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Jiangsu Key Laboratory of Medical Optics, Suzhou Institute of Biomedical Engineering and Technology, Chinese
Academy of Sciences, China
b University of Chinese Academy of Sciences, China
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i n f o
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Article history:
To extend the use of wearable sensor networks for stroke patients training and assessment
in non-clinical settings, this paper proposes a novel remote quantitative Fugl-Meyer assess-
ment (FMA) framework, in which two accelerometer and seven ex sensors were used to
17 February 2016
monitoring the movement function of upper limb, wrist and ngers. The extreme learning
machine based ensemble regression model was established to map the sensor data to clinical FMA scores while the RRelief algorithm was applied to nd the optimal features subset.
Keywords:
Considering the FMA scale is time-consuming and complicated, seven training exercises
were designed to replace the upper limb related 33 items in FMA scale. 24 stroke inpatients
Quantitative assessment
participated in the experiments in clinical settings and 5 of them were involved in the exper-
Stroke
iments in home settings after they left the hospital. Both the experimental results in clinical
and home settings showed that the proposed quantitative FMA model can precisely predict
Fugl-Meyer
the FMA scores based on wearable sensor data, the coefcient of determination can reach
Non-clinical settings
as high as 0.917. It also indicated that the proposed framework can provide a potential
approach to the remote quantitative rehabilitation training and evaluation.
2016 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
A stroke is one of top three causes of mortality and the leading cause of adult disability worldwide [1]. Between 70% and
85% of rst-ever strokes are accompanied by hemiplegia [2].
According to epidemiological statistics [3], the annual stroke
mortality rate is around 1.6 million, approximately 157 per
100,000 in China. Strokes have put enormous mental pressure
and economic burden on our society and families.
Corresponding author at: No. 88, Keling Road, Suzhou, Jiangsu Province 215163, China. Tel.: +86 0512 69588302; fax: +86 0512 69588302.
E-mail address: yul@sibet.ac.cn (L. Yu).
http://dx.doi.org/10.1016/j.cmpb.2016.02.012
0169-2607/ 2016 Elsevier Ireland Ltd. All rights reserved.
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personalized interventions that will maximize the improvements in subjects motor recovery cannot be reached,
which has become the bottleneck of home-based rehabilitation. Additionally, the commonly used assessment scales
have the following two drawbacks: (1) they are susceptible
to subjective factors, the assessment results may different between physicians; (2) they only have several rating
levels and are inuenced by a ceiling effect [7], making
it impossible to exactly detect the improvement in the
movement.
Nowadays, wearable sensor network systems (WSNs)
technology particularly inertial sensors that contain
accelerometers, gyroscopes, and magnetometers can assess
the type, intensity, duration, frequency, and quality of various mobility-related functional activities [815]. Additionally,
some researches combined the inertial measure sensors with
physiological sensors, like ECG [16], sEMG [17], etc. These
sensing systems can introduce new possibilities for continuous, unsupervised, objective monitoring of mobility and
functional activities in clinical and non-clinical settings. From
the aspects of application scenarios, it can be divided into
the following four categories: falling detection [18,19], physical activity monitoring [2022], movement recognition [2325]
and quantitative assessment [2631]. Particularly in the area
of quantitative assessment for stroke patients, there are
many valuable research results have been published. Uswatte
et al. [32] have shown that accelerometer data can provide
clinically-relevant information about upper extremity motor
status via research on 169 stroke survivors. Patel et al. [28,33]
proposed a Random Forests based algorithm to monitor rehabilitation outcomes in stroke patients using accelerometers
attached to the hand, arm and trunk. The authors selected
eight tasks from the Wolf Motor Function Test (WMFT) to estimate the total Functional Ability Scale (FAS) score via analysis
of accelerometer data. Our pilot work has shown that automatic Brunnstrom stage classication can be achieved with
an accuracy of 92.1% by analyzing the accelerometer data
[34]. Zhang et al. [3537] proposed a novel single-index based
assessment approach for quantitative upper limb mobility
evaluation, the experiments collected 145 motion samples
from 21 stroke patients and 8 healthy participants. The results
suggested that the proposed assessment index can not only
differentiate the levels of limb function impairment clearly
but also strongly correlate with the Brunnstrom stages of
recovery.
However, the above researches are all implemented in clinical settings. In other words, to the best of our knowledge, there
is no existing system can remotely assess the motor function
of stroke patients in home settings. Hence in order to help the
stroke patients can do rehabilitation training after they leave
the hospital, this paper proposes a novel remote quantitative Fugl-Meyer assessment system based on wearable sensor
networks.
The rest of the paper is organized as follows. In Section
2, the full view of the proposed framework and modeling
method will be presented. The experimental congurations will be introduced in Section 3. The experimental
results and discussions will be described in Section 4.
Finally, the work and contributes will be concluded in
Section 5.
2.
Methods
2.1.
101
2.2.
As seen in Fig. 1, the core of proposed system is the quantitative Fugl-Meyer assessment (FMA) model, which mapping the
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2.3.
Fig. 2 illustrates the whole procedure of establishing the quantitative Fugl-Meyer assessment model.
Due to the fact that the raw sensor data were often noised
for many reasons, such as random noise, packet loss during
wireless transmission, etc. hence, it is necessary to preprocess
the raw sensor data rstly. Considering the movement signals
of stroke patients are low frequency, in this paper we chose
the 5 points smooth method to eliminate the noise.
After the preprocessing step we extract features which capture characteristics such as intensity, orientation, and signal
complexity from the raw sensor data. There are many methods like time-domain, frequency-domain, and so on [40]. Patel
extracted a set of 216 features from 9 body worn sensors, the
detailed information can be seen in Ref. [41]. Based on the
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yik =
L
kj gj (W, B, X),
k = 1, 2, . . ., m
H = Y
= H+ Y
(2)
ELM Algorithm:
(1)
j=1
103
g(w1 x1 + b1 )
g(wL x1 + b1 )
..
.
..
..
.
g(w1 xN + b1 )
(3)
g(wL xN + bL )
(4)
(5)
3.
Experimental congurations
3.1.
Experimental setup
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16/8
69.4 12.8
7/17
7/17
8.9 4.2
18.3 9.6
and extension movement function of wrist. All the ex sensors were wrapped into a glove so that they were easily for the
patients to wear.
3.2.
Experimental procedure
4.
4.1.
Generalized performance of quantitative
Fugl-Meyer assessment model
Following the steps described in Fig. 2, we established a quantitative Fugl-Meyer assessment model which maps the wearable
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X1
X2
2
Raw
Denoised
g(m/s )
g(m/s2)
0
-1
20
40
60
80
100
0
-1
120
Raw
Denoised
20
40
60
Y1
g(m/s )
g(m/s )
Raw
Denoised
-1
20
40
60
80
100
Raw
Denoised
0
-0.5
-1
120
20
40
60
Z1
80
100
120
Z2
0.4
0.5
g(m/s )
Raw
Denoised
0.2
g(m/s2)
120
0.5
-0.5
0
-0.2
-0.4
100
Y2
-1.5
80
20
40
60
80
Sampling Points
100
120
Raw
Denoised
0
-0.5
-1
20
40
60
80
Sampling Points
100
120
Thumb finger
Raw
Denoised
90
85
80
10
20
30
40
50
60
Sampling Points
Index finger
70
80
90
100
70
Raw
Denoised
65
60
55
0
10
20
30
40
50
60
Sampling Points
70
80
90
100
Fig. 5 Comparison between raw and denoised accelerometer sensor data of shoulder antexion exercise.
sensor data to FMA scores. First of all, the raw sensor data
was denoised with 5 point smooth method. Due to the space
limitations, here we only present the comparison of raw and
denoised sensor data of shoulder antexion and nger touch
exercises in Fig. 5. It can be seen that after smooth preprocessing, the denoised signals were smoother than raw signals, and
some outliers caused by packet loss during wireless transmission were eliminated.
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50
20
40
Exercise 3 (R2 = 0.653)
50
0
20
40
Exercise 5 (R2 = 0.796)
60
50
0
20
40
Exercise 7 (R2 = 0.701)
60
50
0
60
Predictive FMA Scores
50
20
40
Exercise 4 (R2 = 0.823)
60
20
40
Exercise 6 (R2 = 0.724)
60
50
0
50
0
0
20
40
60
Comprehensive model (R2 = 0.839)
50
20
40
60
20
40
60
the selected features kept the main information and characteristic for each exercise. For example, (1) the features from X
axis of two accelerometer sensors were often selected in exercises 1, 2 and 4, which was consistent with the kinematics of
these exercises; similarly, the features from Y and Z axis of
two accelerometer sensors were often selected in exercises 3
and 4; (2) for exercise 5, only the features from two ex sensors
placed on the wrist were selected because during this exercise,
the signals of other ve ex sensors placed on the ngers were
not changed; as well, the features from ex sensor placed on
the thumb were selected for both exercises 6 and 7.
Based on the selected features, we again established the
weak regression model for each exercise and then built a comprehensive quantitative Fugl-Meyer assessment model. The
generalized performance results were shown in Fig. 7. Compared with Fig. 6, it can be seen that the errors between clinical
and predictive FMA scores have reduced a lot; the coefcient
of determination of comprehensive model can reach 0.918.
4.2.
Effects of feature selection on generalized
performance
4.3.
Remote quantitative Fugl-Meyer assessment in
home settings
As mentioned above, the nal goal of this study is to implement the proposed framework in home settings. According
to the experiment described in Section 3.2, the involved ve
stroke patients nished the seven exercises at home once a
week and go to the hospital once a month. The FMA scores
predicted by our framework and physicians were illustrated in
Fig. 8, in which P1P5 denotes the ve stroke patients, respectively. The solid points at the 4th, 8th and 12th week represent
the FMA scores assessed by physicians. From Fig. 8 it is clearly
to see that the errors between predictive and physicians FMA
scores were small enough so that can be ignored. Actually, the
one-way analysis of variance (ANOVA) results of 5 participants
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Exercise Number
2
3
4
AMP_X1
AMP_Y1
AMP_Z1
AMP_X2
AMP_Y2
AMP_Z2
RMS_X1
RMS_Y1
RMS_Z1
RMS_X2
RMS_Y2
RMS_Z2
MEAN_X1
MEAN_Y1
MEAN_Z1
MEAN_X2
MEAN_Y2
MEAN_Z2
JERK_X1
JERK_Y1
JERK_Z1
JERK_X2
JERK_Y2
JERK_Z2
ApEn_X1
ApEn_Y1
ApEn_Z1
ApEn_X2
ApEn_Y2
ApEn_Z2
Exercise Number
5
6
7
AMP_S1
AMP_S2
AMP_S3
AMP_S4
AMP_S5
AMP_S6
AMP_S7
RMS_S1
RMS_S2
RMS_S3
RMS_S4
RMS_S5
RMS_S6
RMS_S7
MEAN _S1
MEAN _S2
MEAN _S3
MEAN _S4
MEAN _S5
MEAN _S6
MEAN _S7
JERK_S1
JERK_S2
JERK_S3
JERK_S4
JERK_S5
JERK_S6
JERK_S7
ApEn_S1
ApEn_S2
ApEn_S3
ApEn_S4
ApEn_S5
ApEn_S6
ApEn_S7
4.4.
Discussion
ELM
12.192
0.839
0.226
ELM FSa
6.964
0.918
0.138
SVM
11.875
0.846
4.562
SVM FSa
6.627
0.922
1.085
ELM FS, SVM FS means models are established after the feature
selection process.
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50
20
40
Exercise 3 (R2 = 0.879)
50
0
20
40
Exercise 5 (R2 = 0.909)
60
50
0
20
40
Exercise 7 (R2 = 0.871)
60
50
0
60
Predictive FMA Scores
50
20
40
Exercise 4 (R2 = 0.921)
60
20
40
Exercise 6 (R2 = 0.884)
60
50
0
50
0
0
20
40
60
Comprehensive model (R2 = 0.918)
50
20
40
60
20
40
60
Fig. 7 Generalized performance of 7 weak models and comprehensive model with RRelief feature selection.
longer than ELM. However, once the training process has nished, there is no obvious difference between the SVM and
ELM for the prediction process.
The proposed framework has some limitations need to be
concerned, among which ceiling effect is an important one.
From Fig. 8, ceiling effect can be seen in both the clinical physicians assessment and our proposed framework. For example,
the FMA scores of P2 and P4 at the 8th and 12th week were
almost same, which is difcult for physicians to precisely
evaluate the movement function of patients and make individual prescriptions. Hence, it is necessary to develop some
new features and evaluation indexes to describe the detail
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5.
Conclusions
[7]
[8]
[9]
[10]
[11]
[12]
Conict of interest
The authors declare that they have no proprietary, nancial,
professional, or other personal competing interests of any
nature or kind.
Acknowledgements
The authors thank Doctor Xudong Gu and Jianming Fu who
come from the Rehabilitation Medical Center of Jiaxing 2nd
Hospital, for their valuable suggestion and guidance during
the clinical experiment design and implementation processes.
[13]
[14]
[15]
references
[17]
[18]
[19]
[20]
[21]
[22]
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