Using wearables to screen motor performance deterioration because of cancer and chemotherapy-induced peripheral neuropathy (CIPN) in adults - Toward an early diagnosis of CIPN

Remote Monitoring of Chemotherapy-Induced Peripheral Neuropathy by the NeuroDetect iOS App: Observational Cohort Study of Patients With Cancer

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is a common and debilitating adverse effect of neurotoxic chemotherapy characterized by symptoms such as numbness, tingling, and weakness. Effective monitoring and detection of CIPN are crucial for avoiding progression to irreversible symptoms. Due to the inconvenience of clinic-based objective assessment, CIPN detection relies primarily on patients' reporting of subjective symptoms, and patient-reported outcomes are used to facilitate CIPN detection. Our previous study found evidence that objective functional assessments completed within a smartphone app may differentiate patients with and those without CIPN after treatment.

OBJECTIVE

This prospective, longitudinal observational cohort study aimed to determine the feasibility and accuracy of app-based remote monitoring of CIPN in patients with cancer undergoing neurotoxic chemotherapeutic treatment and to conduct exploratory comparisons of app-based functional CIPN monitoring versus patient-reported outcome-only monitoring.

METHODS

The NeuroDetect app (Medable Inc) includes subjective EORTC (European Organization for Research and Treatment of Cancer) Quality of Life Questionnaire (QLQ)-20-item scale (CIPN20) and 6 objective functional assessments that use smartphone sensors to mimic neurological examinations, such as walking, standing, and manual dexterity tests. The functional assessment data were collected from patients with cancer undergoing neurotoxic chemotherapy, and a neurological examination was conducted at the end of treatment to diagnose CIPN in the feet (CIPN-f) or CIPN in the hands (CIPN-h). Various classification models including NeuroDetect features only (NeuroDetect Model) CIPN20-only (CIPN20 Model) or a combination of both (Combined Model) were trained and evaluated for accuracy in predicting CIPN probability.

RESULTS

Of the 45 patients who completed functional assessments and neurological examinations, 24 had CIPN-f, and 29 had CIPN-h. The NeuroDetect Model could discriminate between patients with and those without CIPN-f (area under the curve=83.8%, comparison with no information rate P=.02) but not CIPN-h (area under the curve=67.9%, P=.18). The rolling rotation features from the eyes-closed phase of the Romberg Stance assessment showed the greatest contribution to CIPN-f (40% of total variable importance) and the Finger Tapping assessment showed the greatest contribution to CIPN-h (85% of total variable importance). The NeuroDetect Model had numerically, and at some time points statistically, superior performance to the CIPN20 Model in both CIPN-f and CIPN-h, particularly before and early in treatment. The Combined Model numerically, though not statistically, outperformed either assessment strategy individually, indicating that the combination of functional and patient-reported assessment within a smartphone may be optimal to CIPN detection.

CONCLUSIONS

Our findings demonstrate the feasibility of integrating subjective and objective CIPN assessment into a smartphone app for remote, longitudinal CIPN monitoring. Studies of larger patient cohorts are needed to refine the app-based CIPN detection models and determine whether their use in practice improves CIPN detection.

Application of Patient-Generated Health Data Among Older Adults With Cancer: Scoping Review

BACKGROUND

The advancement of information and communication technologies has spurred a growing interest in and increased applications of patient-generated health data (PGHD). In particular, PGHD may be promising for older adults with cancer who have increased survival rates and experience a variety of symptoms.

OBJECTIVE

This scoping review aimed to identify the characteristics of research on PGHD as applied to older adults with cancer and to assess the current use of PGHD.

METHODS

Guided by Arksey and O'Malley as well as the JBI (Joanna Briggs Institute) methodology for scoping reviews, 6 electronic databases were searched: PubMed, Embase, CINAHL, Cochrane Library, Scopus, and Web of Science. In addition, the reference lists of the selected studies were screened to identify gray literature. The researchers independently screened the literature according to the predefined eligibility criteria. Data from the selected studies were extracted, capturing study, participant, and PGHD characteristics.

RESULTS

Of the 1090 identified studies, 88 were selected. The publication trend gradually increased, with a majority of studies published since 2017 (69/88, 78%). Almost half of the studies were conducted in North America (38/88, 43%), followed by Europe (30/88, 34%). The most common setting in which the studies were conducted was the participant's home (69/88, 78%). The treatment status varied; the median sample size was 50 (IQR 33.8-84.0). The devices that were used to measure the PGHD were classified as research-grade wearable devices (57/113, 50.4%), consumer-grade wearable devices (28/113, 24.8%), or smartphones or tablet PCs for mobile apps (23/113, 20.4%). More than half of the studies measured physical activity (69/123, 56.1%), followed by patient-reported outcomes (23/123, 18.7%), vital signs (13/123, 10.6%), and sleep (12/123, 9.8%). The PGHD were mainly collected passively (63/88, 72%), and active collection methods were used from 2015 onward (20/88, 23%). In this review, the stages of PGHD use were classified as follows: (1) identification, monitoring, review, and analysis (88/88, 100%); (2) feedback and reporting (32/88, 39%); (3) motivation (30/88, 34%); and (4) education and coaching (19/88, 22%).

CONCLUSIONS

This scoping review provides a comprehensive summary of the overall characteristics and use stages of PGHD in older adults with various types and stages of cancer. Future research should emphasize the use of PGHD, which interacts with patients to provide patient-centered care through patient engagement. By enhancing symptom monitoring, enabling timely interventions, and promoting patient involvement, PGHD have the potential to improve the well-being of older adults with cancer, contributing to better health management and quality of life. Therefore, our findings may provide valuable insights into PGHD that health care providers and researchers can use for geriatric cancer care.

TRIAL REGISTRATION

Open Science Framework Registry OSF.IO/FZRD5; https://doi.org/10.17605/OSF.IO/FZRD5.

Relationship between chemotherapy-induced peripheral neuropathy and physical activity in cancer survivors: A prospective longitudinal study

Objective

The purpose of this research is to evaluate the relationship between the degree of peripheral neuropathy associated with treatment and physical activity through the use of objective indicators such as wristband activity tracker and subjective evaluations obtained through interviews.

Methods

This study included 11 patients with gynecological cancer, gastrointestinal cancer, and malignant lymphoma. Participants were requested to wear a wristband activity meter at two time points: early and mid-treatment. Activity-meter step counts were compared with factors such as energy expenditure and Functional Assessment of Cancer Therapy-General during early and mid-treatment. Interviews were analyzed qualitatively and inductively.

Results

There was no difference in the number of steps taken by participants in the early and mid-treatment periods (P = 0.050), but they took more steps in the mid-treatment period than in the early period. Participants expended more energy during mid-treatment than early treatment, but these differences were not significant. We noted a correlation between the number of steps and energy expenditure in the mid-treatment period (r = 0.883). Comparisons between measures showed significant differences in "Impact" between early and mid-treatment on Distress and Impact Thermometer (P = 0.034). The impact of numbness on activity was assigned to three categories: loss of routine caused by numbness, coping with the numbness-related inconvenience using various resources, and acceptance of life with numbness with the support of others and self-strength.

Conclusions

The participants devised strategies to maintain activities despite experiencing chemotherapy-induced peripheral neurotoxicity. The use of activity meters may enhance patient motivation, which in our opinion, is beneficial for self-care education.

Physical function as a predictor of chemotherapy-induced peripheral neuropathy in patients with pancreatic cancer

BACKGROUND

A growing body of research indicates that poor functional status before chemotherapy may be correlated with the severity of chemotherapy-induced peripheral neuropathy (CIPN) after the neurotoxic treatment. However, little is known about the associations between pre-chemotherapy physical function and CIPN in patients with pancreatic cancer.

PURPOSE

To identify the predictors of CIPN in relation to pre-chemotherapy physical function in patients with pancreatic cancer.

METHODS

This secondary analysis included data from patients with pancreatic cancer who participated in a longitudinal research study at National Cheng Kung University Hospital, Tainan, Taiwan. Four physical function tests (i.e., grip strength, Timed Up and Go (TUG), 2-minute step test (2MST), and Romberg test) and two questionnaires (The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 [EORTC QLQ-C30] and Chemotherapy-Induced Peripheral Neuropathy Module [CIPN20]) were assessed at baseline (i.e., before first chemotherapy session) and 2-, 3-, 4-, and 6-month follow-up. Multiple linear regression with adjustment for confounding factors was used to assess the associations between the four functional tests at baseline and the CIPN20 total score and individual subscale scores (sensory, motor, and autonomic) at 6-month follow-up.

RESULTS

Data from a total of 209 pancreatic cancer patients (mean age: 64.4 years, 54.5% male) were analyzed. The findings showed that the severity of CIPN at 6-month follow-up was significantly associated with the baseline TUG completion time (β = 0.684, p = 0.003). The TUG completion time was also positively correlated with the 6-month CIPN sensory and autonomic subscales. In addition, a baseline positive Romberg test (β = 0.525, p = 0.009) was a significant predictor of the severity of motor neuropathy at 6-month follow-up.

CONCLUSION

The TUG completion time and positive Romberg test before chemotherapy may be predictive factors of the CIPN severity 6 months after the commencement of chemotherapy. Accordingly, the incorporation of TUG and Romberg tests into the clinical assessment protocol emerges as imperative for individuals diagnosed with pancreatic carcinoma undergoing chemotherapy regimens.

Harnessing physical activity monitoring and digital biomarkers of frailty from pendant based wearables to predict chemotherapy resilience in veterans with cancer

This study evaluated the use of pendant-based wearables for monitoring digital biomarkers of frailty in predicting chemotherapy resilience among 27 veteran cancer patients (average age: 64.6 ± 13.4 years), undergoing bi-weekly chemotherapy. Immediately following their first day of chemotherapy cycle, participants wore a water-resistant pendant sensor for 14 days. This device tracked frailty markers like cadence (slowness), daily steps (inactivity), postural transitions (weakness), and metrics such as longest walk duration and energy expenditure (exhaustion). Participants were divided into resilient and non-resilient groups based on adverse events within 6 months post-chemotherapy, including dose reduction, treatment discontinuation, unplanned hospitalization, or death. A Chemotherapy-Resilience-Index (CRI) ranging from 0 to 1, where higher values indicate poorer resilience, was developed using regression analysis. It combined physical activity data with baseline Eastern Cooperative Oncology Group (ECOG) assessments. The protocol showed a 97% feasibility rate, with sensor metrics effectively differentiating between groups as early as day 6 post-therapy. The CRI, calculated using data up to day 6 and baseline ECOG, significantly distinguished resilient (CRI = 0.2 ± 0.27) from non-resilient (CRI = 0.7 ± 0.26) groups (p < 0.001, Cohen's d = 1.67). This confirms the potential of remote monitoring systems in tracking post-chemotherapy functional capacity changes and aiding early non-resilience detection, subject to validation in larger studies.

Application of Dynamic Mode Decomposition to Characterize Temporal Evolution of Plantar Pressures from Walkway Sensor Data in Women with Cancer

Pressure sensor-impregnated walkways transform a person's footfalls into spatiotemporal signals that may be sufficiently complex to inform emerging artificial intelligence (AI) applications in healthcare. Key consistencies within these plantar signals show potential to uniquely identify a person, and to distinguish groups with and without neuromotor pathology. Evidence shows that plantar pressure distributions are altered in aging and diabetic peripheral neuropathy, but less is known about pressure dynamics in chemotherapy-induced peripheral neuropathy (CIPN), a condition leading to falls in cancer survivors. Studying pressure dynamics longitudinally as people develop CIPN will require a composite model that can accurately characterize a survivor's gait consistencies before chemotherapy, even in the presence of normal step-to-step variation. In this paper, we present a state-of-the-art data-driven learning technique to identify consistencies in an individual's plantar pressure dynamics. We apply this technique to a database of steps taken by each of 16 women before they begin a new course of neurotoxic chemotherapy for breast or gynecologic cancer. After extracting gait features by decomposing spatiotemporal plantar pressure data into low-rank dynamic modes characterized by three features: frequency, a decay rate, and an initial condition, we employ a machine-learning model to identify consistencies in each survivor's walking pattern using the centroids for each feature. In this sample, our approach is at least 86% accurate for identifying the correct individual using their pressure dynamics, whether using the right or left foot, or data from trials walked at usual or fast speeds. In future work, we suggest that persistent deviation from a survivor's pre-chemotherapy step consistencies could be used to automate the identification of peripheral neuropathy and other chemotherapy side effects that impact mobility.

Application of wearables for remote monitoring of oncology patients: A scoping review

Objective

This review aims to systematically map and categorize the current state of wearable applications among oncology patients and to identify determinants impeding clinical implementation.

Methods

A Medline, Embase and clinicaltrials.gov search identified journal articles, conference abstracts, letters, reports, dissertations and registered studies on the use of wearables in patients with malignancies published up to 10 November 2021.

Results

Of 2509 records identified, 112 met the eligibility criteria. Of these, 9.8% (11/112) were RCTs and 47.3% (53/112) of publications were observational. Wearables were investigated pre-treatment (2.7%; 3/112), during treatment (34.8%; 39/112), post-treatment (17.9%; 20/112), in survivors (27.7%; 31/112) and in non-specified or multiple treatment phases (17.0%; 19/112). Medical-grade wearables were applied in 22.3% (25/112) of publications. Primary objectives ranged from technical feasibility (8.0%; 9/112), user feasibility (42.9%; 48/112) and correlational analysis (40.2%; 45/112) to outcome change analysis (8.9%; 10/112). Outcome change was mostly investigated regarding physical activity improvement (80.0%; 8/10). Most publications (42.9%; 48/112) and registered studies (39.3%; 24/61) featured multiple cancer types, with breast cancer as the most prevalent specific type (22.3% in publications, 16.4% in registered studies).

Conclusions

Most studies among oncology patients using wearables are focused on assessing the user feasibility of consumer-grade wearables, whereas rates of RCTs assessing clinical efficacy are low. Substantial improvements in clinically relevant endpoints by the use of wearables, such as morbidity and mortality are yet to be demonstrated.

Digital health in geriatric oncology: A Young International Society of Geriatric Oncology review

The integration of digital health technologies in geriatric oncology has the potential to enhance patient care and self-management. This review article discusses the applications of these technologies, including teleassessment, telemonitoring, and teleintervention, within geriatric oncology, and evaluates their potential to improve cancer care and patient outcomes. We also review challenges to the implementation of digital health technologies among populations of older patients with cancer. The article provides a perspective for clinicians, researchers, policymakers, and patients on the integration and utilisation of digital health technologies in current geriatric oncology practice.

Gait analysis in chemotherapy-induced peripheral neurotoxicity rodent models

Gait analysis could be used in animal models as an indicator of sensory ataxia due to chemotherapy-induced peripheral neurotoxicity (CIPN). Over the years, gait analysis in in vivo studies has evolved from simple observations carried out by a trained operator to computerised systems with machine learning that allow the quantification of any variable of interest and the establishment of algorithms for behavioural classification. However, there is not a consensus on gait analysis use in CIPN animal models; therefore, we carried out a systematic review. Of 987 potentially relevant studies, 14 were included, in which different methods were analysed (observation, footprint and CatWalk™). We presented the state-of-the-art of possible approaches to analyse sensory ataxia in rodent models, addressing advantages and disadvantages of different methods available. Semi-automated methods may be of interest when preventive or therapeutic strategies are evaluated, also considering their methodological simplicity and automaticity; up to now, only CatWalk™ analysis has been tested. Future studies should expect that CIPN-affected animals tend to reduce hind paw support due to pain, allodynia or loss of sensation, and an increase in swing phase could or should be observed. Few available studies documented these impairments at the last time point, and only appeared later on respect to other earlier signs of CIPN (such as altered neurophysiological findings). For that reason, gait impairment could be interpreted as late repercussions of loss of sensory.

Chemotherapy-induced peripheral neuropathy in the detroit research on cancer survivors (ROCS) cohort

PURPOSE

Improved life expectancy has increased the likelihood for long-term complications from chemotherapy among cancer survivors. One burdensome complication is chemotherapy-induced peripheral neuropathy (CIPN). We evaluated rates of CIPN outcomes in the Detroit Research on Cancer Survivorship (ROCS) cohort.

METHODS

The population included 1,034 African American (AA) survivors who received chemotherapy for breast, colorectal, lung or prostate cancer. CIPN prevalence was based on initial occurrence of worsening of self-reported pain, numbness or tingling after chemotherapy. Current CIPN included symptoms still present at the time of the survey, and persistent CIPN symptoms were present 12 or more months post-chemotherapy. CIPN severity was ranked as mild, moderate or severe. Logistic regression was utilized to evaluate sociodemographic and clinical factors associated with the various categories of CIPN.

RESULTS

CIPN prevalence was 68%, with 53% current and 52% persistent. The symptom severity distribution based on prevalent CIPN included 32.2% mild, 30.8% moderate, and 36.9% severe. Factors associated with prevalent CIPN (odds ratio, 95% confidence interval) included primary cancer site (breast: 3.88, 2.02-7.46); and (colorectal: 5.37, 2.69-10.73), lower risk for older age at diagnosis (0.66, 0.53-0.83) and divorced/separated marital status (2.13, 1.42-3.21). Current CIPN was in addition, associated with more advanced stage disease trend (1.34, 1.08-1.66) and greater number of co-morbid medical conditions trend (1.23, 1.09-1.40), as was persistent CIPN. Severity of prevalent CIPN was associated with history of arthritis (1.55, 1.06-2.26) and severity of persistent CIPN with higher BMI (1.58, 1.07-2.35).

CONCLUSIONS

CIPN is a common and persistent complication in AA cancer survivors. Further research is needed to improve our understanding of CIPN predictors in all groups of cancer survivors.

Frailty and Cancer: Current Perspectives on Assessment and Monitoring

Frailty, an age-related condition of increased vulnerability to acute endogenous or exogenous stressors, is a key barrier to successful treatment of cancer in older people. In this group of patients, assessment of frailty is required before starting a new treatment. According to guidelines, the gold standard to assess frailty in older adults with cancer is geriatric screening followed by geriatric assessment (GA) across essential GA-domains (social status, physical function, nutrition, cognition, emotion, co-morbidity, polypharmacy). GA enables tailoring of both oncological therapy and non-oncological interventions to the patient's vulnerabilities. Large clinical trials recently have demonstrated that the feasibility and tolerability of systemic cancer treatment in older patients are significantly improved by such GA-guided management. Indications and optimal tools for frailty monitoring during the course of cancer treatment have not yet been defined in greater detail. New technologies such as wearable sensors or apps offer promising new opportunities to further develop frailty monitoring. This review describes the current standards and perspectives for the assessment and monitoring of frailty in elderly patients with cancer.

Neurological Outcomes of Chemotherapy-Induced Peripheral Neuropathy in Patients With Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

This systematic review and meta-analysis aimed to determine whether chemotherapy-induced peripheral neuropathy (CIPN) affects the risk of falls and physical function in patients with cancer.

METHODS

A literature search was conducted in the CINAHL, Scopus, and PubMed databases for articles published from January 1950 to April 2022. Seven review authors retrieved studies using predetermined eligibility criteria, extracted the data, and evaluated the quality.

RESULTS

Nine studies were included in the analysis. Patients with CIPN had a significantly higher risk of falls than those without CIPN (risk ratio = 1.38, 95% confidence interval [CI] =1.18-1.62). Patients with CIPN had lower grip strength (standardized mean difference [SMD] =-0.42, 95% CIs = -0.70 to -0.14, P = .003), longer chair stand time (SMD = 0.56, 95% CIs = -0.01 to 1.17, P = .05), worse timed up and go test time (SMD = 0.79, 95% CIs = 0.41 to 1.17, P < .0001), and lower mean Fullerton Advanced Balance scale score (SMD = -0.81, 95% CIs = -1.27 to -0.36, P = .005) than patients without CIPN. There were no significant differences in gait speed (P = .38) or Activities-specific Balance Confidence Scale score (P = .09) between patients with and without CIPN.

CONCLUSIONS

This systematic review and meta-analysis demonstrated that patients with CIPN are prone to falls and impaired balance function and muscle strength.

Cancer survivors post-chemotherapy exhibit unique proprioceptive deficits in proximal limbs

BACKGROUND

Oxaliplatin (OX) chemotherapy for colorectal cancer is associated with adverse neurotoxic effects that can contribute to long-term sensorimotor impairments in cancer survivors. It is often thought that the sensorimotor impairments are dominated by OX-induced dying-back sensory neuropathy that primarily affects the distal regions of the limb. Recent preclinical studies have identified encoding dysfunction of muscle proprioceptors as an alternative mechanism. Unlike the dying-back sensory neuropathy affecting distal limbs, dysfunction of muscle proprioceptors could have more widespread effects. Most investigations of chemotherapy-induced sensorimotor impairments have considered only the effects of distal changes in sensory processing; none have evaluated proximal changes or their influence on function. Our study fills this gap by evaluating the functional use of proprioception in the shoulder and elbow joints of cancer survivors post OX chemotherapy. We implemented three multidirectional sensorimotor tasks: force matching, target reaching, and postural stability tasks to evaluate various aspects of proprioception and their use. Force and kinematic data of the sensorimotor tasks were collected in 13 cancer survivors treated with OX and 13 age-matched healthy controls.

RESULTS

Cancer survivors exhibited less accuracy and precision than an age-matched control group when they had to rely only on proprioceptive information to match force, even for forces that required only torques about the shoulder. There were also small differences in the ability to maintain arm posture but no significant differences in reaching. The force deficits in cancer survivors were significantly correlated with self-reported motor dysfunction.

CONCLUSIONS

These results suggest that cancer survivors post OX chemotherapy exhibit proximal proprioceptive deficits, and that the deficits in producing accurate and precise forces are larger than those for producing unloaded movements. Current clinical assessments of chemotherapy-related sensorimotor dysfunction are largely limited to distal symptoms. Our study suggests that we also need to consider changes in proximal function. Force matching tasks similar to those used here could provide a clinically meaningful approach to quantifying OX-related movement dysfunction during and after chemotherapy.

Digital Biomarkers of Cognitive Frailty: The Value of Detailed Gait Assessment Beyond Gait Speed

BACKGROUND

Cognitive frailty (CF), defined as the simultaneous presence of cognitive impairment and physical frailty, is a clinical symptom in early-stage dementia with promise in assessing the risk of dementia. The purpose of this study was to use wearables to determine the most sensitive digital gait biomarkers to identify CF.

METHODS

Of 121 older adults (age = 78.9 ± 8.2 years, body mass index = 26.6 ± 5.5 kg/m2) who were evaluated with a comprehensive neurological exam and the Fried frailty criteria, 41 participants (34%) were identified with CF and 80 participants (66%) were identified without CF. Gait performance of participants was assessed under single task (walking without cognitive distraction) and dual task (walking while counting backward from a random number) using a validated wearable platform. Participants walked at habitual speed over a distance of 10 m. A validated algorithm was used to determine steady-state walking. Gait parameters of interest include steady-state gait speed, stride length, gait cycle time, double support, and gait unsteadiness. In addition, speed and stride length were normalized by height.

RESULTS

Our results suggest that compared to the group without CF, the CF group had deteriorated gait performances in both single-task and dual-task walking (Cohen's effect size d = 0.42-0.97, p < 0.050). The largest effect size was observed in normalized dual-task gait speed (d = 0.97, p < 0.001). The use of dual-task gait speed improved the area under the curve (AUC) to distinguish CF cases to 0.76 from 0.73 observed for the single-task gait speed. Adding both single-task and dual-task gait speeds did not noticeably change AUC. However, when additional gait parameters such as gait unsteadiness, stride length, and double support were included in the model, AUC was improved to 0.87.

CONCLUSIONS

This study suggests that gait performances measured by wearable sensors are potential digital biomarkers of CF among older adults. Dual-task gait and other detailed gait metrics provide value for identifying CF above gait speed alone. Future studies need to examine the potential benefits of gait performances for early diagnosis of CF and/or tracking its severity over time.

Harnessing Digital Health to Objectively Assess Functional Performance in Veterans with Chronic Obstructive Pulmonary Disease

INTRODUCTION

An early detection of impaired functional performance is critical to enhance symptom management for patients with chronic obstructive pulmonary disease (COPD). However, conventional functional measures based on walking assessments are often impractical for small clinics where the available space to administrate gait-based test is limited. This study examined the feasibility and effectiveness of an upper-extremity frailty meter (FM) in identifying digital measures of functional performance and assessing frailty in COPD patients.

METHODS

Forty-eight patients with COPD (age = 68.8 ± 8.5 years, body mass index [BMI] = 28.7 ± 5.8 kg/m2) and 49 controls (age = 70.0 ± 3.0 years, BMI = 28.7 ± 6.1 kg/m2) were recruited. All participants performed a 20-s repetitive elbow flexion-extension test using a wrist-worn FM sensor. Functional performance was quantified by FM metrics, including speed (slowness), range of motion (rigidity), power (weakness), flexion and extension time (slowness), as well as speed and power reduction (exhaustion). Conventional functional measures, including timed-up-and-go test, gait and balance tests, and 5 repetition sit-to-stand test, were also performed.

RESULTS

Compared to controls, COPD patients exhibited deteriorated performances in all conventional functional assessments (d = 0.64-1.26, p < 0.010) and all FM metrics (d = 0.45-1.54, p < 0.050). FM metrics had significant agreements with conventional assessment tools (|r| = 0.35-0.55, p ≤ 0.001). FM metrics efficiently identified COPD patients with pre-frailty and frailty (d = 0.82-2.12, p < 0.050).

CONCLUSION

This study proposes the feasibility of using a 20-s repetitive elbow flexion-extension test and wrist-worn sensor-derived frailty metrics as an alternative and practical solution to evaluate functional performance in COPD patients. Its simplicity and low risk for test administration may also facilitate its application for remote patient monitoring. Furthermore, in settings where the administration of walking test is impractical, for example, when ventilator support is needed or space is limited, FM may be used as an alternative solution. Future studies are encouraged to use the FM to quantitatively monitor the progressive decline in functional performance and quantify outcomes of rehabilitation interventions.

Assessment of gait and balance impairment in people with spinocerebellar ataxia using wearable sensors

OBJECTIVE

To explore the use of wearable sensors for objective measurement of motor impairment in spinocerebellar ataxia (SCA) patients during clinical assessments of gait and balance.

METHODS

In total, 14 patients with genetically confirmed SCA (mean age 61.6 ± 8.6 years) and 4 healthy controls (mean age 49.0 ± 16.4 years) were recruited through the Massachusetts General Hospital (MGH) Ataxia Center. Participants donned seven inertial sensors while performing two independent trials of gait and balance assessments from the Scale for the Assessment and Rating of Ataxia (SARA) and Brief Ataxia Rating Scale (BARS2). Univariate analysis was used to identify sensor-derived metrics from wearable sensors that discriminate motor function between the SCA and control groups. Multivariate linear regression models were used to estimate the subjective in-person SARA/BARS2 ratings. Spearman correlation coefficients were used to evaluate the performance of the model.

RESULTS

Stride length variability, stride duration, cadence, stance phase, pelvis sway, and turn duration were different between SCA and controls (p < 0.05). Similarly, sway and sway velocity of the ankle, hip, and center of mass differentiated SCA and controls (p < 0.05). Using these features, linear regression models showed moderate-to-strong correlation with clinical scores from the in-person rater during SARA assessments of gait (r = 0.73, p = 0.003) and stance (r = 0.90, p < 0.001) and the BARS2 gait assessment (r = 0.74, p = 0.003).

CONCLUSION

This study demonstrates that sensor-derived metrics can potentially be used to estimate the level of motor impairment in patient with SCA quickly and objectively. Thus, digital biomarkers from wearable sensors have the potential to be an integral tool for SCA clinical trials and care.

Evidence of slow and variable choice-stepping reaction time in cancer survivors with chemotherapy-induced peripheral neuropathy

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is reported to affect up to 70 % of cancer survivors. Despite evidence that CIPN-related impairments often translate into balance and mobility deficits, the effects on stepping and quality of gait, well-documented risk factors for falls, are unclear.

AIMS

(i) Establish choice-stepping reaction time (CSRT) performance in survivors with CIPN compared to young and older healthy controls and people with Parkinson's disease; (ii) document walking stability; (iii) investigate relationships between stepping and gait data to objective and patient-reported outcomes.

METHODS

41 cancer survivors with CIPN (mean (SD) age: 60.8 (9.7) years) who were ≥3months post chemotherapy, performed tests of simple and inhibitory CSRT. Walking stability measures were derived from 3-D accelerometry data during the 6-minute walk test. CIPN was assessed using neurological grading and patient-reported outcome measures (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire in CIPN Questionnaire scale EORTC CIPN20).

RESULTS

In both stepping tests, CIPN participants performed at the level of adults aged 10 years older and people with mild to moderate Parkinson's disease. Mean (SD) total stepping response times in both CSRT (1160 (190) milliseconds) and inhibitory CSRT (1191 (164) milliseconds) tests were not associated with objective neurological grading but were correlated with increased difficulty feeling the ground. Participants with lower-limb vibration sensation deficit had slower and more variable CSRT times. There were no associations between walking stability and objective measures of CIPN, and limited correlations with the EORTC-CIPN20.

CONCLUSIONS

Cancer survivors with CIPN showed deficits in voluntary stepping responses and seemed to compensate for their sensory and motor deficits by walking slower to maintain stability. Objective and patient-reported outcomes of CIPN were correlated with slower and more variable stepping response times. Future studies should aim to identify the causes of the apparent premature decline in cognitive-motor function and develop remediating interventions.

The detrimental association between fear of falling and motor performance in older cancer patients with chemotherapy-induced peripheral neuropathy

BACKGROUND

Cancer patients with chemotherapy-induced peripheral neuropathy (CIPN) are at increased risk of falls and developing fear of falling (FoF). Although FoF may continue to impair motor performance and increase the risk of falling even further, this association remains unexplored in CIPN.

RESEARCH QUESTION

Does high FoF in patients with CIPN further deteriorate motor performance beyond the impairment from CIPN-related sensory deficits?

METHODS

In this secondary analysis of data collected from two clinical trials, gait parameters during habitual walking condition and postural sway parameters during 30-second quiet standing (eye-open and eyes-closed) were compared among older participants (≥ 65 years) with CIPN and high FoF (CIPN FoF+; n=16), older participants with CIPN and low FoF (CIPN FoF-; n=19) and normal older controls (i.e., non-cancer, non-diabetic, non-neurologic, and non-orthopedic; n=16). We measured gait and postural sway parameters using wearable sensors (BioSensics, Newton, MA, USA), and FoF severity using the Falls Efficacy Scale-International.

RESULTS

The largest between-group differences were found in gait speed. The CIPN FoF + group had significantly slower gait speed (0.78 ± 0.21 m/s) than the CIPN FoF- (0.93 ± 0.17 m/s) and normal control groups (1.17 ± 0.13 m/s) (all p < .05; effect sizes = 0.79 and 2.23, respectively). We found a significant association between gait speed and FoF severity (R2 = 0.356; p < .001) across all participants with CIPN. Among participants with CIPN, no significant differences in postural sway parameters were found between the CIPN FoF+and CIPN FoF- groups.

SIGNIFICANCE

Our results suggest that gait performance further deteriorates in patients with CIPN and high FoF beyond the impairment from CIPN-related sensory deficits. Our results also suggest further research is needed regarding FoF, and fall risk, as FoF is a simple tool that healthcare providers can use in clinical practice.

Harnessing digital health to objectively assess cancer-related fatigue: The impact of fatigue on mobility performance

Objective

Cancer-related fatigue (CRF) is highly prevalent among cancer survivors, which may have long-term effects on physical activity and quality of life. CRF is assessed by self-report or clinical observation, which may limit timely diagnosis and management. In this study, we examined the effect of CRF on mobility performance measured by a wearable pendant sensor.

Methods

This is a secondary analysis of a clinical trial evaluating the benefit of exercise in cancer survivors with chemotherapy-induced peripheral neuropathy (CIPN). CRF status was classified based on a Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) score ≤ 33. Among 28 patients (age = 65.7±9.8 years old, BMI = 26.9±4.1kg/m², sex = 32.9%female) with database variables of interest, twenty-one subjects (75.9%) were classified as non-CRF. Mobility performance, including behavior (sedentary, light, and moderate to vigorous activity (MtV)), postures (sitting, standing, lying, and walking), and locomotion (e.g., steps, postural transitions) were measured using a validated pendant-sensor over 24-hours. Baseline psychosocial, Functional Assessment of Cancer Therapy–General (FACT-G), Falls Efficacy Scale–International (FES-I), and motor-capacity assessments including gait (habitual speed, fast speed, and dual-task speed) and static balance were also performed.

Results

Both groups had similar baseline clinical and psychosocial characteristics, except for body-mass index (BMI), FACT-G, FACIT-F, and FES-I (p<0.050). The groups did not differ on motor-capacity. However, the majority of mobility performance parameters were different between groups with large to very large effect size, Cohen’s d ranging from 0.91 to 1.59. Among assessed mobility performance, the largest effect sizes were observed for sedentary-behavior (d = 1.59, p = 0.006), light-activity (d = 1.48, p = 0.009), and duration of sitting+lying (d = 1.46, p = 0.016). The largest correlations between mobility performance and FACIT-F were observed for sitting+lying (rho = -0.67, p<0.001) and the number of steps per day (rho = 0.60, p = 0.001).

Conclusion

The results of this study suggest that sensor-based mobility performance monitoring could be considered as a potential digital biomarker for CRF assessment. Future studies warrant evaluating utilization of mobility performance to track changes in CRF over time, response to CRF-related interventions, and earlier detection of CRF.

Chemotherapy-induced peripheral neuropathy detection via smartphone app: a cross-sectional pilot study (Preprint)

Background

Severe chemotherapy-induced peripheral neuropathy (CIPN) can cause long-term dysfunction of the hands and feet, interfere with activities of daily living, and diminish the quality of life. Monitoring to identify CIPN and adjust treatment before it progressing to a life-altering severity relies on patients self-reporting subjective symptoms to their clinical team. Objective assessment is not a standard component of CIPN monitoring due to the requirement for specially trained health care professionals and equipment. Smartphone apps have the potential to conveniently collect both subjective and objective CIPN data directly from patients, which could improve CIPN monitoring.

Objective

The objective of this cross-sectional pilot study was to assess the feasibility of functional CIPN assessment via a smartphone app in patients with cancer that have received neurotoxic chemotherapy.

Methods

A total of 26 patients who had completed neurotoxic chemotherapy were enrolled and classified as CIPN cases (n=17) or controls (n=9) based on self-report symptoms. All participants completed CIPN assessments within the NeuroDetect app a single time, including patient-reported surveys (CIPN20 [European Organization for Research and Treatment of Cancer Quality of Life Questionnaire for Chemotherapy-induced Peripheral Neuropathy 20-item scale] and PRO-CTCAE [Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events]) and functional assessments (Gait and Balance and 9-Hole Peg Test). Functional assessment data were decomposed into features. The primary analysis was done to identify features indicative of the difference between CIPN cases and controls using partial least squares analyses. Exploratory analyses were performed to test if any features were associated with specific symptom subtypes or patient-reported survey scores. Patient interviews were also conducted to understand the challenges they experienced with the app.

Results

Comparisons between CIPN cases and controls indicate that CIPN cases had shorter step length (P=.007), unique swaying acceleration patterns during a walking task, and shorter hand moving distance in the dominant hands during a manual dexterity task (variable importance in projection scores ≥2). Exploratory analyses showed similar signatures associated with symptoms subtypes, CIPN20, and PRO-CTCAE. The interview results showed that some patients had difficulties due to technical issues, which indicated a need for additional training or oversight during the initial app download.

Conclusions

Our results supported the feasibility of remote CIPN assessment via a smartphone app and suggested that functional assessments may indicate CIPN manifestations in the hands and feet. Additional work is needed to determine which functional assessments are most indicative of CIPN and could be used for CIPN monitoring within clinical care.

A review of movement disorders in chemotherapy-induced neurotoxicity

Chemotherapy agents used in the standard treatments for many types of cancer are neurotoxic and can lead to lasting sensory and motor symptoms that compromise day-to-day movement functions in cancer survivors. To date, the details of movement disorders associated with chemotherapy are known largely through self-reported symptoms and functional limitations. There are few quantitative studies of specific movement deficits, limiting our understanding of dysfunction, as well as effective assessments and interventions. The aim of this narrative review is to consolidate the current understanding of sensorimotor disabilities based on quantitative measures in cancer survivors who received chemotherapy. We performed literature searches on PubMed and found 32 relevant movement studies. We categorized these studies into three themes based on the movement deficits investigated: (1) balance and postural control; (2) gait function; (3) upper limb function. This literature suggests that cancer survivors have increased postural sway, more conservative gait patterns, and suboptimal hand function compared to healthy individuals. More studies are needed that use objective measures of sensorimotor function to better characterize movement disabilities and investigate the underlying causes, as required for developing targeted assessments and interventions. By updating our understanding of movement impairments in this population, we identify significant gaps in knowledge that will help guide the direction of future research.

Status and Recommendations of Technological and Data-Driven Innovations in Cancer Care: Focus Group Study

BACKGROUND

The status of the data-driven management of cancer care as well as the challenges, opportunities, and recommendations aimed at accelerating the rate of progress in this field are topics of great interest. Two international workshops, one conducted in June 2019 in Cordoba, Spain, and one in October 2019 in Athens, Greece, were organized by four Horizon 2020 (H2020) European Union (EU)-funded projects: BOUNCE, CATCH ITN, DESIREE, and MyPal. The issues covered included patient engagement, knowledge and data-driven decision support systems, patient journey, rehabilitation, personalized diagnosis, trust, assessment of guidelines, and interoperability of information and communication technology (ICT) platforms. A series of recommendations was provided as the complex landscape of data-driven technical innovation in cancer care was portrayed.

OBJECTIVE

This study aims to provide information on the current state of the art of technology and data-driven innovations for the management of cancer care through the work of four EU H2020-funded projects.

METHODS

Two international workshops on ICT in the management of cancer care were held, and several topics were identified through discussion among the participants. A focus group was formulated after the second workshop, in which the status of technological and data-driven cancer management as well as the challenges, opportunities, and recommendations in this area were collected and analyzed.

RESULTS

Technical and data-driven innovations provide promising tools for the management of cancer care. However, several challenges must be successfully addressed, such as patient engagement, interoperability of ICT-based systems, knowledge management, and trust. This paper analyzes these challenges, which can be opportunities for further research and practical implementation and can provide practical recommendations for future work.

CONCLUSIONS

Technology and data-driven innovations are becoming an integral part of cancer care management. In this process, specific challenges need to be addressed, such as increasing trust and engaging the whole stakeholder ecosystem, to fully benefit from these innovations.

Wearable Health Technology to Quantify the Functional Impact of Peripheral Neuropathy on Mobility in Parkinson's Disease: A Systematic Review

The occurrence of peripheral neuropathy (PNP) is often observed in Parkinson’s disease (PD) patients with a prevalence up to 55%, leading to more prominent functional deficits. Motor assessment with mobile health technologies allows high sensitivity and accuracy and is widely adopted in PD, but scarcely used for PNP assessments. This review provides a comprehensive overview of the methodologies and the most relevant features to investigate PNP and PD motor deficits with wearables. Because of the lack of studies investigating motor impairments in this specific subset of PNP-PD patients, Pubmed, Scopus, and Web of Science electronic databases were used to summarize the state of the art on PNP motor assessment with wearable technology and compare it with the existing evidence on PD. A total of 24 papers on PNP and 13 on PD were selected for data extraction: The main characteristics were described, highlighting major findings, clinical applications, and the most relevant features. The information from both groups (PNP and PD) was merged for defining future directions for the assessment of PNP-PD patients with wearable technology. We established suggestions on the assessment protocol aiming at accurate patient monitoring, targeting personalized treatments and strategies to prevent falls and to investigate PD and PNP motor characteristics.

Role of Kinematics Assessment and Multimodal Sensorimotor Training for Motion Deficits in Breast Cancer Chemotherapy-Induced Polyneuropathy: A Perspective on Virtual Reality Avatars

Chemotherapy-induced polyneuropathy (CIPN), one of the most severe and incapacitating side effects of chemotherapeutic drugs, is a serious concern in breast cancer therapy leading to dose diminution, delay, or cessation. The reversibility of CIPN is of increasing importance since active chemotherapies prolong survival. Clinical assessment tools show that patients experiencing sensorimotor CIPN symptoms not only do they have to cope with loss in autonomy and life quality, but CIPN has become a key restricting factor in treatment. CIPN incidence poses a clinical challenge and has lacked established and efficient therapeutic options up to now. Complementary, non-opioid therapies are sought for both prevention and management of CIPN. In this perspective, we explore the potential that digital interventions have for sensorimotor CIPN rehabilitation in breast cancer patients. Our primary goal is to emphasize the benefits and impact that Virtual Reality (VR) avatars and Machine Learning have in combination in a digital intervention aiming at (1) assessing the complete kinematics of deficits through learning underlying patient sensorimotor parameters, and (2) parameterize a multimodal VR simulation to drive personalized deficit compensation. We support our perspective by evaluating sensorimotor effects of chemotherapy, the metrics to assess sensorimotor deficits, and relevant clinical studies. We subsequently analyse the neurological substrate of VR sensorimotor rehabilitation, with multisensory integration acting as a key element. Finally, we propose a closed-loop patient-centered design recommendation for CIPN sensorimotor rehabilitation. Our aim is to provoke the scientific community toward the development and use of such digital interventions for more efficient and targeted rehabilitation.

Real-time, personalized medicine through wearable sensors and dynamic predictive modeling: a new paradigm for clinical medicine

Accurately predicting the onset and course of a disease in an individual is a major unmet challenge in medicine due to the complex and dynamic nature of disease progression. Continuous data from wearable technologies and biomarker data with a fine time resolution provide a unique opportunity to learn more about disease evolution and to usher in a new era of personalized and real-time medicine. Herein, we propose the potential of real-time, continuously measured physiological data as a noninvasive biomarker approach for detecting disease transitions, using allogeneic hematopoietic stem cell transplant (HCT) patient care as an example. Additionally, we review a recent computational technique, the landscape dynamic network biomarker method, that uses biomarker data to identify transition states in disease progression and explore how to use it with both biomarker and physiological data for earlier detection of graft-versus-host disease specifically. Throughout, we argue that increased collaboration across multiple fields is essential to realizing the full potential of wearable and biomarker data in a new paradigm of personalized and real-time medicine.

The impact of diabetic foot ulcers and unilateral offloading footwear on gait in people with diabetes

BACKGROUND

Unilateral offloading footwear prescribed to patients with diabetic foot ulcers elevates one limb relative to the other, which may lead to limp and abnormal gait. This study investigated whether the unilateral foot ulcer and offloading combination negatively impacts gait function beyond diabetic peripheral neuropathy.

METHODS

Eighty-six participants were recruited in 3 groups: 12 with diabetic peripheral neuropathy and unilateral foot ulcers wearing offloading footwear (offloading group, age = 55.6 ± 9.5 years, BMI = 30.9 ± 4.5 kg/m2), 27 with diabetic peripheral neuropathy (neuropathy group, age = 64.3 ± 7.7 years, BMI = 30.9 ± 5.4 kg/m2), and 47 non-diabetic controls (non-diabetic group, age = 62.9 ± 16.1 years, BMI = 29.0 ± 6.0 kg/m2). Gait function was quantified during a habitual speed walking test using a validated wearable platform.

FINDINGS

The offloading group exhibited deteriorated gait function compared to the non-diabetic group (p < 0.005, Cohen's effect size d = 0.90-2.61). They also had decreased gait speed (p < 0.001, d = 1.79) and stride length (p < 0.001, d = 1.76), as well as increased gait cycle time (p < 0.001, d = 1.67) and limp (p < 0.050, d = 0.72-1.49) compared to the neuropathy group. The offloading group showed increased gait unsteadiness compared to the neuropathy group, but the difference did not reach statistical significance in our samples.

INTERPRETATION

This study demonstrated that while diabetic peripheral neuropathy deteriorates gait function, including increasing gait unsteadiness and limp, the diabetic foot ulcer and offloading combination magnifies the deterioration beyond diabetic peripheral neuropathy. These findings promote caution of the current standards of care for treating diabetic foot ulcers with offloading footwear. However, it is possible that a contralateral shoe lift may remedy deteriorated gait function and improve quality of life for unilateral offloading users.

Sensor-Based Daily Physical Activity: Towards Prediction of the Level of Concern about Falling in Peripheral Neuropathy

Concern about falling is prevalent and increases the risk of falling in people with peripheral neuropathy (PN). However, the assessment of concern about falling relies on self-report surveys, and thus continuous monitoring has not been possible. We investigated the influence of concern about falling on sensor-based daily physical activity among people with PN. Forty-nine people with PN and various levels of concern about falling participated in this study. Physical activity outcomes were measured over a period of 48 hours using a validated chest-worn sensor. The level of concern about falling was assessed using the falls efficacy scale-international (FES-I). The low concern group spent approximately 80 min more in walking and approximately 100 min less in sitting/lying compared to the high concern group. In addition, the low concern group had approximately 50% more walking bouts and step counts compared to the high concern group. Across all participants, the duration of walking bouts and total step counts was significantly correlated with FES-I scores. The duration of walking bouts and total step counts may serve as eHealth targets and strategies for fall risk assessment among people with PN.

The Effect of Daily Use of Plantar Mechanical Stimulation Through Micro-Mobile Foot Compression Device Installed in Shoe Insoles on Vibration Perception, Gait, and Balance in People With Diabetic Peripheral Neuropathy

OBJECTIVE

People with diabetic peripheral neuropathy (DPN) have impaired gait and balance performance. The aim of this study is to investigate therapeutic effectiveness of mechanical stimulation through a wearable foot compression device equipped in a shoe insole on vibration perception, balance control and gait performance in people with DPN.

METHODS

Using a single-arm 4-week intervention study design, we examined effectiveness of daily use of shoes equipped with the foot compression device (Footbeat™, AVEX, Grand Junction, CO, USA) on improving vibration perception threshold (VPT_max), skin perfusion pressure (SPP), ankle brachial index (ABI), lower extremities edema (circumferences in the calf and ankle), and motor performance (postural sway with eyes open and closed conditions, and gait performance during normal, dual-task and fast walking). Thirty people with type 2 diabetes and symptoms of PN completed the experimental protocol.

RESULTS

Improvements in VPT_max (before = 27.4 V, after = 23.3 V, P = .007, d = 0.33, where d denotes effect size), center-of-mass sway in the mediolateral direction with both eyes open and closed conditions (before = 0.94 cm, after = 0.76 cm, P = .020, d = 0.47; before = 1.10 cm, after = 0.83 cm, P = .033, d = 0.66, respectively), and stride velocity for normal walking, dual-task walking and fast walking tasks (before = 0.87 m/s, after = 0.96 m/s, P = .017, d = 0.41; before = 0.75 m/s, after = 0.91 m/s, P = .001, d = 0.77; before = 1.10 m/s, after = 1.20 m/s, P = .043, d = 0.33, respectively) were found post treatment. There was no significant improvement in SPP, ABI, and circumferences in the calf and ankle.

CONCLUSIONS

Our findings suggest the wearable foot compression device may be effective for reducing neuropathic symptoms and enhancing motor performances in people with DPN.

Daily Use of Bilateral Custom-Made Ankle-Foot Orthoses for Fall Prevention in Older Adults: A Randomized Controlled Trial

OBJECTIVE

To examine the effects of bilateral custom-made ankle-foot orthoses (AFOs) to prevent falls for older adults with concern about or at risk for falling over 12-month daily use.

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Community-dwelling older adults.

INTERVENTION

Half of the participants were randomly allocated to an intervention group (IG) that received fitted walking shoes and bilateral custom-made AFOs, and the other half were randomly allocated to a control group (CG) that only received fitted walking shoes.

MEASUREMENTS

Self-reported fall history of 12-month duration was investigated at baseline and 12-month follow-up for both groups. Fall incidence rate and proportion of fallers were used as outcome measures to determine effects of 12-month footwear intervention in either group.

PARTICIPANTS

Adults aged 65 years and older with concern about or at risk for falling (n = 44).

RESULTS

No significant between-group differences in participant characteristics were observed at the baseline (P = .144-.882). Within the IG, significant reductions were found in the fall incidence rate (P = .039) and the proportion of fallers (P = .036) at the 12-month follow-up compared to the baseline. Within the CG, no significant change was found at the 12-month follow-up compared to the baseline for the fall incidence rate (P = .217) or the proportion of fallers (P = .757). When comparing the IG with the CG, there was no significant difference in the change from the baseline to the 12-month follow-up for the fall incidence rate (P = .572) or the proportion of fallers (P = .080).

CONCLUSION

This study failed to demonstrate a significant benefit of bilateral custom-made AFOs to reduce falls compared to fitted walking shoes. However, the AFO users had significant reductions in falls compared to the preceding year. A future study with a larger sample size is recommended to confirm these observations. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT02819011. J Am Geriatr Soc 67:1656-1661, 2019.