Development of a self-administered web-based test for longitudinal cognitive assessment.

Sequential testing with brief cognitive tools has been recommended to improve cognitive screening and monitoring, however the few available tools still depend on an external evaluator and periodic visits. We developed a self-administered computerized test intended for longitudinal cognitive testing (Brain on Track). The test can be performed from a home computer and is composed of several subtests, expected to evaluate different cognitive domains, all including random elements to minimize learning effects. An initial (A) and a refined version of the test (B) were applied to patients with mild cognitive impairment or early dementia (n = 88) and age and education-matched controls. A subsample of a population-based cohort (n = 113) performed the test at home every three months to evaluate test-retest reliability. The test's final version Cronbach's alpha was 0.90, test scores were significantly different between patients and controls (p = 0.001), the area under the receiver operating characteristic curve was 0.75 and the smallest real difference (43.04) was lower than the clinical relevant difference (56.82). In the test-retest reliability analysis 9/10 subtests showed two-way mixed single intraclass consistency correlation coefficient >0.70. These results imply good internal consistency, discriminative ability and reliability when performed at home, encouraging further longitudinal clinical and population-based studies.

Motor task performance under vibratory feedback early poststroke: single center, randomized, cross-over, controlled clinical trial.

Stroke rehabilitation is far from meeting patient needs in terms of timing, intensity and quality. This study evaluates the efficacy and safety of an innovative technological tool, combining 3D motion analysis with targeted vibratory feedback, on upper-limb task performance early poststroke (<4 weeks). The study design was a two-sequence, two-period, randomized, crossover trial (NCT01967290) in 44 patients with upper-limb motor deficit (non-plegic) after medial cerebral artery ischemia. Participants were randomly assigned to receive either the experimental session (repetitive motor task under vibratory feedback and 3D motor characterization) or the active comparator (3D motor characterization only). The primary outcome was the number of correct movements per minute on a hand-to-mouth task measured independently. Vibratory feedback was able to modulate motor training, increasing the number of correct movements by an average of 7.2/min (95%CI [4.9;9.4]; P < 0.001) and reducing the probability of performing an error from 1:3 to 1:9. This strategy may improve the efficacy of training on motor re-learning processes after stroke, and its clinical relevance deserves further study in longer duration trials.

Web-based cognitive training: patient adherence and intensity of treatment in an outpatient memory clinic.

BACKGROUND: Cognitive training has been playing an increasing role in the treatment of patients with cognitive deficits. This type of intervention, namely its intensity, can be optimized by incorporating information technology-based systems. OBJECTIVE: The intent of the study was to determine the treatment intensity and patient adherence to home-based cognitive training strategies (Web-based cognitive training). METHODS: A cohort of 45 patients with neurologic and psychiatric diseases attending an outpatient memory clinic (average age 50.7 years, SD 17.0; average education 7.8 years, SD 4.9) was followed over 18 months. Participants were challenged to use a Web-based cognitive training system, "COGWEB", on a daily basis, and fulfilled at least four weeks of training supervised remotely. Additionally, 11 patients attended face-to-face sessions. RESULTS: The average duration of continuous cognitive training was 18.8 weeks (SD 18.9). Each patient performed on average 363.5 minutes/week (SD 136.6). At 6-month follow-up, 82.8% complied with their treatment plan. The average proportion of complete weeks was 0.75 (SD 0.22). Patients with dementia trained more intensively (444.6 minutes/week), followed by patients with static brain lesion (414.5 minutes/week; P=.01). The group that held face-to-face sessions performed more training overall (481.4 vs 366.9 minutes/week), achieving a stronger expression and statistical significance in the last week of training (652.6 versus 354.9 minutes/week, P=.027). CONCLUSIONS: Overall, the weekly training intensity was high. Patients with dementia and static lesions performed more cognitive training. Face-to-face sessions were associated with higher intensities. The combination of classical methods with information technology systems seems to ensure greater training intensity.

Implementation and Outcomes of a Collaborative Multi-Center Network Aimed at Web-Based Cognitive Training - COGWEB Network.

BACKGROUND: Cognitive care for the most prevalent neurologic and psychiatric conditions will only improve through the implementation of new sustainable approaches. Innovative cognitive training methodologies and collaborative professional networks are necessary evolutions in the mental health sector. OBJECTIVE: The objective of the study was to describe the implementation process and early outcomes of a nationwide multi-organizational network supported on a Web-based cognitive training system (COGWEB). METHODS: The setting for network implementation was the Portuguese mental health system and the hospital-, academic-, community-based institutions and professionals providing cognitive training. The network started in August 2012, with 16 centers, and was monitored until September 2013 (inclusions were open). After onsite training, all were allowed to use COGWEB in their clinical or research activities. For supervision and maintenance were implemented newsletters, questionnaires, visits and webinars. The following outcomes were prospectively measured: (1) number, (2) type, (3) time to start, and (4) activity state of centers; age, gender, level of education, and medical diagnosis of patients enrolled. RESULTS: The network included 68 professionals from 41 centers, (33/41) 80% clinical, (8/41) 19% nonclinical. A total of 298 patients received cognitive training; 45.3% (n=135) female, mean age 54.4 years (SD 18.7), mean educational level 9.8 years (SD 4.8). The number enrolled each month increased significantly (r=0.6; P=.031). At 12 months, 205 remained on treatment. The major causes of cognitive impairment were: (1) neurodegenerative (115/298, 38.6%), (2) structural brain lesions (63/298, 21.1%), (3) autoimmune (40/298, 13.4%), (4) schizophrenia (30/298, 10.1%), and (5) others (50/298, 16.8%). The comparison of the patient profiles, promoter versus all other clinical centers, showed significant increases in the diversity of causes and spectrums of ages and education. CONCLUSIONS: Over its first year, there was a major increase in the number of new centers and professionals, as well as of the clinical diversity of patients treated. The consolidation of such a national collaborative network represents an innovative step in mental health care evolution. Furthermore, it may contribute to translational processes in the field of cognitive training and reduce disease burden.

A rehabilitation tool designed for intensive web-based cognitive training: description and usability study.

BACKGROUND: Cognitive deficits are among the most disabling of neurological diseases and have a serious impact on the quality of life of patients and families. Cognitive training has been proven successful in improving or compensating for neuropsychological deficits after acute brain injury, but its efficacy highly depends on the intensity of treatment over an extended period of time. Therefore, cognitive training indicates expensive human resources and renders the rehabilitation process vulnerable to physical and economic barriers for the majority of patients. OBJECTIVE: The aim of this study was to develop and test a new Web-based rehabilitation tool that provides intensive cognitive training at home under clinical prescription and monitoring, at affordable costs. METHODS: From a pool of 60 original exercises, designed and used over the past 10 years for cognitive training at our center, we developed 27 exercises on a computer game format, with automatic increase or decrease of difficulty levels. These exercises were assembled in a clean, user-friendly design and covered various cognitive domains such as attention (n=4), memory (n=11), language (n=3), calculus (n=3), praxis (n=2), and executive functions (n=3). A Web 2.0 platform was also designed to provide medical prescription of cognitive training sessions, performed at the patient's home. These sessions included continuous monitoring of compliance, performance, and evolution; algorithms for automatic adjustment and long-term learning through use, and database recording of all activities. The end-user interaction test included 80 patients from our memory clinic from several groups including subjective memory complaints (n=20), traumatic brain injury (n=20), stroke and other static brain lesions (n=20), and mild Alzheimer's disease (n=20). During a 1-hour session, patients and their relatives were taught to use the system and allowed to practice using it. At the end of the session, they were asked to complete a questionnaire. RESULTS: A total of 48/80 patients (60%) attended the training session. The mean age of the patients was 60 years (SD 13.3, range 41-78), and the mean level of formal education was 6 years (range 4-16). Of all the participants, 32/48 patients (66%) have previously used a computer. All patients and their relatives made a positive evaluation of the cognitive training tool. Only 2/48 patients (4%) were not interested in performing the exercises at home; 19/48 patients (39%) mentioned the need for further coaching from a relative or health care professional. The patients who mentioned difficulties in performing the exercises have not used the computer earlier. CONCLUSIONS: This new Web-based system was very well accepted by patients and their relatives, who showed high levels of motivation to use it on a daily basis at home. The simplicity of its use and comfort were especially outlined. This tool will have an important effect on human resource management, in increasing the patient access to specialized health care and improving the quality and national health system costs of rehabilitation programs.

The SWORD tele-rehabilitation system.

In spite of the growing interest verified in the field of technology-based interventions for Stroke rehabilitation, there is still no global solution that is both successful and suitable for a widespread use [1,2]. In this article, we present a novel tele-rehabilitation tool designed to be used for ambulatory patients, and developed towards the motor recovery of the patient's upper-limb. The SWORD system combines a movement quantification system that analyzes the quality of the motor task performed with a biofeedback console. The proposed structure defines the SWORD system as a complete tele-rehabilitation framework that enables a direct connection between clinical and ambulatory settings. Currently a randomized clinical trial is being designed in order to assess the effectiveness of the SWORD tele-rehabilitation system.

A real time, wearable ECG and continous blood pressure monitoring system for first responders.

The study of stress and fatigue among First Responders is a major step in mitigating this public health problem. Blood pressure, heart rate variability and fatigue related arrhythmia are three of the main "windows" to study stress and fatigue. In this paper we present a wearable medical device, capable of acquiring an electrocardiogram and estimating blood pressure in real time, through a pulse wave transit time approach. The system is based on an existent certified wearable medical device called "Vital Jacket" and is aimed to become a tool to allow cardiologists in studying stress and fatigue among first response professionals.