Академический Документы
Профессиональный Документы
Культура Документы
20 March 2014
Expert Systems with Applications xxx (2014) xxxxxx
1
Q1
Q2
8
9
10
11
1
2 3
0
14
15
16
17
18
19
a
b
Institut Guttmann, Hospital de Neurorehabilitaci, Cami Can Ruti s/n, 08916 Badalona, Barcelona, Spain
Departament dEstadstica i Investigaci Operativa, Universitat Politcnica de Catalunya BarcelonaTech, Jordi Girona 1-3, 08034 Barcelona, Spain
a r t i c l e
i n f o
Keywords:
Machine learning
Algorithms
Statistics
a b s t r a c t
Cognitive rehabilitation (CR) treatment consists of hierarchically organized tasks that require repetitive
use of impaired cognitive functions in a progressively more demanding sequence. Active monitoring of
the progress of the subjects is therefore required, and the difculty of the tasks must be progressively
increased, always pushing the subjects to reach a goal just beyond what they can attain. There is an
important lack of well-established criteria by which to identify the right tasks to propose to the patient.
In this paper, the NeuroRehabilitation Range (NRR) is introduced as a means of identifying formal
operational models. These are to provide the therapist with dynamic decision support information for
assigning the most appropriate CR plan to each patient. Data mining techniques are used to build
data-driven models for NRR. The Sectorized and Annotated Plane (SAP) is proposed as a visual tool by
which to identify NRR, and two data-driven methods to build the SAP are introduced and compared.
Application to a specic representative cognitive task is presented. The results obtained suggest that
the current clinical hypothesis about NRR might be reconsidered. Prior knowledge in the area is taken
into account to introduce the number of task executions and task performance into NRR models and a
new model is proposed which outperforms the current clinical hypothesis. The NRR is introduced as a
key concept to provide an operational model identifying when a patient is experiencing activities in
his or her Zone of Proximal Development and, consequently, experiencing maximum improvement.
For the rst time, data collected through a CR platform has been used to nd a model for the NRR.
2014 Elsevier Ltd. All rights reserved.
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
1. Introduction
43
Acquired Brain Injury (ABI) of either vascular or traumatic nature is one of the most important causes of neurological disabilities.
According to the World Health Organization, Traumatic Brain Injury (TBI) is the leading cause of death and disability in children
and young adults around the world and is a factor in nearly half
of all trauma deaths (Walsh, Donal, Stephen, & Muldoon, 2012).
In Europe, brain injuries from trauma are responsible for more
years of disability than any other cause (Maas, Stocchetti, &
Bullock, 2008).
Despite new techniques for early intervention and intensive
ABI, both of which increase the survival rate, there is still no surgical or pharmacological treatment for the re-establishment of lost
functions following brain injury. Cognitive rehabilitation (CR) is
44
45
46
47
48
49
50
51
52
53
54
55
Corresponding author. Tel.: +34 93 401 73 23; fax: +34 93 401 58 55.
E-mail addresses: agarciar@guttmann.com (A. Garca-Rudolph), karina.gibert@
upc.edu (K. Gibert).
1
Tel.: +34 93 497 77 00; fax: +34 93 497 77 07.
http://dx.doi.org/10.1016/j.eswa.2014.03.001
0957-4174/ 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Garca-Rudolph, A., & Gibert, K. A data mining approach to identify cognitive NeuroRehabilitation Range in Traumatic
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
ESWA 9208
20 March 2014
2
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
CR, as part of neuropsychological rehabilitation, tries to improve the decits caused by ABI in daily living activities (Bernabeu
& Roig, 1999) by retraining attention, memory, reasoning/problem
solving, and executive functions. The plasticity of the central nervous system plays a central role (Pascual-Leone et al., 2005) in
CR, based on therapeutic plans to stimulate that non-damaged
neurons can modify their structure by learning from experience
the damaged functions, through repetition (Luria, 1978). Plasticity
may represent a surrogate marker of functional recovery, indicating behavioral change that is resistant to decay. In Kleim and Jones
(2008) is suggested that a sufcient level of rehabilitation is likely
to be required in order to get the subject over the hump i.e. repetition may be needed to obtain a sufcient level of improvement and
brain reorganization for the patient to continue using the affected
function outside of therapy and to achieve and maintain further
functional gains. A great deal of research indicates that behavioral
experience can enhance behavioral performance and optimize
restorative brain plasticity after brain damage. Simply engaging a
neural circuit in task performance is not sufcient to drive plasticity. Repetition of a newly learned (or relearned) behavior may be
required to induce lasting neural changes. In fact, from the experts
point of view, there is a clear perception that the effectiveness of
the task also depends on the replication, as Luria also asserts.
A typical CR program mainly provides exercises that require
repetitive use of the impaired cognitive system in a progressively
more demanding (Sohlberg, 2001) sequence of tasks. Each task targets a principal cognitive function and can be performed at different levels of difculty, according to the response of the patient. The
design of a CR program has become an essential issue for patient
recovery.
As said before, the rehabilitating effect of a task or exercise depends on the ratio between the skills of the treated patient and
the challenges involved in the execution of the task itself. The dif-
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
Please cite this article in press as: Garca-Rudolph, A., & Gibert, K. A data mining approach to identify cognitive NeuroRehabilitation Range in Traumatic
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
ESWA 9208
20 March 2014
A. Garca-Rudolph, K. Gibert / Expert Systems with Applications xxx (2014) xxxxxx
265
treatments, other relevant factors exist that are much more difcult
to control, and which are related to the high variability of the lesions, the complexity of cognitive functions, and the lack of proper
instrumentation by which to systematize interventions. This produces intrinsic group heterogeneity and the classical comparative
studies do not perform well (Gibert & Garca-Rudolph, 2007), which
makes it difcult to advances knowledge on the pathophysiology of
cognitive neurorehabilitation.
In Serra et al. (2013) basic machine learning algorithms were
used to predict the probability of improvement of a patient given
their initial neuropsychological assessment. This approach,
although it is able to identify subpopulations of patients more suitable for improvement using CR treatments, did not provide any
information to help CR therapists adapt CR programs to increase
the improvement itself or to enlarge the subpopulations that might
activate improvement to CR treatments. Going a little bit further, in
Marcano, Chausa, Garcia-Rudolph, Cceres, and Tormos (2013) the
performance obtained by the patient in a certain task has been included in the model together with the initial assessment. Machine
learning methods signicantly improved predictive capacity. This
work provided evidence that task performance is involved in patient improvement; However, it did not provide information on
successful patterns of tasks to be proposed to the patients so that
they improved as much as possible.
For these reasons, other approaches have to be found to better
understand the CR process, with the aim of obtaining scientic evidence about its effectiveness and providing relevant information
for the establishment of general guidelines for CR program design
that can assist CR therapists in clinical practice.
Analyzing data from new perspectives can contribute to this
eld (Jagaroo, 2009). Our proposal is trying to approach the problem from a data-driven perspective, by developing new tools that
can reduce uncertainty in the eld. This paper introduces elements
to assess when a patient is performing a task under a NeuroRehabilitation Range, as an indicator that maximum improvement of
the patient might be expected on the targeted cognitive function.
This contributes to a better understanding of the role over clinical
improvement of a particular degree of performance of a CR task. In
fact, the NRR helps provide an operational denition for the zone of
maximum rehabilitation potential and represents an operationalization of the ZPD.
The work is based on the experience of Institut Guttmann Neurorehabilitation Hospital (IG) regarding the introduction of Information and Communication Technologies (ICTs) in CR. Data used
in this work comes from a CR computerized platform conceived
by IG and developed in collaboration with clinical and technological
partners, namely PREVIRNEC a serious game platform for CR (Tormos et al., 2009). PREVIRNEC is specically designed to manage
the CR plans assigned to subjects, as well as obtaining precise follow-up information about the process. At the time of submission
(December 2013) PREVIRNEC has already been integrated into
the clinical practices of more than 24 clinical centers. As the whole
behavior of the patients working in PREVIRNEC is registered in a
central server, this provides a unique database of on-eld interventions, with detailed information that is potentially valuable for a
better understanding of the circumstances under which CR therapy
would be most benecial to individual patients. The PREVIRNEC
database permits knowledge extraction from data, and provides a
framework in which new knowledge can be introduced into the
system to be veried and continuously rened, also contributing
to elaborate data-driven personalized treatments.
266
267
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
268
of the targeted cognitive function. This approach requires implementation of repetitive exercises within the planned program which
require patients to use their impaired cognitive skills at a productive
level. In this work therefore, given the initial assessment of the
patient impairments, the therapists assign repetitive tasks to be executed in PREVIRNEC, a serious game platform for cognitive
rehabilitation.
The emergence of serious games broadens the discipline of
entertainment-education in numerous dimensions. Serious games
have recently been applied in diverse areas e.g. military training,
health, higher education, city planning (Rego, Moreira, & Reis,
2010). Prior research demonstrates that videogame attributes, such
as task difculty, realism, and interactivity, affect learning outcomes in game-based learning environments (Orvis, Horn, & Belanich, 2008). These prior works suggest that in order to be most
effective, instructional games should present an optimal level of
difculty to learners. This optimal range of difculty is aligned
with the Vygotskys concept of ZPD, where training should be difcult to the learner, but not beyond his or her capabilities.
Videogames involving the sensory-motor system and problemsolving skills are serious candidates for neuro-rehabilitation and
motor or cognitive training. In Green and Bavelier (2007) several
improvements in gaming activity were identied, from reaction
times to spatial skills. The opportunities for using this kind of media to improve cognitive functions in individuals with particular
needs (as reviewed for surgeons and soldiers) or for training and
retraining of individuals with special health-related problems
(such as young disabled or elder people) involving the nervous system were also highlighted. An improvement in the spatial resolution of attention in videogame players has been observed (Green
& Bavelier, 2007).
A persistent difculty is that training can be more or less efcient depending on how it is administered and this is directly related with tasks difculty management (Linkenhoker & Knudsen,
2002).
269
304
305
Please cite this article in press as: Garca-Rudolph, A., & Gibert, K. A data mining approach to identify cognitive NeuroRehabilitation Range in Traumatic
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
326
327
328
329
330
331
ESWA 9208
20 March 2014
4
332
333
334
335
336
337
338
339
340
341
342
343
344
345
346
als with high Internet search skills and a search task that presents a
high navigational challenge.
From a research perspective however, ow is poorly dened in
CME because of the numerous ways it is conceptualized, operationalized, and measured. Flow experience is associated with a person doing an activity. In traditional ow studies, the activities tend
to be very clear: playing music, climbing a cliff, playing chess or
reading a book. Most existing ow studies in CME do not clearly
differentiate between factors that are related to the task and those
that are related to the artifact.
Thus, there is a need to re-conceptualize ow in CME to consider the uniqueness of the artifacts and the complexity they add
to the ow phenomenon. Indeed one of the aims of this work is
to use PREVIRNEC to produce ow experiences in the subject,
thus incrementing the benets of the neurorehabilitation process.
347
348
As introduced in the previous section, there is a need to re-conceptualize ow in CME to consider the uniqueness of the artifacts
and the complexity they add to the ow phenomenon. As an attempt to re-conceptualization, in Finneran and Zhang (2005) a conceptual model for ow antecedents is proposed: the PersonArtifact-Task (PAT) model.
PAT removes the ambiguities among the ow antecedents by
considering the task and the artifact as separate entities when
looking at the factors that lead to a ow state.
The PAT model considers each of the three main components of
person, artifact, and task independently and their interactions, to
understand the holistic picture of ow antecedents.
The intention is therefore to conceptualize the major components of a person working on a computer-related activity that
can inuence the ow experience the person may have. Individual
differences, which are shown to be important in early non-computer-mediated ow studies, are probably even more important
in CME. According to Finneran and Zhang (2005) much empirical
research is needed to validate or clarify which individual factors
inuence the ow experience and where they occur in the process.
349
350
351
352
353
354
355
356
357
358
359
360
361
362
363
364
365
366
367
368
3. Conceptual framework
369
370
371
372
373
374
375
376
377
378
379
380
381
382
383
384
385
386
387
388
389
390
391
392
393
394
395
396
397
398
399
400
401
402
403
405
407
406
408
409
410
411
412
413
414
415
416
417
418
419
423
424
3.2.1. Person
One hundred and twenty-three Traumatic Brain Injury (TBI) patients with moderate to severe cognitive affectation (according to
Glasgow Coma Scale) and who underwent rehabilitation at IG were
included in this analysis. All subjects gave informed consent to the
neuropsychological procedure, which was approved by IGs Ethical
Committee. The patient (mean age 36.56 6.5, range 1868 years;
91 male and 32 female) diagnosis was made according to the
clinical protocols of the IG Neuropsychological department. All
patients met criteria to initiate IG neuropsychological rehabilitation
treatment. It includes a Neuropsychological Assessment Battery
(NAB), 28 items covering the major cognitive domains (language,
attention, memory and learning, and executive functions)
measured using standardized cognitive tests.
After NAB initial evaluation all patients started a CR program
lasting four to six months based on personalized interventions,
where patients worked in each one of the specic cognitive
domains, considering the degree of the decit and the residual
functional capacity. All patients were administered the same NAB
neuropsychological assessment at the end of the rehabilitation
program. All NAB items are normalized to a 04 scale (where
0 = no affectation, 1 = mild affectation, 2 = moderate affectation,
3 = severe affectation and 4 = acute affectation). Differences
between pre- and post-treatment NAB test scores were used to
measure particular patient improvement in the elds of attention,
memory, and executive functions. Improvement criteria in the
respective cognitive functions are dened in IG cognitive rehabilitation protocols.
426
Please cite this article in press as: Garca-Rudolph, A., & Gibert, K. A data mining approach to identify cognitive NeuroRehabilitation Range in Traumatic
420
421
422
425
427
428
429
430
431
432
433
434
435
436
437
438
439
440
441
442
443
444
445
446
447
448
449
450
451
452
453
ESWA 9208
20 March 2014
A. Garca-Rudolph, K. Gibert / Expert Systems with Applications xxx (2014) xxxxxx
454
455
456
457
458
459
460
461
462
463
464
465
466
467
468
469
470
471
472
473
474
475
476
477
478
479
480
481
482
483
484
485
486
487
488
489
490
491
492
493
494
495
496
497
498
499
500
501
502
503
504
505
506
507
508
509
510
511
512
513
514
515
3.2.2. Artifact
PREVIRNEC (Tormos et al., 2009) comprises a series of rehabilitation tasks for training different cognitive functions: attention,
memory, executive functions, and language. For each specic task
that the patient executes, the result of the task (0100 real number) is assigned into one of the following three ranges: NRR, INRR,
and SNRR. As a rst hypothesis, PREVIRNEC is currently assuming
that NRR(T) = [65, 85] These limits have been dened according to
the expertise of the CR therapists of making the task difcult enough not to be innocuous, but not so difcult as to be blocking.
To maintain the interest of the patient throughout the execution of tasks, PREVIRNEC includes an algorithm that proposes
tasks to patients while trying to keep them inside NRR limits. PREVIRNEC is a cognitive tele-rehabilitation platform, developed
over an architecture based on web 2.0 technologies. It is conceived
as a tool for the enhancement of cognitive rehabilitation, the
strengthening of the relationship between the neuropsychologist
and the patient, the personalization of treatment, the monitoring
of results, and the performance of tasks. The platform architecture
consists of four main modules that group related functionalities
vertically, sharing the user interface that is personalized depending
on the users role. This interface is also multi-language, with Catalan, Spanish and English already implemented, but being open to
support any other language. The system also has a help module,
which guides the user in order to complete each action. Security
aspects are transversal and have to be taken into account in every
module to keep information and all connections safe, due to the
condentiality concerns of medical applications. The security module is responsible for controlling every access, including the ones
related to the patients Electronic Health Record (EHR). The four
modules are briey described below:
Q5 3.2.2.1. Information management. This module groups functionalities related to the generation and edition of information that depends on the patients EHR, as well as the tests used to
determine the grade of affection of each cognitive function. These
tests are used to dene the affection prole of the patient. In addition, this module controls the assignation of therapies to the patients, determining which computerized tasks a patient has to do
on a certain day. The results of the execution of these tasks are registered in the system, and can then be used by the clinicians to see
the evolution of the therapy, as well as showing graphics and reports related to the completion of the sessions, tasks that have
been used, both global and individual results, and much more.
3.2.2.2. Monitoring. To comply with data protection laws, every action carried out by a user is stored in both the database and also in
a log le, so that the administrator can track every action related to
a patient and their data. The system also offers a module for monitoring the execution of the tasks, so the therapist can then reproduce a task as it was done by the patient. This allows the therapist
to see exactly what a patient did in the monitored task. This is very
useful because sometimes merely seeing the numeric results is not
enough.
3.2.2.3. Administration. This module, although it is the one with
fewer functionalities and users, includes very important functionalities such as the users management and their proles, as well
as system monitoring (using logs).
3.2.2.4. Communication. The main element of this module is the video conference that allows users to communicate using video,
audio, and chat. Using the videoconference therapists can hold
tele-appointments with patients or other therapists, removing
the distance barriers between users, and helping the patients to
feel closer to the clinical team. In addition to the videoconference,
516
3.2.2.5. Patients. Man or woman of any age with one or some cognitive functions affected, as a consequence of suffering ABI. The
caregiver role appears here, considered a secondary actor that will
help the patient use the system when necessary.
540
544
548
552
Please cite this article in press as: Garca-Rudolph, A., & Gibert, K. A data mining approach to identify cognitive NeuroRehabilitation Range in Traumatic
517
518
519
520
521
522
523
524
525
526
527
528
529
530
531
532
533
534
535
536
537
538
539
541
542
543
545
546
547
549
550
551
553
554
555
556
557
558
559
560
561
562
563
564
565
566
567
568
569
570
571
572
573
574
575
ESWA 9208
20 March 2014
6
576
577
578
579
580
581
582
583
584
585
586
587
588
589
590
591
592
593
594
595
596
597
598
599
600
601
602
603
604
605
606
607
608
609
610
611
612
613
614
615
616
617
618
619
620
621
622
623
624
625
626
627
628
3.2.3. Tasks
As introduced in Section 3.2.1, following NAB initial evaluation
all analyzed subjects initiated a CR program lasting four to six
months based on personalized interventions in PREVIRNEC
platform.
The therapeutic content used in PREVIRNEC tele-rehabilitation sessions consists of computerized tasks, grouped by cognitive
functions. The neuropsychologist creates a tele-rehabilitation session by assigning a set of tasks to a certain session day. He or
she is able to congure the difculty of each task because they
all have a set of input parameters.
At the time of this analysis, PREVIRNEC includes one hundred
and fteen rehabilitations tasks. Each task is dened by a series of
parameters that determine its level of difculty. The therapist selects for each task the parameter to be used for the automatic
adjustment of the difculty level described above. This dynamic
adjustment of the difculty level is performed twice for each task
as necessary. This means that if the patient does not obtain a task
result in NRR in the rst execution, PREVIRNEC automatically
generates the task with the adjusted difculty level once; if again
the obtained result is not in TR, PREVIRNEC likewise generates
a second version of the task.
3.2.3.1. Visual memory task description. For illustrative purposes
one such task designed for visual memory treatment is described
below in more detail. This task (identied as idTask = 151) has
been one of the most extensively administrated by neuropsychologists and executed by participants during the analyzed period
(described in Section 3.2.1.) and will be used throughout the different sections of this paper.
The objective of the task is to recall the position of pairs of identical images in a grid. A grid of xed size (e.g. 5 5 dark colored
cells) is presented to the participant at the start. When the participant left-clicks on a cell in the grid, an image of an object on a
white background appears in the cell. This image remains until a
second cell is clicked, then both images are shown for a period of
time (e.g. 1500 ms) for the participant to remember them; afterwards both images are covered. Only two cells can be simultaneously discovered in one go. When two identical images are
discovered, both of them remain visible in their cells. The aim of
the task is to discover all the images in the grid with the minimum
number of clicks. The parameters that determine the different difculty levels are shown in Table 1.
The quantied result parameters for the evaluation of task completion are: the total execution time, the total number of discovering clicks, the total number of wrong clicks (this number increases
if the participant clicks on an image already discovered before,
meaning that errors are computed after an initial exploration
phase), the total number of correct clicks (in this case, although
it is computed for homogeneity with other tasks, the number of
clicks for all participants is constant because the task is considered
unnished until all the images are discovered; this also means that
task151 does not produce omissions, and they are presumed to be
zero). The task result is computed as:
629
631
4. Methods
632
633
646
647
668
Please cite this article in press as: Garca-Rudolph, A., & Gibert, K. A data mining approach to identify cognitive NeuroRehabilitation Range in Traumatic
634
635
636
637
638
639
640
641
642
643
644
645
648
649
650
651
652
653
654
655
656
657
658
659
660
661
662
663
664
665
666
667
669
670
671
672
673
674
675
676
677
ESWA 9208
20 March 2014
7
678
679
680
681
682
683
Number of
cells
Stimulus type
44
55
66
88
Abstract objects
Numbers
Animals
Colors
Proximity of
the
second image
Presentation time
(ms)
2 Cells
3 Cells
4 Cells
Random
1500
3000
4000
This exploratory analysis is used to identify systematic relationships between variables when there is no previous knowledge
about the nature of those relationships. The constant-Y regions detected in the plot can be expressed in the form of logical rules
involving the implied variables. The SAP is built on the basis of
these rules.
699
700
684
685
686
687
688
689
690
691
692
693
694
695
696
697
698
701
702
703
704
705
706
707
708
709
When Y is a binary variable P(Y = yes | S) it provides the sensitivity of S, while P(Y = No | S) provides the specicity. As usual,
the higher the sensibility and specicity, the higher the quality of S.
We dene the global quality of the SAP as the pooled condence
of all sectors. Additionally for the SAP of binary variables a pooled
specicity and a pooled sensitivity can be used as quality
indicators.
710
717
711
712
713
714
715
716
718
719
720
721
722
723
724
725
726
727
728
729
730
731
732
733
734
735
736
737
H0 : pMR pMR
738
740
741
743
744
pMR pMR
e r
H0 z
1
1
p0 1 p0 nMR nMNoR
747
745
748
749
750
752
753
^ MR
pMR p
nMR
^ MR
pMR p
nMR
755
756
758
The test is solved under the z-distribution, with alpha = 0.05. The
greater the difference between pMR and pMR (pMR > pMR ) the more
sensitive and specic is the NRR criterion tested, the lower the p-value of the test, and better performs over real patients.
759
763
764
Please cite this article in press as: Garca-Rudolph, A., & Gibert, K. A data mining approach to identify cognitive NeuroRehabilitation Range in Traumatic
760
761
762
765
766
767
768
769
770
771
ESWA 9208
20 March 2014
8
Table 2
Attributes of classied instances.
Execs151
Result
Improvement
23
83.4
YES
784
785
786
772
773
774
775
776
777
778
779
780
781
782
783
787
788
789
790
791
792
793
794
795
796
797
798
799
800
801
802
803
804
805
806
5.2. Analysis of PREVIRNEC visual memory task using visualizationbased SAP (Vis-SAP)
811
813
807
808
809
810
812
814
815
816
817
818
819
820
821
822
823
824
825
826
827
828
829
830
831
832
833
Please cite this article in press as: Garca-Rudolph, A., & Gibert, K. A data mining approach to identify cognitive NeuroRehabilitation Range in Traumatic
834
835
836
837
838
839
840
841
842
843
844
ESWA 9208
20 March 2014
A. Garca-Rudolph, K. Gibert / Expert Systems with Applications xxx (2014) xxxxxx
Table 3
Contingency table for NRR with Result e [65, 85] for idTask = 151.
Improvement
Yes
No
Total
^p(YES)
In NRR
Yes
No
Total
30
23
53
0.5660
1652
1661
3313
0.4986
1682
1684
3366
0.4997
846
ability of improving visual memory function. Thus, upon the VisSAP criterion, NRR(task151) = Execs151 > 60 and Results > 20.
847
848
845
849
850
851
852
853
854
855
856
857
858
859
860
861
862
863
864
865
866
867
868
869
870
871
872
882
Following the NRR identication phase, 327 patients not included so far in this study were considered for participation in order to validate the results. The clinical staff of the hospital
randomly selected 10 of them after participants provided consent
in the usual way for these interventions to test the validity of the
clinical hypothesis about NRR of task 151 arising from Section 5.2
of this study. Patients were evaluated before treatment according
to the standard clinical protocol (Neuropsychological Assessment
Battery) introduced in Section 3.2.1 of this paper. The neuropsychologists in charge of the NR program of each patient included
in the program the execution of task 151 a minimum of 60 times
in such a difculty conguration as to guarantee that the patient
obtained a result higher than 20. In this validation phase, the conguration of the tasks were manually tuned for each patient by the
specialist, according to the performance shown in previous executions and the specic clinical condition of each participating
patient.
All patients were evaluated after treatment following the same
standard protocol and the improvement of the patient was assessed in the usual way by comparing scores before the treatment
with scores at the end of it.
Of the 317 patients following the classical NR program, 189
showed improvement and 128 did not. Meanwhile, we could verify
that all of the participating patients under the NRR recommendations improved in the targeted cognitive function. A twofold
impact was observed: SAP recommendations can support cognitive
therapies with new (previously unknown and specic) congurations of tasks and those recommendations show a higher probability
883
Fig. 4. Letterplot of TaskExecs vs. Result vs. Improving/not for idTask 151.
Please cite this article in press as: Garca-Rudolph, A., & Gibert, K. A data mining approach to identify cognitive NeuroRehabilitation Range in Traumatic
873
874
875
876
877
878
879
880
881
884
885
886
887
888
889
890
891
892
893
894
895
896
897
898
899
900
901
902
903
904
905
906
907
908
909
910
ESWA 9208
20 March 2014
10
Table 4
Contingency table for VIS-SAP TR for idTask = 151.
Improvement
Yes
No
Total
^p(YES)
In NRR
Yes
No
Total
199
13
212
0.9386
1483
1671
3154
0.4701
1682
1684
3366
0.4997
911
912
913
914
915
916
917
918
919
920
Q12
921
6. Discussion
930
931
Please cite this article in press as: Garca-Rudolph, A., & Gibert, K. A data mining approach to identify cognitive NeuroRehabilitation Range in Traumatic
922
923
924
925
926
927
928
929
932
933
934
935
936
ESWA 9208
20 March 2014
A. Garca-Rudolph, K. Gibert / Expert Systems with Applications xxx (2014) xxxxxx
Table 5
Contingency table for DT-SAT TR for idTask = 151.
Improvement
Yes
NO
Total
^p(YES)
In NRR
YES
NO
Total
375
71
446
0.8408
1307
1613
2920
0.4476
1682
1684
3366
0.4997
11
969
970
971
972
973
974
975
937
938
939
940
941
942
943
944
945
946
947
948
949
950
951
952
953
954
955
956
957
958
959
960
961
962
963
964
965
966
967
968
know, this is the rst time that the number of repetitions of the
task is considered for modeling the NRR of the task.
This goes one step ahead on the current state of the art. Most of
the work done on maximizing the rehabilitative effect of a task has
been oriented to a proper management of the level of difculty of
the tasks presented to the patient. In the context of rehabilitation
through a serious game strategy, the determination of tasks and
game difculty is made statically by the therapists in most therapeutic games proposed in the literature. For example (Heuser
Q6 et al., 2006) suggest ve therapeutic games exercises, each one
involving a set of difculty levels following patients recovery;
the difculty level is statically designed in an increasing way and
the simulation stops the exercise when the patient fails. In Ma
et al. (2007) the therapeutic game trains visual discrimination
and selective attention using three difculty levels: Beginner,
Intermediate and Expert; the system includes a matrix assigning
suitable difculty levels for a set of patient proles, that is used
to suggest a difculty level to each patient.
PREVIRNEC is assuming an expert-based constant NRR for the
whole set of available tasks: [65, 85]; the system automatically increases difculty if the patient performs over the NRR and decreases it if he/she performs below NRR. All these systems try to
deal with the degree of difculty of the task to be proposed to
the patient, but none of them include any kind of guide about
the number of executions required to empower the rehabilitation
effect.
According to Lurias theory (Luria, 1978), present research
shows that repetition is important in CR. The main result emerged
from this analysis is that the number of executions of the CR tasks
is clearly relevant to determine NRR and that including them in the
model provides signicant improvement with regards to current
practice.
Please cite this article in press as: Garca-Rudolph, A., & Gibert, K. A data mining approach to identify cognitive NeuroRehabilitation Range in Traumatic
977
978
979
980
981
982
983
984
985
986
987
988
989
990
991
992
993
994
995
996
997
998
999
1000
1001
1002
1003
1004
ESWA 9208
20 March 2014
12
Fig. 8. ROC curves comparison for VIS-SAP current hypothesis, VIS-SAP proposed NRR and DT -SAP.
1005
1006
1007
1008
1009
1010
1011
1012
1013
1014
1015
1016
1017
1018
1019
1020
1021
1022
1023
1024
1025
1026
1027
1028
1029
1030
1031
1032
1033
1034
1035
1036
1037
Table 6
Contingency table for validation of idTask = 151.
Improvement
Yes
NO
Total
^p(YES)
In NRR
YES
NO
Total
10
0
10
1.000
189
128
317
0.5962
199
128
327
0.6100
1038
1046
This work is a contribution towards the personalized, predictable, and data driven CR design from both a theoretical and practical point of view.
From the theoretical point of view, the paper introduces a new
concept, the NeuroRehabilitation Range (NRR) as the framework to
describe the degree of performance of a CR task which produces
maximum rehabilitation effects. The NRR contributes to provide
an operational denition for the zone of maximum rehabilitation
potential and represents an operationalization of the Zone of Proximal Development referred in Vygotsky (1934).
Analytical and visual tools are also proposed in this paper, dened and validated, to nd an operational denition of a NRR from
a data driven approach. On the one hand, the SAP has been introduced as a general visualization tool to nd areas with high probability of occurrence of a target event. A particular case of SAP for
detecting cognitive improvement in relation with results and repetitions of a certain cognitive rehabilitation task is presented in the
paper. For this particular application, the SAP identies areas with
high probability of cognitive improvement. Although SAP is not a
complex concept, it has shown a great potential to nd the NRR region of a cognitive rehabilitation task in a quick, simple and very
intuitive way, which has shown to be highly useful at clinical practice level. Also, for the rst time, the NRR is dened as a bivariate
structure involving conditions in both results and repetitions of the
tasks.
Another contribution of the paper is to propose two different
methodologies to build the SAP in a given real problem: Direct construction of SAP by visualization of raw data (Vis-SAP method); and
DT-SAP, which is based on decision-tree induction and could be
automated. Decision trees have been considered because their
inherent structure is directly providing the NRR model, which is
built as the OR of all branches bringing to a leaf labeled as improvement. Both methods effectively determine the areas where proba-
1047
Please cite this article in press as: Garca-Rudolph, A., & Gibert, K. A data mining approach to identify cognitive NeuroRehabilitation Range in Traumatic
1039
1040
1041
1042
1043
1044
1045
1048
1049
1050
1051
1052
1053
1054
1055
1056
1057
1058
1059
1060
1061
1062
1063
1064
1065
1066
1067
1068
1069
1070
1071
1072
1073
1074
1075
1076
1077
1078
1079
ESWA 9208
20 March 2014
A. Garca-Rudolph, K. Gibert / Expert Systems with Applications xxx (2014) xxxxxx
1080
1081
1082
1083
1084
1085
1086
1087
1088
1089
1090
1091
1092
1093
1094
1095
1096
1097
1098
1099
1100
1101
1102
1103
1104
1105
1106
1107
1108
1109
1110
1111
1112
1113
1114
1115
1116
1117
1118
1119
1120
1121
1122
1123
1124
1125
1126
1127
1128
1129
1130
1131
1132
1133
1134
1135
1136
1137
1138
1139
1140
1141
1142
1143
1144
1145
13
of the institution, as well as operationalized for PREVIRNEC platform, that provides the support to verify clinical hypothesis.
As discussed in previous section, the Vis-SAP provides a semideterministic criterion that outperforms DT-SAP, but the later is
automatable. On the other hand, the proposed analysis considers
each task individually
Till now, CR plans are mainly built from scratch for every patient, on the basis of the expertise of therapist and the follow-up
of the patient, as no standard guidelines are available in this domain yet. The ndings from the present study led to new actionable knowledge in the eld of rehabilitation practice, opening the
door towards more precise, predictable and powerful CR treatments, customized for the individual patient. Some clinical
hypothesis are being formulated by specialists on the basis of these
results and currently under validation, as a previous step to the
establishment of a methodology for personalized therapeutic
interventions based on clinical evidence.
As future research lines, the automatic construction of SAP still
requires more work since decision trees imply, by construction,
some intrinsic error taxes in every branch that will be always propagated to the NRR performance and automation from Vis-SAP has
to be faced from scratch.
This work is currently being enriched by analyzing how patients
walk through the SAP areas (or sectors) during their rehabilitation
process. This can be analyzed by connecting the points corresponding to a same patient in the SAP and nding prototypical patterns
according to the form of the paths designed on the SAP. This dynamic analysis can be later generalized to nd dynamic patterns
on the global treatment of the patient involving the whole sequence of tasks performed during the treatment, and providing
information about the possible positive interactions among tasks
that empower the improvement capacity.
Although the NRR models using number of executions and results seem to provide quite high sensitiveness and specicity, there
are other factors supposed to be highly determinant of cognitive
improvement, like task difculty. Extension of the current proposals to include such other factors is currently being explored.
Finally, obtained results are expected to be more interpretable
by clinicians when other demographic and clinical variables are included in the model, e.g. participants educational level, age, time
since injury, obtained results in pre-treatment evaluation.
1146
Acknowledgments
1187
1188
References
1200
1201
1202
1203
1204
1205
1206
1207
1208
Please cite this article in press as: Garca-Rudolph, A., & Gibert, K. A data mining approach to identify cognitive NeuroRehabilitation Range in Traumatic
1147
1148
1149
1150
1151
1152
1153
1154
1155
1156
1157
1158
1159
1160
1161
1162
1163
1164
1165
1166
1167
1168
1169
1170
1171
1172
1173
1174
1175
1176
1177
1178
1179
1180
1181
1182
1183
1184
1185
1186
1189
1190
1191
1192
1193
1194
1195
1196
1197
1198
1199
Q7
ESWA 9208
20 March 2014
14
1209
1210
1211
1212
1213
1214
1215
1216
1217
1218
1219
1220
1221
1222
1223
1224
1225
1226
1227
1228
1229
1230
1231
1232
1233
1234
1235
1236
1237
1238
1239
1240
1241
1242
1243
1244
1245
1246
1247
1248
1249
1250
1251
1252
1253
1254
1255
1256
1257
1258
1259
Q8
Cicerone, K. D., Langenbahn, D. M., Braden, C., Malec, J. F., & Kalmar, K. (2011).
Evidence-based cognitive rehabilitation: Updated review of the literature from
2003 through 2008. Archives of Physical Medicine and Rehabilitation, 92(5),
1930.
Csikszentmihalyi, M. (1991). Flow: The psychology of optimal experience. Harper
perennial
DiPiro, J. T., & Spruill, W. J. (2010). Concepts in clinical pharmacokinetics (5th ed.)
American Society of Health-System Pharmacists (January 1) ISBN-13: 9781585282418.
Ecri. Cognitive rehabilitation therapy for traumatic brain injury: What we know and
dont know about its efcacy. EDITORIAL NOTE 10/11/11: IOMs New Report on
Brain Injury Treatments Draws Conclusions Similar to ECRI Institutes Earlier
Findings.
Finneran, C. M., & Zhang, P. (2005). Flow in computer-mediated environments:
Promises and challenges. Communications of the Association for Information
Systems, 15, 82101.
Gibert, K., & Garca-Rudolph, A. (2007). Desarrollo de herramientas para evaluar el
resultado de las tecnologas aplicadas al proceso rehabilitador Estudio a partir
de dos modelos concretos: Lesin Medular y Dao Cerebral Adquirido. Cap 6:
Posibilidades de aplicacin de minera de datos para el descubrimiento de
conocimiento a partir de la prctica clnica. Madrid: Plan Nacional para el
Sistema Nacional de Salud del Ministerio de Sanidad y Consumo. Barcelona:
Agncia dAvaluaci de Tecnologia I Recerca Mdiques. Informes de Evaluacin
de Tecnologias Sanitarias. AATRM nm. 2006/11. Barcelona.
Green, C., & Bavelier, D. (2005). In Messaris & Humphreys (Eds.), Digital media:
Transformations in human communication.
Green, C. S., & Bavelier, D. (2007). Action-video-game experience alters the spatial
resolution of vision. Psychological Science, 18(1), 8894.
Hall, M., Frank, E., Holmes, G., Pfahringer Reutemann, P., & Witten, I. H. (2009). The
WEKA data mining software: An update. SIGKDD Explorations, 11(1).
Heuser, H. A., Kourtev, H., Winter, S., Fensterheim, D., Burdea, G., Hentz, V., et al.
(2006). Tele-rehabilitation using the Rutgers master II glove following carpal
tunnel release surgery. In 2006 International workshop on virtual rehabilitation
(pp. 8893). IEEE publisher.
Jagaroo, V. (2009). Neuroinformatics for neuropsychologists (1st ed). Springer (August
21).
Kleim, J. A., & Jones, T. A. (2008). Principles of experience-dependent neural
plasticity: Implications for rehabilitation after brain damage. Journal of Speech,
Language, and Hearing Research, 51, S225S239. February D American SpeechLanguage-Hearing Association 10924388/08/5101-S225.
Linkenhoker, B. A., & Knudsen, E. I. (2002). Incremental training increases the
plasticity of the auditory space map in adult barn owls. Nature, 419(6904),
293296.
Luria, A. (1978). Neuropsychology. In Great soviet encyclopedia: A translation of the
third edition (pp. 514515). New York, London: MacMillan, Collier Macmillan.
Vol. 17.
Ma, M., Charles, D., McDonough S., Crosbie, Oliver, L., & McGoldrick C., 2007.
Adaptive virtual reality games for rehabilitation of motor disorders. Universal
Access in HumanComputer Interaction, Ambient, Interaction.
Maas, A. I., Stocchetti, N., & Bullock, R. (2008). Moderate and severe traumatic brain
injury in adults. Lancet Neurology, 7(8), 728741.
Marcano, A., Chausa, P., Garcia-Rudolph, A., Cceres, C., & Tormos, J. M. (2013). Data
mining applied to the cognitive rehabilitation of patients with acquired brain
injury. Data mining applied to the cognitive rehabilitation of patients with
acquired brain injury. Expert Systems with Applications, 40(4), 10541060. ISSN
0957-4174.
Mathwick, C., & RigdonPlay, E. (2004). Flow, and the online search experience.
Journal of Consumer Research, 31(2), 324332.
Norea, D., Rios-Lago, M., Bombin-Gonzalez, I., Sanchez-Cubillo, I., Garcia-Molina,
A., & Tirapu-Ustarroz, J. (2010). Efectividad de la rehabilitacin neuropsicolgica
en el dao cerebral adquirido (I): atencin, velocidad de procesamiento,
memoria y lenguaje. Revista de Neurologia, 51, 687698.
Orvis, K., Horn, D., & Belanich, J. (2008). The roles of task difculty and prior
videogame experience on performance and motivation in instructional
videogames. Computers in Human Behavior, 24, 24152433.
Pascual-Leone, A. et al. (2005). The plastic human brain cortex. Annual Review of
Neuroscience, 28, 377401.
Quinlan, R. (1993). C4.5: Programs for machine learning. San Mateo, CA: Morgan
Kaufmann Publishers.
Rego, P., Moreira, P. M. & Reis, L. P. (2010). Serious games for rehabilitation a survey
and a classication towards a taxonomy. In Information systems and technologies
(CISTI) (pp. 16).
Rohling, M. L., Faust, M. E., et al. (2009). Effectiveness of cognitive rehabilitation
following acquired brain injury: A meta-analytic re-examination of Cicerone
et al.s (2000, 2005) systematic reviews. Neuropsychology, 23(1), 2039.
Serra, J., Arcos, J. Ll., Garcia-Rudolph, A., Garca-Molina, A., Roig, T., & Tormos, J. M.
(2013). Cognitive prognosis of acquired brain injury patients using machine
learning techniques. In International conference on advanced cognitive
technologies and applications (COGNITIVE), IARIA (pp. 108113). Valencia, Spain.
Sohlberg, M. M. (2001). In A. Mateer (Ed.), Cognitive rehabilitation. An interactive
neuropsychological approach. Catherine. ISBN: 9781572306134.
Tormos, J. M., Garcia-Molina, A., Garcia Rudolph, A., & Roig, T. (2009). Information
and communications technology in learning development and rehabilitation.
International Journal of Integrated Care, 9. 22 June, ISSN 1568-4156.
Vygotsky, L. S. (1934). Dinamika umstvennogo razvitiia shkolnika v sviazi s
obucheniem. In Umstvennoe razvitie detei v protsesse obucheniia (pp. 3352).
Gosuchpedgiz: Moscow-Leningrad.
Vygotsky, L. S. (1978). Mind and society: The development of higher mental processes.
Cambridge, MA: Harvard University Press.
Walsh, R. S., Donal, G., Stephen, G., & Muldoon, T. (2012). Acquired brain injury:
Combining social psychological and neuropsychological perspectives. Health
Psychology Review.
Whalen, S. (1998). Revisiting the problem of match. In N. Colangelo, S. Assouline
(Eds.), Proceedings from the Henry B. and Jocelyn Wallace national research
symposium on talent development.
Whyte, J., & Hart, T. (2003). Its more than a black box; its a Russian doll: Dening
rehabilitation treatments. American Journal of Physical Medicine and
Rehabilitation, 82, 639652.
Witten, I. H., & Frank, E. (2005). Data mining: Practical machine learning tools and
techniques (3rd ed.). The Morgan Kaufmann series in data management systems.
Please cite this article in press as: Garca-Rudolph, A., & Gibert, K. A data mining approach to identify cognitive NeuroRehabilitation Range in Traumatic
1260
1261
1262
1263
1264
1265
1266
1267
1268
1269
1270
1271
1272
1273
1274
1275
1276
1277
1278
1279
1280
1281
1282
1283
1284
1285
1286
1287
1288
1289
1290
Q9 1291
Q101292
1293
1294
1295
1296
1297
1298
1299
1300
1301
1302
1303
1304
1305
1306
1307
Q111308
1309