease affects many systems of human body, a multimodality treatment of this condition is necessary to improve the quality of life of patients. This book provides detailed information on the currently available variety of treatments for Parkinson's disease including pharmacotherapy, physical therapy and surgical treatments of Parkinson's disease. Postoperative care of patients of Parkinson's disease has also been discussed in an organized manner in this text. Clinicians dealing with day to day problems caused by Parkinson's disease as well as other healthcare workers can use beneficial treatment outlines provided in this book

Sensor Approach for Brain Pathophysiology of Freezing of Gait in Parkinson\u27s Disease Patients

Parkinson\u27s Disease (PD) affects over 1% of the population over 60 years of age and is expected to reach 1 million in the USA by the year 2020, growing by 60 thousand each year. It is well understood that PD is characterized by dopaminergic loss, leading to decreased executive function causing motor symptoms such as tremors, bradykinesia, dyskinesia, and freezing of gait (FoG) as well as non-motor symptoms such as loss of smell, depression, and sleep abnormalities. A PD diagnosis is difficult to make since there is no worldwide approved test and difficult to manage since its manifestations are widely heterogeneous among subjects. Thus, understanding the patient subsets and the neural biomarkers that set them apart will lead to improved personalized care. To explore the physiological alternations caused by PD on neurological pathways and their effect on motor control, it is necessary to detect the neural activity and its dissociation with healthy physiological function. To this effect, this study presents a custom ultra-wearable sensor solution, consisting of electroencephalograph, electromyograph, ground reaction force, and symptom measurement sensors for the exploration of neural biomarkers during active gait paradigms. Additionally, this study employed novel de-noising techniques for dealing with the motion artifacts associated with active gait EEG recordings and compared time-frequency features between a group of PD with FoG and a group of age-matched controls and found significant differences between several EEG frequency bands during start and end of normal walking (with a p\u3c0.05)

The Influence of Dopamine Replacement on Movement Impairments During Bimanual Coordination in Parkinson’s Disease (PD)

The purpose of the current thesis was to investigate the influence of dopamine replacement on performance during bimanual coordination in individuals with Parkinson’s disease (PD) There has been conflicting research on the cause of movement impairments such as coordination deficits, slowed switching and upper limb freezing that occur during coordinated movements It is unclear whether decreased function of the dopaminergic system after withdrawal from dopamine replacement is responsible for these deficits Healthy age-matched control participants were compared to PD participants in two experiments to determine the movement impairments that occurred during three-dimensional wrist flexion-extension bimanual coordination as a result of PD. In addition, individuals with PD were compared without (‘off’) and with (‘on’) dopamine replacement in both experiments to determine whether modulation of the dopaminergic system influenced coordinated movements. In Experiment 1, continuous bimanual coordination was performed in m-phase (simultaneous wrist flexion and extension) and anti-phase (flexion of one wrist while extending other wrist) with movements externally paced with increasing across seven cycle frequencies (0.75 to 2 Hz). Visual feedback was also manipulated in one of three sensory conditions no vision, normal vision or augmented vision. Visual feedback, phase and cycle frequency manipulation was performed to determine whether other deficits (e.g. sensory and/or attentional deficits) may influence coordinated movements Despite reduced amplitude of movements in both limbs of individuals with PD (PD ‘off’), coordination deficits were not observed in PD compared to healthy control participants. In addition, there was an increased occurrence of upper limb freezing (ULF) when cycle frequency demand was greater Dopamine replacement did increase the amplitude of movements in individuals with PD but did not influence coordination performance or the occurrence of ULF. In Experiment 2, coordinated movements were initiated in either m-phase or antiphase and participants were required to voluntarily switch to the other phase pattern when an auditory cue was presented Trials were performed at one of two cycle frequencies (1 or 2 Hz) and one of two sensory conditions (no vision or normal vision) to determine whether other deficits (e.g. sensory and/or attentional deficits) may influence coordinated movement. In addition, a separate block of trials were performed in anti-phase coordination with an auditory cue that did not require a switch Non-switching trials were included to investigate whether the presence of a distracting cue could evoke ULF comparable to when switching between movements was required PD ‘off’ participants demonstrated slower switching, more delayed responses and deficits in coordination performance when compared to healthy control participants. The increased demand of cycle frequency particularly when initiating anti-phase coordination, after voluntary switching and with the presence of the auditory cue without switching contributed to a large occurrence of ULF in individuals with PD. Dopamine replacement improved the ability to switch between phase patterns but had no overall influence on coordination performance or the occurrence of ULF. Overall, the results of the current thesis demonstrated that dopamine replacement can improve motor symptoms during coordinated movements (e g hypometna and bradykinesia) but does not contribute to coordination performance or ULF in individuals with PD. As a consequence, it was concluded that coordination deficits and ULF are not caused by the dysfunctional dopaminergic system but rather associated to secondary impairment caused by PD. The movement impairments caused by secondary dysfunction of PD were proposed to be associated with increased attentional demands and possible executive dysfunction related to fronto-stnatal pathways that cannot be modulated by dopamine replacement. Thus, treatment of complex movement impairments such as coordination deficits and ULF may benefit from rehabilitation or non-dopamine therapies that focus on the global dysfunction caused by PD

Proceedings of the 3rd International Mobile Brain/Body Imaging Conference : Berlin, July 12th to July 14th 2018

The 3rd International Mobile Brain/Body Imaging (MoBI) conference in Berlin 2018 brought together researchers from various disciplines interested in understanding the human brain in its natural environment and during active behavior. MoBI is a new imaging modality, employing mobile brain imaging methods like the electroencephalogram (EEG) or near infrared spectroscopy (NIRS) synchronized to motion capture and other data streams to investigate brain activity while participants actively move in and interact with their environment. Mobile Brain / Body Imaging allows to investigate brain dynamics accompanying more natural cognitive and affective processes as it allows the human to interact with the environment without restriction regarding physical movement. Overcoming the movement restrictions of established imaging modalities like functional magnetic resonance tomography (MRI), MoBI can provide new insights into the human brain function in mobile participants. This imaging approach will lead to new insights into the brain functions underlying active behavior and the impact of behavior on brain dynamics and vice versa, it can be used for the development of more robust human-machine interfaces as well as state assessment in mobile humans.DFG, GR2627/10-1, 3rd International MoBI Conference 201

Consensus Paper: Neurophysiological Assessments of Ataxias in Daily Practice

The purpose of this consensus paper is to review electrophysiological abnormalities and to provide a guideline of neurophysiological assessments in cerebellar ataxias. All authors agree that standard electrophysiological methods should be systematically applied in all cases of ataxia to reveal accompanying peripheral neuropathy, the involvement of the dorsal columns, pyramidal tracts and the brainstem. Electroencephalography should also be considered, although findings are frequently non-specific. Electrophysiology helps define the neuronal systems affected by the disease in an individual patient and to understand the phenotypes of the different types of ataxia on a more general level. As yet, there is no established electrophysiological measure which is sensitive and specific of cerebellar dysfunction in ataxias. The authors agree that cerebellar brain inhibition (CBI), which is based on a paired-pulse transcranial magnetic stimulation (TMS) paradigm assessing cerebellar-cortical connectivity, is likely a useful measure of cerebellar function. Although its role in the investigation and diagnoses of different types of ataxias is unclear, it will be of interest to study its utility in this type of conditions. The authors agree that detailed clinical examination reveals core features of ataxia (i.e., dysarthria, truncal, gait and limb ataxia, oculomotor dysfunction) and is sufficient for formulating a differential diagnosis. Clinical assessment of oculomotor function, especially saccades and the vestibulo-ocular reflex (VOR) which are most easily examined both at the bedside and with quantitative testing techniques, is of particular help for differential diagnosis in many cases. Pure clinical measures, however, are not sensitive enough to reveal minute fluctuations or early treatment response as most relevant for pre-clinical stages of disease which might be amenable to study in future intervention trials. The authors agree that quantitative measures of ataxia are desirable as biomarkers. Methods are discussed that allow quantification of ataxia in laboratory as well as in clinical and real-life settings, for instance at the patients' home. Future studies are needed to demonstrate their usefulness as biomarkers in pharmaceutical or rehabilitation trials

Asymmetry measures for quantification of mechanisms contributing to dynamic stability during stepping-in-place gait

The goal of this study is to introduce and to motivate the use of new quantitative methods to improve our understanding of mechanisms that contribute to the control of dynamic balance during gait. Dynamic balance refers to the ability to maintain a continuous, oscillating center-of-mass (CoM) motion of the body during gait even though the CoM frequently moves outside of the base of support. We focus on dynamic balance control in the frontal plane or medial–lateral (ML) direction because it is known that active, neurally-mediated control mechanisms are necessary to maintain ML stability. Mechanisms that regulate foot placement on each step and that generate corrective ankle torque during the stance phase of gait are both known to contribute to the generation of corrective actions that contribute to ML stability. Less appreciated is the potential role played by adjustments in step timing when the duration of the stance and/or swing phases of gait can be shortened or lengthened to allow torque due to gravity to act on the body CoM over a shorter or longer time to generate corrective actions. We introduce and define four asymmetry measures that provide normalized indications of the contribution of these different mechanisms to gait stability. These measures are ‘step width asymmetry’, ‘ankle torque asymmetry’, ‘stance duration asymmetry’, and ‘swing duration asymmetry’. Asymmetry values are calculated by comparing corresponding biomechanical or temporal gait parameters from adjacent steps. A time of occurrence is assigned to each asymmetry value. An indication that a mechanism is contributing to ML control is obtained by comparing asymmetry values to the ML body motion (CoM angular position and velocity) at the time points associated with the asymmetry measures. Example results are demonstrated with measures obtained during a stepping-in-place (SiP) gait performed on a stance surface that either remained fixed and level or was pseudorandomly tilted to disturb balance in the ML direction. We also demonstrate that the variability of asymmetry measures obtained from 40 individuals during unperturbed, self-paced SiP were highly correlated with corresponding coefficient of variation measures that have previously been shown to be associated with poor balance and fall risk