Physical therapy exercises are critically important for the rehabilitation of patients with motor deficits. While these exercises can be most effective when performed properly under the supervision of a physical therapist, it may not be a viable option for all patients. Thus, there is a growing trend towards at-home physical rehabilitation tracking systems as they can be more accessible and flexible for patients. However, existing systems mostly depend on camera and wearable based solutions, which can be costly and limited. To this end, we propose a low-cost and non-intrusive end-to-end solution using IoT-based wireless sensing devices. Our solution, Wi-PT-Hand, leverages Channel State Information (CSI) captured from ambient WiFi signals and uses Bayesian optimizers and a hierarchical deep learning model trained to recognize the prescribed hand exercises. The proposed system includes (i) segmentation of the therapy time into activity and non-activity durations, (ii) recognition of the exercise performed in an activity segment, and (iii) counting of the number of repetitions of the exercise performed within that segment. Extensive experimental results show that the proposed system is robust and performs well in various real life scenarios, and thanks to the lightweight design it can work on low-resource edge devices properly.

Importance: Parent recall is the primary method for measuring positioning practices such as tummy time in infants. Concerns regarding the accuracy of parent recall have been raised in the literature. To date, no study has examined the agreement of tummy time recall measures with gold-standard methods. Objective: To assess the agreement between parental recall versus direct observation of tummy time in infants, and to explore the impact of prematurity on this relationship. Design: Cross-sectional observational study, spanning 1 yr. Setting: Participants' homes Participants: Thirty-two infant-parent dyads (19 full-term, 13 preterm), with infants ages 3 to 6 mo and caregivers ages older than 18 yr. Outcome and Measures: Home-recorded videos of infant play across 3 days were used as a proxy for direct observation of tummy time and compared with a 12-item parent recall survey. Results: Parent recall had a significant moderate correlation (r = .54, p = .002) with direct observation in full-term infants but was not correlated (p = .23) with direct observation in preterm infants. On average, parents of preterm infants overestimated tummy time by 2.5 times per day compared with direct observation. Conclusions and Relevance: For full-term infants, parent recall measures of tummy time exhibit an acceptable level of agreement with direct observation and can be reliably used over shorter periods. Parents of preterm infants may display a bias in recalling tummy time, leading to overestimations. To accurately assess tummy time in this population, a combination of subjective and objective measures should be explored.

The vestibular ocular reflex (VOR) provides gaze stability during head movements by driving eye movements in a direction opposing head motion. Although vestibular-based rehabilitation strategies are available, it is still unclear whether VOR can be modulated by training. By examining adaptations in gaze stabilization mechanisms in a population with distinct visuomotor requirements for task success (i.e., gymnasts), this study was designed to determine whether experience level (as a proxy of training potential) was associated with gaze stabilization modifications during fixed target (VOR promoting) and fixed-to-head-movement target (VOR suppressing) tasks. Thirteen gymnasts of different skill levels participated in VOR and VOR suppression tasks. The gain between head and eye movements was calculated and compared between skill levels using an analysis of covariance. Across experience levels, there was a similar degradation in VOR gain away from −1 at higher movement speeds. However, during the suppression tasks, more experienced participants were able to maintain VOR gain closer to 0 across movement speeds, whereas novice participants showed greater variability in task execution regardless of movement speed. Changes in adaptive modifications to gaze stability associated with experience level suggest that the mechanisms impacting gaze stabilization can be manipulated through training.

Trunk control and postural instability remain critical markers of functional status in Parkinson’s Disease (PD). As pharmacological and invasive neuro-stimulation interventions provide only limited benefits for trunk and postural control, exercise-based interventions may provide the only effective path to improving functional outcomes for balance in PD. We describe the framework for a virtual reality (VR) graded exercise-based intervention focused on improving trunk mobility and control, including preliminary outcomes on perceptions and motion capabilities of individuals with PD. The study collected whole-body motion capture from 11 PD participants (8M, 3F; H Y Stage I–III) as they performed tasks within a custom-designed set of VR therapies. Therapies involved static interactions (e.g., matching a cube sequence set to anthropometrically relevant locations to elicit specific trunk motions—Matchality), and more dynamic tasks (e.g., intercepting virtual fish jumping from a lake—Fishality, or a virtual session of dodgeball—Dodgeality). Participants were able to safely complete all tasks while performing trunk excursions requiring functionally relevant ranges of motion, and which altered across VR environment (F(1,10) = 8.319, p = 0.016). Overall, satisfaction with the MoVR therapy suite was high with 96

Physical therapy (PT) exercises are critically important for the rehabilitation of patients with motor deficits. While rehabilitation exercises can be most effective when performed properly under the supervision of a physical therapist, it can be costly in terms of several aspects and may not be a viable option for all patients. At-home systems offer more accessible and less costly solutions to patients while also providing flexibility in scheduling prescribed exercises. However, current systems mostly depend on camera based solutions that have limitations (i.e., deployment cost, requiring patients to be in the sight of camera, potential privacy violations) or wearable solutions that are cumbersome and intrusive. To this end, in this paper, our goal is to leverage the WiFi infrastructure available in most indoor locations (i.e., homes, apartments, nursing homes, etc.) for tracking the exercises prescribed to patients during their rehabilitation. Our solution, Wi-PT, is based on the analysis of Channel State Information (CSI) captured from ambient WiFi signals, and uses deep learning models trained to recognize the prescribed physical therapy exercises. Through our experiments, we show that the proposed solution can successfully recognize different types of physical therapy exercises such as hand and finger movements, limb movements and movements performed with exercise equipment. Moreover, we show that our system can recognize the person performing different activities and can identify when they are at rest or actively performing an exercise.

Background Complex movement pathologies that are biopsychosocial in nature (eg, back pain) require a multidimensional approach for effective treatment. Virtual reality is a promising tool for rehabilitation, where therapeutic interventions can be gamified to promote and train specific movement behaviors while increasing enjoyment, engagement, and retention. We have previously created virtual reality–based tools to assess and promote lumbar excursion during reaching and functional gameplay tasks by manipulating the position of static and dynamic contact targets. Based on the framework of graded exposure rehabilitation, we have created a new virtual reality therapy aimed to alter movement speed while retaining the movement-promoting features of our other developments. Objective This study aims to compare lumbar flexion excursion and velocity across our previous and newly developed virtual reality tools in a healthy control cohort. Methods A total of 31 healthy participants (16 males, 15 females) took part in 3 gamified virtual reality therapies (ie, Reachality, Fishality, and Dodgeality), while whole-body 3D kinematics were collected at 100 Hz using a 14-camera motion capture system. Lumbar excursion, lumbar flexion velocity, and actual target impact location in the anterior and vertical direction were compared across each virtual reality task and between the 4 anthropometrically defined intended target impact locations using separate 2-way repeated measures analysis of variance models. Results There was an interaction between game and impact height for each outcome (all P<.001). Post-hoc simple effects models revealed that lumbar excursion was reduced during Reachality and Fishality relative to that during Dodgeality for the 2 higher impact heights but was greater during Reachality than during Fishality and Dodgeality for the lowest impact height. Peak lumbar flexion velocity was greater during Dodgeality than during Fishality and Reachality across heights. Actual target impact locations during Dodgeality and Fishality were lower relative to those during Reachality at higher intended impact locations but higher at lower intended impact locations. Finally, actual target impact location was further in the anterior direction for Reachality compared to that for Fishality and for Fishality relative to that for Dodgeality. Conclusions Lumbar flexion velocity was reduced during Fishality relative to that during Dodgeality and resembled velocity demands more similar to those for a self-paced reaching task (ie, Reachality). Additionally, lumbar motion and target impact location during Fishality were more similar to those during Reachality than to those during Dodgeality, which suggests that this new virtual reality game is an effective tool for shaping movement. These findings are encouraging for future research aimed at developing an individualized and graded virtual reality intervention for patients with low back pain and a high fear of movement.

Chronic low back pain (cLBP) rates among younger individuals are rising. Although pain and disability are often less severe, underlying changes in trunk behavior may be responsible for recurrence. We examine the biomarker capacity of a simple Trunk Compliance Index (TCI) to distinguish individuals with and without cLBP. A random subset (n = 49) of the RELIEF RCT were matched to healthy controls for sex, age, height and weight. We measured TCI (as displacement/ weight-normalized perturbation force) using anthropometrically-matched, suddenly-applied pulling perturbations to the trunk segment, randomized across three planes of motion (antero-posterior, medio-lateral, and rotational). Mean differences between cLBP, sex and perturbation direction were assessed with repeated-measures analysis of variance. Discriminatory accuracy of TCI was assessed using Receiver Operator Characteristic (ROC) analysis. Baseline characteristics between groups were equivalent (x̅ [range]): sex (57% female / group), age (23.0 [18–45], 22.8 [18–45]), height, cm (173.0 [156.5–205], 171.3 [121.2–197], weight, kg (71.8 [44.5–116.6], 71.7 [46.8–117.5]) with cLBP associated with significantly lower TCI for 5 of 6 directions (range mean difference, − 5.35: − 1.49, range 95% CI [− 6.46: − 2.18 to − 4.35: − 0.30]. Classification via ROC showed that composite TCI had high discriminatory potential (area under curve [95% CI], 0.90 [0.84–0.96]), driven by TCI from antero-posterior perturbations (area under curve [95% CI], 0.99 [0.97–1.00]). Consistent reductions in TCI suggests global changes in trunk mechanics that may go undetected in classic clinical examination. Evaluation of TCI in younger adults with mild pain and disability may serve as a biomarker for chronicity, leading to improved preventative measures in cLBP. Trial Registration and Funding RELIEF is registered with clinicaltrials.gov (NCT01854892) and funded by the NIH National Center for Complementary & Integrative Health (R01AT006978).

Aims: The American Academy of Pediatrics recommends “parents to incorporate supervised, awake ‘prone play’ in their infant’s routine to support motor development and minimize the risk of plagiocephaly”. The purpose of this feasibility study was to compare usual care to a reward contingency–based intervention, developed to increase prone tolerance and improve motor skills. Methods: Ten full-term infants, 3–6- months old, with poor prone tolerance were randomized to either the Education group or Reward contingency group. Each group participated in three parent education sessions and 15 intervention sessions, over the period of three weeks. Infants in the Reward contingency group used the Prone Play Activity Center, a technology developed to reinforce motor behavior of infants in prone position. Intervention frequency and parent feedback data determined the feasibility of the interventions. Results: Infants in the Reward contingency group practiced a median of 12 of the 15 anticipated intervention sessions in the Prone Play Activity Center. These infants used the device for a mean of 18 minutes per day. Parents of infants in the Education group practiced a median of 10 sessions of the 15 anticipated intervention sessions. Conclusion: The reward contingency–based intervention is feasible for use in a future clinical trial with some modifications.

Date Presented 03/26/20 Infants who sustain brachial plexus injury are at risk for neuromuscular and sensibility deficits contributing to prehensile dysfunction. OTs practicing in early intervention often have limited resources available to improve muscle activation. Yet our experimental program offers a solution, since infant-initiated muscle activation or arm movement will trigger a toy to move, reinforcing them to move again. If done repeatedly, this program could contribute to their recovery. Primary Author and Speaker: Susan Duff Contributing Authors: Milan Stevanovic, Jamie Berggren, Barbara Sargent, Andrew Kimbel, Cyril Rakovski, Ehsan Yaghmaei, Peter Pidcoe, Benjamin Leiby, Mitchel Seruya, Eric Wade

BACKGROUND:Associative learning is the ability to discover a relationship between two or more events. We combined principles of learning and technology to develop a paradigm to assess associative learning in prone.PURPOSE:The purpose of this study was to determine whether 3- to 6-month-old infants can demonstrate: (1) short-term learning of an association between their upper body movements in prone and activation of a toy, and (2) retention of the association learned on day 1, 24 hours later.METHODS:Twenty-eight infants who were 3 to 6 months of age and who were typically developing were tested for 2 consecutive days in an instrumented play gym. Both days of testing had a baseline and 4 acquisition phases (2 minutes each). During the acquisition phase, the toy activated for a maximum of 10 seconds when the infant's head was above a threshold. A criterion was set a priori to distinguish infants as short-term learners and retainers of the association learned on day 1.RESULTS:Of 28 infants, 22 and 14 infants completed all phases of the testing on day 1 and day 2, respectively. Fourteen (50%) of the infants met the criteria for short-term learners. On day 2, there was an analyzable sample of 9 short-term learners. Three of the 12 short-term learners (25%) demonstrated retention on day 2.CONCLUSION:Consistent with prior infant motor learning research, half of the infants demonstrated associative learning in this novel assessment in prone; however, based on study criteria, the infants had limited retention of the association on day 2.

Immersive virtual reality has recently developed into a readily available system that allows for full-body tracking. Can this affordable system be used for component tracking to advance or replace expensive kinematic systems for motion analysis in the clinic? The aim of this study was to assess the accuracy of position and orientation measures from Vive wireless body trackers when compared to Vicon optoelectronic tracked markers attached to (1) a robot simulating trunk flexion and rotation by repeatedly moving to know locations, and (2) healthy adults playing virtual reality games necessitating significant trunk displacements. The comparison of both systems showed component tracking with Vive trackers is accurate within 0.68 ± 0.32 cm translationally and 1.64 ± 0.18° rotationally when compared with a three-dimensional motion capture system. No significant differences between Vive trackers and Vicon systems were found suggesting the Vive wireless sensors can be used to accurately track joint motion for clinical and research data.

“How could I apply this information?” Modified ride-on cars are becoming commonplace in homes and clinics as programs facilitating their design and construction proliferate. They are often less expensive alternatives to promote self-directed mobility in children with disabilities. Although there is conjecture and limited evidence about the efficacy of using these interventions on younger and younger populations, studies such as this one are an important link in determining their usefulness. Although skill development appears to be dose dependent, children younger than 2 years can learn to drive cars even though there was a large variance in adherence rates. The home use of self-directed mobility aids at this age is earlier than is typically prescribed in clinical settings. “What should I be mindful of in applying this information?” Although the children had diverse medical diagnosis, impairments, and mobility histories, generalization of results in this single subject case series to a broader population is limited. There is no measure of skill retention and limited subject adherence to suggested drive-time dosage. These data alone are not enough to fully support the use of modified ride-on cars as therapeutic aids in the home with a young population, but all participants were reported to have fun! Peter Pidcoe, PT, DPT, PhD Department of Physical Therapy, Virginia Commonwealth University Richmond, Virginia

The Academy of Pediatric Physical Therapy Research Summit IV issued a Call to Action for community-wide intensification of a research enterprise in inquiries related to pediatric brain injury and motor disability by way of technological integration. But the barriers can seem high, and the pathways to integrative clinical research can seem poorly marked. Here, we answer the Call by providing framework to 3 objectives: (1) instrumentation, (2) biometrics and study design, and (3) data analytics. We identify emergent cases where this Call has been answered and advocate for others to echo the Call both in highly visible physical therapy venues and in forums where the audience is diverse.

Starting from an upright standing posture and reaching for a target that requires some forward bending of the trunk can involve many different configurations of the trunk and limb segments. We sought to determine if configurations of the limb and trunk segments during our standardized full-body reaching tasks were influenced by the visual environment. This paper examined movement patterns of healthy participants (n=17, eight female and nine male) performing full body reaching tasks to: 1) real-world targets; 2) virtual targets presented on a 3-D television; and 3) virtual targets presented using a head-mounted display. For reaches performed in the virtual world, the avatar was presented from a third-person perspective for the 3-D television and from a first-person perspective for the head-mounted display. Reaches to virtual targets resulted in significantly greater excursions of the ankle, knee, hip, spine, and shoulder compared with reaches made to real-world targets. This resulted in significant differences in the forward and downward displacements of the whole-body center of mass between the visual environments. Visual environment clearly influences how subjects perform full-body reaching tasks to static targets. Because a primary goal of virtual reality within rehabilitation is often to restore movement following orthopedic or neurologic injury, it is important to understand how visual environment will affect motor behavior. The present findings suggest that the existing game systems that track and present avatars from a third-person perspective elicit significantly different motor behavior when compared with the same tasks being presented from a first-person perspective.

Altering footstrike pattern subsequently alters running kinematics and kinetics. It has been suggested that a midfoot strike pattern (MFS) may reduce injury risk. However, attempts to alter strike pattern have had limited success. Use of a constrained system may aid in motor learning and improve adoption of a new strike pattern. PURPOSE:To determine if training using an elliptical ergometer modified to mimic MFS would improve ability of runners with a habitual rearfoot strike pattern (RFS) to successfully adopt a MFS. METHODS:Six subjects completed a three-dimensional gait analysis on a treadmill instrumented with a force platform. Subjects ran at a self-selected pace using their natural RFS, and then were instructed to run using MFS (PRE). Subjects then completed 5 20-minute training sessions over 2 weeks on an elliptical trainer modified to mimic MFS. After training, gait analysis was repeated (POST). 2-Way ANOVAs (time x strike pattern) evaluated foot angle at initial contact (FIC), peak vertical ground reaction force (VGRF), vertical loading rate (VLR), peak knee extension moment (KEM), peak knee abduction moment (KAM), peak knee internal rotation moment (KIRM) and stride frequency (SF). RESULTS:When compared to RFS, MFS demonstrated lesser FIC (RFS: 7.1±4.8, MFS: 0.9±6.2 degrees, p=0.01). There were no differences in FIC PRE vs POST. There were no significant differences in VLR between RFS (53.7±10.4 BW/s) and MFS (49.5±16.3 BW/s). There were no differences in VGRF across any conditions. MFS produced lower KEM than RFS (1.39±0.37 vs 1.54±0.26 Nm/kg, p=0.02), but there was no change with training. KIRM was not different between strike patterns, but decreased with training (PRE: 0.34±0.03, POST: 0.31±0.05 Nm/kg, p=0.03). KAM did not change across any conditions. SF was greater with MFS than RFS (171±3 vs 175±4 steps per minute, p=0.01) during PRE. Training also produced an increase in SF using RFS (POST: 173±3 steps per minute, p=0.02). CONCLUSIONS:Runners are able to change the angle of the foot relative to the ground immediately with instruction. This running style produces an expected change in stride frequency and knee extension moment. Training with the modified elliptical trainer alters stride frequency and knee internal rotation moment, but does not result in changes in preferred strike pattern or VLR.

Background Virtual reality (VR) interventions hold great potential for rehabilitation as commercial systems are becoming more affordable and can be easily applied to both clinical and home settings. Objective In this study, we sought to determine how differences in the VR display type can influence motor behavior, cognitive load, and participant engagement. Methods Movement patterns of 17 healthy young adults (8 female, 9 male) were examined during games of Virtual Dodgeball presented on a three-dimensional television (3DTV) and a head-mounted display (HMD). The participant’s avatar was presented from a third-person perspective on a 3DTV and from a first-person perspective on an HMD. Results Examination of motor behavior revealed significantly greater excursions of the knee (P=.003), hip (P<.001), spine (P<.001), shoulder (P=.001), and elbow (P=.026) during HMD versus 3DTV gameplay, resulting in significant differences in forward (P=.003) and downward (P<.001) displacement of the whole-body center of mass. Analyses of cognitive load and engagement revealed that relative to 3DTV, participants indicated that HMD gameplay resulted in greater satisfaction with overall performance and was less frustrating (P<.001). There were no significant differences noted for mental demand. Conclusions Differences in visual display type and participant perspective influence how participants perform in Virtual Dodgeball. Because VR use within rehabilitation settings is often designed to help restore movement following orthopedic or neurologic injury, these findings provide an important caveat regarding the need to consider the potential influence of presentation format and perspective on motor behavior.

STUDY DESIGNRandomized controlled trial.OBJECTIVESTo determine if thoracic spinal manipulative therapy (SMT) alters thoracic kinematics, thoracic excursion, and scapular kinematics compared to a sham SMT in individuals with subacromial impingement syndrome, and also to compare changes in patient-reported outcomes between treatment groups.BACKGROUNDPrior studies indicate that thoracic SMT can improve pain and disability in individuals with subacromial impingment syndrome. However, the mechanisms underlying these benefits are not well understood.METHODSParticipants with shoulder impingement symptoms (n = 52) were randomly assigned to receive a single session of thoracic SMT or sham SMT. Thoracic and scapular kinematics during active arm elevation and overall thoracic excursion were measured before and after the intervention. Patient-reported outcomes measured were pain (numeric pain-rating scale), function (Penn Shoulder Score), and global rating of change.RESULTSFollowing the intervention, there were no significant differences in changes between groups for thoracic kinematics or excursion, scapular kinematics, and patient-reported outcomes (P>.05). Both groups showed an increase in scapular internal rotation during arm raising (mean, 0.9°; 95% confidence interval [CI]: 0.3°, 1.6°; P = .003) and lowering (0.8°; 95% CI: 0.0°, 1.5°; P = .041), as well as improved pain reported on the numeric pain-rating scale (1.2 points; 95% CI: 0.3, 1.8; P<.001) and function on the Penn Shoulder Score (9.1 points; 95% CI: 6.5, 11.7; P<.001).CONCLUSIONThoracic spine extension and excursion did not change significantly following thoracic SMT. There were small but likely not clinically meaningful changes in scapular internal rotation in both groups. Patient-reported pain and function improved in both groups; however, there were no significant differences in the changes between the SMT and the sham SMT groups. Overall, patient-reported outcomes improved in both groups without meaningful changes to thoracic or scapular motion.LEVEL OF EVIDENCETherapy, level 1b-.

Objective: After traumatic brain injury (TBI), postural instability often results. This can effect ambulation and, subsequently, activities of daily living. Various forms of rehabilitation have been developed, but few offer engaging activities that provide informative dynamic balance training. The goal of this pilot study was to build a goal-based system that provided visual biofeedback to create an enriched environment for dynamic postural rehabilitation. The study aimed to determine if visual biofeedback had an effect on posture and balance during training for healthy participants; as well as determine the optimal man-machine visual-biofeedback interface. Method: A modified elliptical trainer was developed that incorporated visual-biofeedback from measured left and right lower extremity loads. Four visual displays were constructed and tested on a sample of 15 healthy participants. These displays provided targeted feedback to aid in symmetric performance. The displays differed in the amount of information provided and in the extent of algorithmic pre-processing. Data were evaluated by calculating the index of symmetry (IOS) and statistically comparing display types. Results: Participants performed significantly better with the introduction of visual biofeedback than baseline measurements with no display based on index of symmetry values. The data suggests that the feedback display that incorporated both temporal historical data and differential pre-processing performed the best. This display was called the differential-temporal display. Conclusion: Our results reflect that performance is enhanced with the introduction of visual biofeedback during dynamic postural training. We also established that the differential-temporal display was the optimal feedback system to reduce IOS values during elliptical trainer use. From our results, it became apparent that incorporating visual biofeedback during postural training is a sophisticated approach to improve baseline asymmetries inherent in healthy participants. It is anticipated that similar results are likely to occur in a cohort of TBI patients due to the reduction of cognitive demand.

Due to the high percentage of musicians who suffer from musculoskeletal disorders, there is a need for more research in the field of music and medicine. The purpose of this study was to analyze the possible relationship between anxiety, muscle activation, and muscle fatigue in undergraduate trumpet players. Assessment tools included surface electromyography (sEMG) data, State Trait Anxiety Inventory (STAI), and Visual Analogue Scales (VAS) of perceived anxiety. Data were collected from 27 undergraduate music students across five universities (22 males, 5 females) aged 18 to 24 years. The three muscles targeted by the sEMG were the upper trapezius, sternocleidomastoid, and masseter muscles. Participants were randomly divided into two single-blinded groups: (1) anxiety-induction and (2) control. The anxiety-induction group was instructed to play as accurately as possible and informed that mistakes were being counted and evaluated, while the control group was instructed to play without any concern for possible mistakes. The anxiety-induction group was shown to have more masseter muscle activation than the control; the anxiety-induction group also displayed a higher fatigue rate in all three muscles versus the controls. Subjects with high perceived-anxiety (as measured by VAS) displayed higher masseter activation and higher fatigue rates in the upper trapezius and sternocleidomastoid than non-anxious participants. Despite these notable trends, there was no statistical significance for any of the muscle groups for muscle activation or fatigue.

Background: Prone locomotion, a core of early infant learning, is extremely compromised in infants with Cerebral Palsy (CP). Despite research supporting its centrality to diverse psychological processes that have lasting effects on learning, no tested interventions exist to promote this skill. Equally lacking are successful movement learning approaches that take advantage of current technological innovations and learning theories. The self-initiated prone progression crawler (SIPPC), a robotic system recently developed to simultaneously augment and measure infants’ self-produced movement effort during prone locomotion, provides a unique opportunity to study movement learning.