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Objectives This study aimed to evaluate the cost-effectiveness of the randomized clinical trial STEP-KOA (STepped Exercise Program for patients with Knee OsteoArthritis). Methods The trial included 230 intervention and 115 control participants from 2 Veterans Affairs (VA) medical centers. A decision tree simulated outcomes for cohorts of patients receiving arthritis education (control) or STEP-KOA (intervention), which consisted of an internet-based exercise training program (step 1), phone counseling (step 2), and physical therapy (step 3) according to patient’s response. Intervention costs were assessed from the VA perspective. Quality of life (QOL) was measured using 5-level EQ-5D US utility weights. Incremental cost-effectiveness ratios (ICERs) were calculated as the difference in costs divided by the difference in quality-adjusted life-years (QALYs) between arms at 9 months. A Monte Carlo probabilistic sensitivity analysis was used to generate a cost-effectiveness acceptability curve. Results The adjusted model found differential improvement in QOL utility weights of 0.042 (95% confidence interval 0.003-0.080; P=.03) for STEP-KOA versus control at 9 months. In the base case, STEP-KOA resulted in an incremental gain of 0.028 QALYs and an incremental cost of $279 per patient for an ICER of $10 076. One-way sensitivity analyses found the largest sources of variation in the ICER were the impact on QOL and the need for a VA-owned tablet. The probabilistic sensitivity analysis found a 98% probability of cost-effectiveness at $50 000 willingness-to-pay per QALY. Conclusions STEP-KOA improves QOL and has a high probability of cost-effectiveness. Resources needed to implement the program will decline as ownership of mobile health devices increases.

In a recent article in this Journal, Gift (2019) attempts to measure the marginal revenue product (MRP) of individual Ultimate Fighting Championship (UFC) fighters. According to Gift’s estimates, top-tier UFC Fighters are frequently and substantially underpaid relative to their MRP while “a sizable percentage of UFC fighters generated little to no MRP,” and are consequently “overpaid by traditional measures.” In this Comment, we examine possible explanations for this finding, including various limitations of Gift’s data and methods. We also examine the underlying economics of the sport, in which quasi-fixed broadcast revenue streams, ignored in Gift's MRP estimates, play a large and increasingly dominant role. As Berri et al. (2015 ) have emphasized, comparisons of athlete compensation and standard MRP metrics (even if estimated correctly) are “meaningless” in the presence of substantial quasi-fixed revenues. Critically, Gift assumes zero MRP for all fighters in all bouts in all non-Pay-Per-View (PPV) events. As a result, Gift's method assumes fighters are “overpaid” for the vast majority (75 percent) of fighter-bouts. Even setting this aside, we argue that Gift's use of Google Trends data—at best an extremely crude proxy for a fighter's contribution to PPV revenue—suffers from measurement error, producing attenuation bias. As a consequence, Gift's data and methods are likely to substantially underestimate UFC fighters’ economic value.

Clinical care interactions influence important health outcomes in older adults such as nosocomial infections, falls, and care satisfaction. However, traditional measurements of interactions are often time-consuming, costly, biased, or they interfere with normal clinical care. Wearable sensors measure interpersonal contact with a high degree of spatial and temporal detail and accuracy when applied to examining the spread of infection. This study aims to test the feasibility of implementing two types of commercially available wearable sensors to collect spatial and temporal data for measuring care interactions in health care settings. EMBC02 (Bluetooth) and OpenBeacon (RFID) sensors were tested in a simulation laboratory. Five nursing students wore the sensors along with name tags and enacted a scenario of a fallen nursing home resident. Sensor data were plotted in Python and compared with video recordings of the simulated care interaction to determine sensor usability, accuracy, and precision. EMBC02 and OpenBeacon detected multiple wearers and provided spatial and temporal data. OpenBeacon showed better usability and validity than EMBC02 for using proximity data collected by sensors to infer care interactions. Both OpenBeacon and EMCB02 showed some limitations in accuracy and precision, such as increased data missingness due to idling function and high data noise. Bluetooth and RFID sensors measure different aspects of proximity. OpenBeacon outperformed EMBC02 for measuring care interactions. Combining Bluetooth with RFID may provide richer information for measuring and understanding care interactions. Simulation laboratories can be leveraged to test health technology before use in clinical research.

Background and Objectives Social networks affect the health and well-being of older adults. Advancements in technology (e.g., digital devices and mHealth) enrich our ability to collect social networks and health data. The purpose of this scoping review was to identify and map the use of technology in measuring older adults’ social networks for health and social care. Research Design and Methods The Joanna Briggs Institute methodology was followed. PubMed (MEDLINE), Sociological Abstracts, SocINDEX, CINAHL, and Web of Science were searched for relevant articles. Conference abstracts and proceedings were searched via Conference Papers Index, the American Sociological Society, and The Gerontological Society of America. Studies published in English from January 2004 to March 2020 that aimed to improve health or social care for older adults and used technology to measure social networks were included. Data were extracted by 2 independent reviewers using an a priori extraction tool. Results The majority of the 18 reviewed studies were pilot or simulation research conducted in Europe that focused on older adults living in the community. The various types of technologies used can be categorized as environment-based, person-based, and data-based. Discussion and Implications Technology facilitates objective and longitudinal data collection on the social interactions and activities of older adults. The use of technology to measure older adults’ social networks, however, is primarily in an exploratory phase. Multidisciplinary collaborations are needed to overcome operational, analytical, and implementation challenges. Future studies should leverage technologies for addressing social isolation and care for older adults, especially during the coronavirus disease 2019 pandemic.

Background Evidence-based models are needed to deliver exercise-related services for knee osteoarthritis efficiently and according to patient needs. Objective To examine a stepped exercise program for patients with knee osteoarthritis (STEP-KOA). Design Randomized controlled trial. (ClinicalTrials.gov: NCT02653768). Setting 2 U.S. Department of Veterans Affairs sites. Participants 345 patients (mean age, 60 years; 15% female; 67% people of color) with symptomatic knee osteoarthritis. Intervention Participants were randomly assigned in a 2:1 ratio to STEP-KOA or an arthritis education (AE) control group, respectively. The STEP-KOA intervention began with 3 months of an internet-based exercise program (step 1). Participants who did not meet response criteria for improvement in pain and function after step 1 progressed to step 2, which involved 3 months of biweekly physical activity coaching calls. Participants who did not meet response criteria after step 2 went on to in-person physical therapy visits (step 3). The AE group received educational materials via mail every 2 weeks. Measurements Primary outcome was Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Scores for the STEP-KOA and AE groups at 9 months were compared by using linear mixed models. Results In the STEP-KOA group, 65% of participants (150 of 230) progressed to step 2 and 35% (81 of 230) to step 3. The estimated baseline WOMAC score for the full sample was 47.5 (95% CI, 45.7 to 49.2). At 9-month follow-up, the estimated mean WOMAC score was 6.8 points (CI, -10.5 to -3.2 points) lower in the STEP-KOA than the AE group, indicating greater improvement. Limitation Participants were mostly male veterans, and follow-up was limited. Conclusion Veterans in STEP-KOA reported modest improvements in knee osteoarthritis symptoms compared with the control group. The STEP-KOA strategy may be efficient for delivering exercise therapies for knee osteoarthritis. Primary funding source Department of Veterans Affairs, Health Services Research and Development Service.

BACKGROUND: Gait speed is an important measure of health status for older adults and individuals with neurological conditions. Literature reports that measurements made by people are not as accurate as automatic timers. RESEARCH QUESTION: Is the GaitBox (GB), a device to measure walking speed (WS) automatically and accurately, a valid approach to walking speed measurement in a clinical setting? METHODS: Two prospective validation studies were completed comparing the GB to human timers (HT) and the Sprint Timing System (STS). Subjects were recruited from convenience samples of healthy older adults (S1, N=35, 72.4 ± 7.4 years of age) and individuals with Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), or unknown / no diagnosis (S2, N=44, 35.3 ± 13.5 years of age). Subjects completed 4 timed walks. The GB, HT, and STS simultaneously measured WS across a 4 m or 10 m course. Protocol followed an adapted version of the NIH Walk Test. Subjects were instructed to walk at a normal pace. Validity and reliability were determined using Pearson correlations, absolute mean differences, Intraclass Correlation Coefficients (ICC’s) and Bland-Altman plots. RESULTS: WS measured in both studies demonstrated strong correlations between GB and STS (r=0.98-0.99, p

Background Gait and mobility aid assessments are important components of rehabilitation. Given the increasing use of telehealth to meet rehabilitation needs, it is important to examine the feasibility of such assessments within the constraints of telerehabilitation. Objective The objective of this study was to examine the reliability and validity of the Tinetti Performance-Oriented Mobility Assessment gait scale (POMA-G) and cane height assessment under various video and transmission settings to demonstrate the feasibility of teleassessment. Design This repeated-measures study compared the test performances of in-person, slow motion (SM) review, and normal-speed (NS) video ratings at various fixed frame rates (8, 15, and 30 frames per second) and bandwidth (128, 384, and 768 kB/s) configurations. Methods Overall bias, validity, and interrater reliability were assessed for in-person, SM video, and NS video ratings, with SM video rating as the gold standard, as well as for different frame rate and bandwidth configurations within NS videos. Results There was moderate to good interrater reliability for the POMA-G (intraclass correlation coefficient [ICC] = 0.66–0.77 across all configurations) and moderate validity for in-person (β = 0.62; 95% confidence interval [CI] = 0.37–0.87) and NS video (β = 0.74; 95% CI = 0.67–0.80) ratings compared with the SM video rating. For cane height, interrater reliability was good (ICC = 0.66–0.77), although it was significantly lower at the lowest frame rate (8 frames per second) (ICC = 0.66; 95% CI = 0.54–0.76) and bandwidth (128 kB/s) (ICC = 0.69; 95% CI = 0.57–0.78) configurations. Validity for cane height was good for both in-person (β = 0.80; 95% CI = 0.62–0.98) and NS video (β = 0.86; 95% CI = 0.81–0.90) ratings compared with SM video rating. Limitations Some lower frame rate and bandwidth configurations may limit the reliability of remote cane height assessments. Conclusions Teleassessment for POMA-G and cane height using typically available internet and video quality is feasible, valid, and reliable.

IntroductionThe aim of this research was to evaluate the impact of a novel tele-rehabilitation system on self-reported functional outcomes compared to usual care during the first three months after stroke.MethodsA parallel, two-arm, evaluator-blinded, randomised controlled trial was conducted. Adults aged ≥40 years who had suffered a stroke within four weeks of the start of the study were recruited from the general community. The intervention group received access to a novel tele-rehabilitation system and programme for three months. The primary outcome measures utilised were the frequency and limitation total scores of the Late-Life Function and Disability Instrument (LLFDI) at three months.ResultsA total of 124 individuals were recruited. The mean differences in the LLDFI frequency and limitation total scores at three months comparing the intervention and control groups were –3.30 (95% confidence interval (CI) –7.81 to 1.21) and –6.90 (95% CI –15.02 to 1.22), respectively. Adjusting for the respective baseline covariates and baseline Barthel Index also showed no significant difference between interventions in the LLFDI outcomes.DiscussionThe intervention and control groups self-reported similar improvements in functional outcomes. Tele-rehabilitation may be a viable option to provide post-stroke rehabilitation services in Singapore while reducing barriers to continue rehabilitation conventionally after discharge from hospital and encouraging more participation.

This manuscript describes tests and results of a study to evaluate classification algorithms derived from accelerometer data collected on healthy adults and older adults to better classify posture movements. Specifically, tests were conducted to 1) compare performance of 1 sensor vs. 2 sensors; 2) examine custom trained algorithms to classify for a given task 3) determine overall classifier accuracy for healthy adults under 55 and older adults (55 or older). Despite the current variety of commercially available platforms, sensors, and analysis software, many do not provide the data granularity needed to characterize all stages of movement. Additionally, some clinicians have expressed concerns regarding validity of analysis on specialized populations, such as hospitalized older adults. Accurate classification of movement data is important in a clinical setting as more hospital systems are using sensors to help with clinical decision making. We developed custom software and classification algorithms to identify laying, reclining, sitting, standing, and walking. Our algorithm accuracy is 93.2% for healthy adults under 55 and 95% for healthy older adults over 55 for the tasks in our setting. The high accuracy of this approach will aid future investigation into classifying movement in hospitalized older adults. Results from these tests also indicate that researchers and clinicians need to be aware of sensor body position in relation to where the algorithm used was trained. Additionally, results suggest more research is needed to determine if algorithms trained on one population can accurately be used to classify data from another population.

The objective of this study was to investigate the performance of 3 brain-computer interface (BCI) paradigms in an amyotrophic lateral sclerosis (ALS) population (n = 11). Using a repeated-measures design, participants completed 3 BCI conditions: row/column (RCW), checkerboard (CBW), and gray-to-color (CBC). Based on previous studies, it is hypothesized that the CBC and CBW conditions will result in higher accuracy, information transfer rate, waveform amplitude, and user preference over the RCW condition. An offline dynamic stopping simulation will also increase information transfer rate. Higher mean accuracy was observed in the CBC condition (89.7%), followed by the CBW (84.3%) condition, and lowest in the RCW condition (78.7%); however, these differences did not reach statistical significance ( P = .062). Eight of the eleven participants preferred the CBC and the remaining three preferred the CBW conditions. The offline dynamic stopping simulation significantly increased information transfer rate ( P = .005) and decreased accuracy ( P < .000). The findings of this study suggest that color stimuli provide a modest improvement in performance and that participants prefer color stimuli over monochromatic stimuli. Given these findings, BCI paradigms that use color stimuli should be considered for individuals who have ALS.

Health and fitness are contributing factors to physical resilience, or the ability to resist or recover from functional decline following health stressors. Accelerometer based activity monitors have been used in both the in-patient and outpatient setting to monitor mobility. While using sensors to track mobility is increasing, most clinical settings rely on patient reported outcomes. These measures often under or overestimate movement. The lack of a clinically meaningful way to measure mobility in the in-patient setting is a barrier to improving the mobility of hospitalized individuals. This is especially important when considering that over one-third of hospitalized older adults are discharged with a major new functional disability in performing activities of daily living. Our goal was to automatically determine if the subject is laying, reclining, sitting, standing, and walking to better reflect actual activity. Other platforms and studies indicate the ability to determine a difference in activity vs. inactivity or laying and reclining vs. standing and walking, but not all five phases of movement defined here. The aim of this study was to use accelerometer data to train a machine learning algorithm to automatically classify the postural changes (i.e. laying, reclining, sitting, standing, and walking). Preliminary results demonstrate that our trained algorithm is overall 95% accurate in determining each position from unlabeled data from the subject population. Additionally, this algorithm will be applied to in-patient hospitalized older adults for tracking of positions throughout the day.

Background Physical therapy (PT) and other exercise-based interventions are core components of care for knee osteoarthritis (OA), but both are underutilized, and some patients have limited access to PT services. This clinical trial is examining a STepped Exercise Program for patients with Knee OsteoArthritis (STEP-KOA). This model of care can help to tailor exercise-based interventions to patient needs and also conserve higher resource services (such as PT) for patients who do not make clinically relevant improvements after receiving less costly interventions. Methods / Design Step-KOA is a randomized trial of 345 patients with symptomatic knee OA from two Department of Veterans Affairs sites. Participants are randomized to STEP-KOA and Arthritis Education (AE) Control groups with a 2:1 ratio, respectively. STEP-KOA begins with 3 months of access to an internet-based exercise program (Step 1). Participants not meeting response criteria for clinically meaningful improvement in pain and function after Step 1 progress to Step 2, which involves bi-weekly physical activity coaching calls for 3 months. Participants not meeting response criteria after Step 2 progress to in-person PT visits (Step 3). Outcomes will be assessed at baseline, 3, 6 and 9 months (primary outcome time point). The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), and secondary outcomes are objective measures of physical function. Linear mixed models will compare outcomes between the STEP-KOA and AE control groups at follow-up. We will also evaluate patient characteristics associated with treatment response and conduct a cost-effectiveness analysis of STEP-KOA. Discussion STEP-KOA is a novel, efficient and patient-centered approach to delivering exercise-based interventions to patients with knee OA, one of the most prevalent and disabling health conditions. This trial will provide information on the effectiveness of STEP-KOA as a novel potential model of care for treatment of OA. Trial Registration Clinicaltrials.gov, NCT02653768 (STepped Exercise Program for Knee OsteoArthritis (STEP-KOA)), Registered January 12, 2016. Electronic supplementary material The online version of this article (10.1186/s12891-019-2627-8) contains supplementary material, which is available to authorized users.

The NIH 4m Walk Test is a clinically validated tool to measure adult walking speed. Human reaction limitations can contribute to measurement error when manually timing gait speed. This is important considering a 0.10m/s decrease in walking speed is associated with a 12% decrease in life expectancy for older adults. The goal of this study was to validate a low cost, custom built device, Gait Box (GB), compared to human timer (HT) and a research grade Sprint Timing System (STS) with an older adult (mean 72.4 + 7.4 years of age) population (N = 35). Validity was assessed via accuracy (correlations), precision (mean differences), and bias (Bland-Altman plots). Results showed strong correlations between the GB and HT (0.99) and the GB and STS (0.98), with negligible mean differences. This demonstrates the GB can be used to accurately and precisely measure gait speed in clinical and research settings.

Information communication technology (ICT) refers to various technologies encompassing software, networking, the Internet, telecommunications, information systems, and more. As healthcare organizations adopt ICT devices and platforms, patients and providers will have more tools available to improve access to monitoring, telehealth, and timely interventions. The use of alternative methods of collecting, recording, and displaying data (e.g., smart speakers, chat bots, wearables) promise to improve health outcomes for the older adult population. As the U.S. population ages, opportunities for development designed specifically for older adults should be a focus for healthcare organizations. While there are challenges and barriers to enabling new technology within this population, research shows that older adults are adopting new technology. This symposium is focused on these emerging technologies and will showcase diverse examples of ICT implemented across various older adult populations and clinical application areas. The first paper describes the validation of Gaitbox, a walking speed measurement device. The second paper describes using multiple sensors to capture real-world loss of balance and recovery responses. The third paper reports the feasibility of using fitness gamification with a Virtual Reality Treadmill in older adults. The fourth paper describes a smartphone-based assessment of dual task standing and walking. The fifth paper describes wearable sensor-based assessment of falls risk of Timed Up-and-Go test. The Claude D. Pepper Centers maintain year-round coordination and collaboration through a national coordinating center. This powerful network, working towards the common goal of improving the lives of older Americans, has sparked technologic advances that will be highlighted here.

For older adults living with dementia, social network quality influences health outcomes. However, current social network measurement methods are time consuming and mentally draining for people living with dementia. This study aimed to accurately measure social networks using sensor technology. Bluetooth and radio-frequency identification (RFID) sensors were used to collect social network data in a simulation of a falling nursing home resident living with dementia. Participants wore sensors on their clothing, and video recordings were compared to sensor data. Bluetooth data reflected general direction of movement and instances of idling but were neither precise or accurate. RFID data was accurate after applying data filters. Both systems detected multiple sensors simultaneously. The Bluetooth system is not feasible for clinical use, but the RFID system shows potential for clinical application and accurate measurement of social network factors as interaction frequency and duration.

This manuscript describes the development and testing of a device to measure walking speed. The Gaitbox is a custom, microprocessor-based device that uses an infrared distance sensor to automatically measure, calculate and display walking speed. Walking speed is a critical performance measure that has been shown to be a strong indicator of long-term health and life expectancy in older people. The Gaitbox was compared to the measures obtained by clinicians administering the timed NIH 4-m walk test and the Sprint System device.

© 2017 The Author(s). Over 50 million United States citizens (1 in 6 people in the US) have a developmental, acquired, or degenerative disability. The average US citizen can expect to live 20% of his or her life with a disability. Rehabilitation technologies play a major role in improving the quality of life for people with a disability, yet widespread and highly challenging needs remain. Within the US, a major effort aimed at the creation and evaluation of rehabilitation technology has been the Rehabilitation Engineering Research Centers (RERCs) sponsored by the National Institute on Disability, Independent Living, and Rehabilitation Research. As envisioned at their conception by a panel of the National Academy of Science in 1970, these centers were intended to take a "total approach to rehabilitation", combining medicine, engineering, and related science, to improve the quality of life of individuals with a disability. Here, we review the scope, achievements, and ongoing projects of an unbiased sample of 19 currently active or recently terminated RERCs. Specifically, for each center, we briefly explain the needs it targets, summarize key historical advances, identify emerging innovations, and consider future directions. Our assessment from this review is that the RERC program indeed involves a multidisciplinary approach, with 36 professional fields involved, although 70% of research and development staff are in engineering fields, 23% in clinical fields, and only 7% in basic science fields; significantly, 11% of the professional staff have a disability related to their research. We observe that the RERC program has substantially diversified the scope of its work since the 1970's, addressing more types of disabilities using more technologies, and, in particular, often now focusing on information technologies. RERC work also now often views users as integrated into an interdependent society through technologies that both people with and without disabilities co-use (such as the internet, wireless communication, and architecture). In addition, RERC research has evolved to view users as able at improving outcomes through learning, exercise, and plasticity (rather than being static), which can be optimally timed. We provide examples of rehabilitation technology innovation produced by the RERCs that illustrate this increasingly diversifying scope and evolving perspective. We conclude by discussing growth opportunities and possible future directions of the RERC program.

This paper examines some of the recent literature on the estimation of production functions. We focus on techniques suggested in two recent papers, Olley and Pakes (1996) and Levinsohn and Petrin (2003). While there are some solid and intuitive identification ideas in these papers, we argue that the techniques can suffer from functional dependence problems. We suggest an alternative approach that is based on the ideas in these papers, but does not suffer from the functional dependence problems and produces consistent estimates under alternative data generating processes for which the original procedures do not.

Background There is limited research about the effects of video quality on the accuracy of assessments of physical function. Methods A repeated measures study design was used to assess reliability and validity of the finger–nose test (FNT) and the finger-tapping test (FTT) carried out with 50 veterans who had impairment in gross and/or fine motor coordination. Videos were scored by expert raters under eight differing conditions, including in-person, high definition video with slow motion review and standard speed videos with varying bit rates and frame rates. Results FTT inter-rater reliability was excellent with slow motion video (ICC 0.98–0.99) and good (ICC 0.59) under the normal speed conditions. Inter-rater reliability for FNT ‘attempts’ was excellent (ICC 0.97–0.99) for all viewing conditions; for FNT ‘misses’ it was good to excellent (ICC 0.89) with slow motion review but substantially worse (ICC 0.44) on the normal speed videos. FTT criterion validity (i.e. compared to slow motion review) was excellent (β = 0.94) for the in-person rater and good ( β = 0.77) on normal speed videos. Criterion validity for FNT ‘attempts’ was excellent under all conditions ( r ≥ 0.97) and for FNT ‘misses’ it was good to excellent under all conditions ( β = 0.61–0.81). Conclusions In general, the inter-rater reliability and validity of the FNT and FTT assessed via video technology is similar to standard clinical practices, but is enhanced with slow motion review and/or higher bit rate.

Objective. Dry electrodes have an advantage over gel-based 'wet' electrodes by providing quicker set-up time for electroencephalography recording; however, the potentially poorer contact can result in noisier recordings. We examine the impact that this may have on brain–computer interface communication and potential approaches for mitigation. Approach. We present a performance comparison of wet and dry electrodes for use with the P300 speller system in both healthy participants and participants with communication disabilities (ALS and PLS), and investigate the potential for a data-driven dynamic data collection algorithm to compensate for the lower signal-to-noise ratio (SNR) in dry systems. Main results. Performance results from sixteen healthy participants obtained in the standard static data collection environment demonstrate a substantial loss in accuracy with the dry system. Using a dynamic stopping algorithm, performance may have been improved by collecting more data in the dry system for ten healthy participants and eight participants with communication disabilities; however, the algorithm did not fully compensate for the lower SNR of the dry system. An analysis of the wet and dry system recordings revealed that delta and theta frequency band power (0.1–4 Hz and 4–8 Hz, respectively) are consistently higher in dry system recordings across participants, indicating that transient and drift artifacts may be an issue for dry systems. Significance. Using dry electrodes is desirable for reduced set-up time; however, this study demonstrates that online performance is significantly poorer than for wet electrodes for users with and without disabilities. We test a new application of dynamic stopping algorithms to compensate for poorer SNR. Dynamic stopping improved dry system performance; however, further signal processing efforts are likely necessary for full mitigation.

Introduction/Background Stroke is a leading cause of disability worldwide. Functional, financial and social barriers commonly prevent individuals with acute stroke and disabilities from receiving rehabilitation following their hospital discharge. Home-based rehabilitation is an alternative to center-based rehabilitation but it is often costlier. Tele-rehabilitation is a promising solution for optimizing rehabilitation utilization, as it can enable clinicians to supervise patients and conversely, patients to receive the recommended care remotely. Our team therefore developed a novel tele-rehabilitation, with the primary aim to estimate the extent to which the proposed tele-rehabilitation resulted in an improvement in function during the first three-months after stroke in comparison to usual rehabilitation. Material and method This was a randomized controlled trial. We used the Late-Life Function and Disability Instrument (FDI) to assess our primary outcome (with adjustment made for baseline covariate). Results We recruited 124 participants and randomized them to receive either 12-week home-based tele-rehabilitation or usual rehabilitation. Rehabilitation Over the 12-week rehabilitation period, the intervention group spent 2246-minutes on their rehabilitation whereas the control group spent 2565-minutes. The median difference between the two groups was not statistically significant (P = 0.649). Primary Outcome (FDI) The mean FDI frequency score post-rehabilitation for the intervention and control groups were 39.7 (SD 11.7) and 43.0 (SD 10.6) respectively. The mean FDI limitation score post-rehabilitation for the intervention group was 78.5 (SD 20.6) and that for the control group was 85.4 (SD 19.6). The unadjusted and adjusted differences in both FDI scores between the two groups were not statistically significant (Models 1 and 2). Conclusion Both groups reported comparable amount of time spent on rehabilitation and similarly positive impact on the primary outcome. Home-based tele-rehabilitation can be an effective strategy for minimizing or eliminating rehabilitation utilization barriers while achieving the same functional outcome as center-based rehabilitation.

OBJECTIVE: To compare Berg Balance Scale (BBS) rating using videos with differing transmission characteristics with direct in-person rating. DESIGN: Repeated-measures study for the assessment of the BBS in 8 configurations: in person, high-definition video with slow motion review, standard-definition videos with varying bandwidths and frame rates (768 kilobytes per second [kbps] videos at 8, 15, and 30 frames per second [fps], 30 fps videos at 128, 384, and 768 kbps). SETTING: Medical center. PARTICIPANTS: Patients with limitations (N=45) in ≥1 of 3 specific aspects of motor function: fine motor coordination, gross motor coordination, and gait and balance. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: Ability to rate the BBS in person and using videos with differing bandwidths and frame rates in frontal and lateral views. RESULTS: Compared with in-person rating (7%), 18% (P=.29) of high-definition videos and 37% (P=.03) of standard-definition videos could not be rated. Interrater reliability for the high-definition videos was .96 (95% confidence interval, .94–.97). Rating failure proportions increased from 20% in videos with the highest bandwidth to 60% (P

Most acute stroke patients with disabilities do not receive recommended rehabilitation following discharge to the community. Functional and social barriers are common reasons for non-adherence to post-discharge rehabilitation. Home rehabilitation is an alternative to centre-based rehabilitation but is costlier. Tele-rehabilitation is a possible solution, allowing for remote supervision of rehabilitation and eliminating access barriers. The objective of the Singapore Tele-technology Aided Rehabilitation in Stroke (STARS) trial is to determine if a novel tele-rehabilitation intervention for the first three months after stroke admission improves functional recovery compared to usual care. This is a single blind (evaluator blinded), parallel, two-arm randomised controlled trial study design involving 100 recent stroke patients. The inclusion criteria are age ≥40 years, having caregiver support and recent stroke defined as stroke diagnosis within 4 weeks. Consenting participants will be randomized with varying block size of 4 or 6 assuming a 1:1 treatment allocation with the participating centre as the stratification factor. The baseline assessment will be done within 4 weeks of stroke onset, followed by follow-up assessments at 3 and 6 months. The tele-rehabilitation intervention lasts for 3 months and includes exercise 5-days-a-week using an iPad-based system that allows recording of daily exercise with video and sensor data and weekly video-conferencing with tele-therapists after data review. Those allocated to the control group will receive usual care. The primary outcome measure is improvement in life task’s social activity participation at three months as measured by the disability component of the Jette Late Life Functional and Disability Instrument (LLFDI). Secondary outcome variables consist of gait speed (Timed 5-Meter Walk Test) and endurance (Two-Minute Walk test), performance of basic activities of daily living (Shah-modified Barthel Index), balance confidence (Activities-Specific Balance Confidence Scale), patient self-reported health-related quality-of-life [Euro-QOL (EQ-5D)], health service utilization (Singapore Stroke Study Health Service Utilization Form) and caregiver reported stress (Zarit Caregiver Burden Inventory). The goal of this trial is to provide evidence on the potential benefit and cost-effectiveness of this novel tele-rehabilitation programme which will guide health care decision-making and potentially improve performance of post-stroke community-based rehabilitation. This trial protocol was registered under ClinicalTrials.gov on 18 July 2013 as study title “The Singapore Tele-technology Aided Rehabilitation in Stroke (STARS) Study” (ID: The STARS Study, ClinicalTrials.gov Identifier: NCT01905917 ).

Objective. The P300 speller is a brain–computer interface (BCI) that can possibly restore communication abilities to individuals with severe neuromuscular disabilities, such as amyotrophic lateral sclerosis (ALS), by exploiting elicited brain signals in electroencephalography (EEG) data. However, accurate spelling with BCIs is slow due to the need to average data over multiple trials to increase the signal-to-noise ratio (SNR) of the elicited brain signals. Probabilistic approaches to dynamically control data collection have shown improved performance in non-disabled populations; however, validation of these approaches in a target BCI user population has not occurred. Approach. We have developed a data-driven algorithm for the P300 speller based on Bayesian inference that improves spelling time by adaptively selecting the number of trials based on the acute SNR of a user’s EEG data. We further enhanced the algorithm by incorporating information about the user’s language. In this current study, we test and validate the algorithms online in a target BCI user population, by comparing the performance of the dynamic stopping (DS) (or early stopping) algorithms against the current state-of-the-art method, static data collection, where the amount of data collected is fixed prior to online operation. Main results. Results from online testing of the DS algorithms in participants with ALS demonstrate a significant increase in communication rate as measured in bits/min (100–300%), and theoretical bit rate (100–550%), while maintaining selection accuracy. Participants also overwhelmingly preferred the DS algorithms. Significance. We have developed a viable BCI algorithm that has been tested in a target BCI population which has the potential for translation to improve BCI speller performance towards more practical use for communication.

P300-based BCIs have been proposed as potential communication alternatives for individuals whose severe neuro-muscular limitations, e.g. due to amyotrophic lateral sclerosis (ALS), preclude their use of most commercially available assistive technologies. However, BCIs are currently limited by their relatively slower selection rates due to the significant amount of data collection required to improve the signal-to- noise ratio (SNR) of the elicited brain responses to achieve desired system accuracy levels. The conventional strategy is to average over a fixed amount of data prior to BCI decision making, an approach that might be inefficient given the inherent variation in a user’s responses during BCI use. There is need for the development of improved algorithms that can demonstrate increased performance in online testing, especially in target end-user populations. We have developed an algorithm that uses a Bayesian approach to collect only the amount of data necessary to reach a specified confidence level in the BCI’s decision based on continuous evaluation of the quality of a user’s responses. We further optimized the algorithm by incorporating statistical information about the user’s language. Results from online testing in participants with ALS demonstrate that using the Bayesian dynamic stopping algorithm resulted in a significant reduction in character selection time with minimal effect on accuracy, compared to conventional static data collection. In post-use surveys, the participants overwhelmingly preferred the dynamic stopping algorithms.

Should we prefer surrogates for antitrust violations that permit errors, or should we instead rely on a more nebulous rule-of-reason inquiry? Kevin Caves & Hal Singer (Economists Incorporated)

Telemedicine applications, based on two-dimensional (2D) video conferencing technology, have been around for the past 15 to 20 yr. They have been demonstrated to be acceptable for face-to-face consultations and useful for visual examination of wounds and abrasions. However, certain telerehabilitation assessments need the use of spatial information in order to accurately assess the patient's condition and sending three-dimensional video data over low-bandwidth networks is extremely challenging. This article proposes an innovative way of extracting the key spatial information from the patient's movement during telerehabilitation assessment based on 2D video and then presenting the extracted data by using graph plots alongside the video to help physicians in assessments with minimum burden on existing video data transfer. Some common rehabilitation scenarios are chosen for illustrations, and experiments are conducted based on skeletal tracking and color detection algorithms using the Microsoft Kinect sensor. Extracted data are analyzed in detail and their usability discussed.

Sometimes communication supports and services for school-aged children with extensive disabilities are re-duced over time or removed on the basis of inappropri-ate reasons or eligibility criteria that are flawed. Family members may feel unequipped to argue against the de-cisions that schools or agencies make for their child, and professionals may be in a difficult position to disagree with their administrators. The National Joint Committee for the Communication Needs of Persons with Severe Disabilities has written a position statement on these re-strictive eligibility practices. This position statement ad-dresses concerns about inappropriate eligibility criteria and may be used to help individuals, family members, and providers gain access to necessary communication supports and services.

Modern day information technology (IT) is converging around wireless networks. It is now possible to check E-mail and view information from the World Wide Web from commercially available mobile phones. For individuals with disabilities, the ability to access multiple and different types of information not only promises convenience, but also can help to promote independence and facilitate access to public and private information systems. There are many barriers to access for people with disabilities, including technological hurdles, security, privacy, and access to these emerging wireless technologies. However, legislation, advocacy, standards, and research and development can ensure that users of augmentative and alternative communication (AAC) and assistive technology have access to these technologies. This article provides a historical context for the field of AAC and IT development, a review of the current state of these technologies, a glimpse of the potential of wireless information access for the lives of AAC users, and a description of some of the barriers and enablers to making access available to users of AAC and assistive technologies.

Objective Various augmentative and alternative communication (AAC) devices have been developed in order to aid communication for individuals with communication disorders. Recently, there has been interest in combining EEG data and eye-gaze data with the goal of developing a hybrid (or 'fused') BCI (hBCI) AAC system. This work explores the effectiveness of a speller that fuses data from an eye-tracker and the P300 speller in order to create a hybrid P300 speller. Approach This hybrid speller collects both eye-tracking and EEG data in parallel, and the user spells characters on the screen in the same way that they would if they were only using the P300 speller. Online and offline experiments were performed. The online experiments measured the performance of the speller for sixteen non-disabled participants, while the offline simulations were used to assess the robustness of the hybrid system. Main results Online results showed that for fifteen non-disabled participants, using eye-gaze in a Bayesian framework with EEG data from the P300 speller improved accuracy ([Formula: see text], [Formula: see text], [Formula: see text] for estimated, medium and high variance configurations) and reduced the average number of flashes required to spell a character compared to the standard P300 speller that relies solely on EEG data ([Formula: see text], [Formula: see text], [Formula: see text] for estimated, medium and high variance configurations). Offline simulations indicate that the system provides more robust performance than a standalone eye gaze system. Significance The results of this work on non-disabled participants shows the potential efficacy of hybrid P300 and eye-tracker speller. Further validation on the amyotrophic lateral sceloris population is needed to assess the benefit of this hybrid system.

Objective To compare Berg Balance Scale (BBS) rating using videos with differing transmission characteristics with direct in-person rating. Design Repeated-measures study for the assessment of the BBS in 8 configurations: in person, high-definition video with slow motion review, standard-definition videos with varying bandwidths and frame rates (768 kilobytes per second [kbps] videos at 8, 15, and 30 frames per second [fps], 30 fps videos at 128, 384, and 768 kbps). Setting Medical center. Participants Patients with limitations (N=45) in ≥1 of 3 specific aspects of motor function: fine motor coordination, gross motor coordination, and gait and balance. Interventions Not applicable. Main Outcomes Measures Ability to rate the BBS in person and using videos with differing bandwidths and frame rates in frontal and lateral views. Results Compared with in-person rating (7%), 18% ( P =.29) of high-definition videos and 37% ( P =.03) of standard-definition videos could not be rated. Interrater reliability for the high-definition videos was .96 (95% confidence interval, .94–.97). Rating failure proportions increased from 20% in videos with the highest bandwidth to 60% ( P P Conclusions Although there is some loss of information when using videos to rate the BBS compared to in-person ratings, it is feasible to reliably rate the BBS remotely in standard clinical spaces. However, optimal video rating requires frontal and lateral views for each assessment, high-definition video with high bandwidth, and the ability to carry out slow motion review.

To determine whether differences could be detected in mobility outcomes during community mobility and home mobility tasks according to type of mobility assistive device.Randomized, repeated measures.Community mobility task: traversing 341.4m between the rehabilitation clinic and hospital entrance; home mobility task: traversing 39m into and out of a patient training bathroom and bedroom.Community-dwelling, cognitively intact ambulatory veterans (N=59) who used a mobility device within the 14 days prior to the study.Participants tested 3 types of mobility assistive devices with wheels: 4-wheeled walker (WW), manual wheelchair (MWC), and powered wheelchair (PWC). The first and last devices used by each participant were randomly assigned as either MWC or WW. The PWC was always the second device.Speed (m/s), collisions (total), fatigue (0-10 Likert scale), and pain (0-10 Likert scale, diagram).The community mobility task was performed with all 3 devices by 52 (88%) veterans, and the home mobility task was performed with all 3 devices by 53 (90%) participants. In each task, 28 participants used the WW and 28 participants used the MWC as the final device. In the community mobility task, statistically significant differences (P.05) were seen with ≥1 device comparison for all studied outcomes (eg, standardized mean difference for the MWC compared with the PWC showed -.67 fewer collisions for the MWC). In the home mobility task, speed, collisions, and fatigue showed statistically significant (P.05) device-related differences (eg, standardized mean difference for the WW compared with the MWC showed -.88 fewer collisions for the WW).We found statistically significant and substantively different effects from 3 commonly used mobility assistive devices with wheels on diverse mobility outcomes when used in typical community mobility and home mobility tasks, providing proof of concept support for a research methodology applicable to comparative outcome studies of diverse mobility aids.

Background. Partial unweighted treadmill training is a potentially effective modality for improving fitness and function in frail elders. We tested the feasibility of partial unweighted treadmill training in older, mobility-impaired veterans.Methods. Eight mobility-impaired elders participated in partial unweighted treadmill training three times/week for twelve weeks. Outcome measures included gait speed, performance-oriented mobility assessment (POMA), eight foot up and go, and the SF-36 physical functioning short form.Results. There was significant improvement in treadmill walking time (+8.5 minutes;P<0.001), treadmill walking speed (+0.14 meters/second;P=0.02), and percent of body weight support (−2.2%;P=0.02). Changes in physical performance included usual gait speed (+0.12 meters/second;P=0.001), rapid gait speed (+0.13 meters/second;P=0.01), POMA (+2.4 summary score;P<0.001), and eight foot up and go (−1.2 seconds;P=0.05).Conclusions. Partial unweighted treadmill training is feasible in mobility-impaired elders. Improvements in treadmill training capacity resulted in clinically meaningful improvements in fitness levels and improved mobility.