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Accessible and Assistive ICT

VERITAS
Virtual and Augmented Environments and Realistic User Interactions To
achieve Embedded Accessibility DesignS
247765
Abstract physical models definition

Deliverable No. D1.3.1

SubProject No. SP1 SubProject Title User Modelling

Workpackage No. W1.3 Workpackage Title Physical Models

Activity No. A1.3.2 Activity Title Existing Rules From


SoA and Standards

Authors Mauro Da Lio, Alberto Paludet (UNITN) Nicola


Cofelice (LMS), Eleni Chalkia (CERTH/HIT), Villy
Portouli (BYTE), Francesco Palma (CRF) Dimitrios
Tzovaras, Konstantinos Moustakas (CERTH/ITI).

Status (F: final; D: draft; RD: revised F


draft):

File Name: VERITAS_D1.3.1_v9_5.doc

Project start date and duration Start date: month 1; duration: 36 months

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Version History table


Version no. Dates and comments

1 18 March 2010; First version prepared by UNITN.

2 17 June 2010; Second version, edited by UNITN.

3 1 July 2010; Third version, edited by LMS.

4 1 September 2010; Contributions of BYTE and CERTH/HIT inserted by UNITN.

5 9 September 2010; Fifth version, edited by UNITN.

6 12 November 2010; Sixth version, edited by UNITN. Revised prioritization.

7 18 November 2010; Seventh version, edited by UNITN. Extended disease list in the
ICD-10 block.

8 24 December 2010; Final version for peer review by UNITN. Completed data
for all disabilities, including elderly and ICD-10 G block.

9 20 January 2011; Final version by UNITN. Included peer review comments and
other improvements.

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Table of Contents

Executive summary......................................................................................................................... 7
1. Spectrum and priority of diseases ............................................................................................ 8
1.1. Prioritization of motor diseases .......................................................................................... 8
1.2. Prioritization of visual diseases ........................................................................................ 10
1.3. Prioritization of speech diseases...................................................................................... 11
1.4. Prioritization of hearing diseases ..................................................................................... 12
1.5. Data storage table ........................................................................................................... 13
2. Metrics ................................................................................................................................... 15
2.1. Metrics for motor impairments ......................................................................................... 15
2.2. Metrics for visual impairments ......................................................................................... 17
2.3. Metrics for speech impairments ....................................................................................... 17
2.4. Metrics for hearing impairments ....................................................................................... 18
3. Literature review about able-bodied people ............................................................................ 19
3.1. Anthropometric data ........................................................................................................ 19
3.2. Mobility of the body .......................................................................................................... 31
3.3. Strength Data .................................................................................................................. 33
3.4. Dexterity/control data ....................................................................................................... 36
3.4.1. Fitts law. ................................................................................................................... 36
3.4.2. Gait metrics ............................................................................................................... 38
3.5. Other miscellaneous data ................................................................................................ 39
4. Literature review about disabled people ................................................................................. 43
4.1. Literature review about motor impairments ...................................................................... 43
4.1.1. Rheumatoid arthritis .................................................................................................. 43
4.1.2. Gout .......................................................................................................................... 48
4.1.3. Kyphosis and lordosis ............................................................................................... 48
4.1.4. Ankylosing spondylitis ............................................................................................... 51
4.1.5. Hand Osteoarthirtis (incl. arthrosis of first carpometacarpal joint) .............................. 55
4.1.6. Gonarthrosis (osteoarthritis of the knee).................................................................... 56
4.1.7. Coxarthrosis (osteoarthritis of the hip) ....................................................................... 58
4.1.8. Shoulder adhesive capsulitis ..................................................................................... 58
4.1.9. Parkinsons disease .................................................................................................. 60
4.1.10. Dystonia .................................................................................................................. 64
4.1.11. Multiple sclerosis ..................................................................................................... 67

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4.1.12. Cerebral palsy ......................................................................................................... 71


4.1.13. Hereditary and idiopathic neuropathies ................................................................... 82
4.1.14. Stroke ..................................................................................................................... 86
4.1.15. Elder people ............................................................................................................ 91
4.2. Literature review about visual impairments ...................................................................... 98
4.2.1. Senile or age related macular degeneration .............................................................. 98
4.2.2. Diabetic retinopathy .................................................................................................. 99
4.2.3. Glaucoma................................................................................................................ 100
4.2.4. Color vision deficiencies .......................................................................................... 102
4.3. The experts opinion ...................................................................................................... 103
5. The abstract user model....................................................................................................... 105
5.1. The abstract user model for motor impairments ............................................................. 105
5.2. The abstract user model for visual impairments ............................................................. 183
5.3. The abstract user model for speech impairments .......................................................... 195
5.4. The abstract user model for hearing impairments .......................................................... 202
6. Conclusions ......................................................................................................................... 207
B.1. Description of the metrics of motor impairments ............................................................... 222
B.1.1. Gait parameters ......................................................................................................... 222
B.1.2. Upper body parameters ............................................................................................. 223
B.1.3. Lower body parameters ............................................................................................. 226
B.1.4. Strength parameters .................................................................................................. 226
B.1.5. Dexterity/control parameters ...................................................................................... 228
B.1.6. Other parameters....................................................................................................... 230
B.2. Description of the metrics of visual impairments ............................................................... 231
B.2.1. Visual acuity assessment........................................................................................... 231
B.2.2. Visual field assessment ............................................................................................. 233
B.2.3. Contrast sensitivity assessment ................................................................................. 235
B.2.4. Glare sensitivity assessment ..................................................................................... 237
B.2.5. Color vision defects ................................................................................................... 238
B.3. Description of the metrics of speech impairments ............................................................ 239
B.3.1. Percentage of consonants correct (PCC) ................................................................... 240
B.3.2. Articulation Competence Index (ACI) ......................................................................... 242
B.4. Description of the metrics of hearing impairments ............................................................ 243
Annex C ...................................................................................................................................... 247
C.1. Task analysis ................................................................................................................... 247

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Executive summary
This document describes the abstract physical model of VERITAS. This means sets of disease-
related parameters and data that are abstract, i.e., independent of the actual modelling technique
that will have to be later used to produce virtual users.
Abstract data and parameters describe functional limitations. They have to be useful for the
production of virtual users, which means that they must be easy to map onto the parameters of the
specific model implementations. For this reason, data that are reported in this document are
quantitative objective and measurable indices. We mention also medical scales that can be found
in the literature, however these scales were developed for rating the severity of the disease and
are of little usefulness for developing virtual human beings with modelled disabilities.

We can roughly divide abstract data and parameters into two groups: the first group collects
parameters that can be mapped on the models in a straightforward fashion. For example: the
range of motion of joints. The second group collects parameters that need identification methods to
be transformed into models. For example the spiral test is a task related test, which measures
performance of people affected by Parkinsons disease. A virtual user with Parkinsons disease will
include some internal parameters (e.g. in the control patterns) that have to be tuned to reproduce
the spiral test. Nonetheless the spiral test is quantitative and thus tuning is possible.

In section number 1 we provide a prioritization of diseases, focusing on the most frequent ones.
For motor impairments we focused on 9 disease of the ICD 10 M block (with arthritis the most
important), 5 disease of the G block (including Parkinsons, Cerebral Palsy and Multiple Sclerosis),
1 of the I block (stroke). For visual impairments we focus on 4 pathologies of the H block; for
speech impairments 5 of the F_H_R blocks; for hearing impairments 4 of the H block.
In section 2 we introduce the metrics, i.e., a collection of measurable indices for the
characterization of each disability. In annex B.1 a detailed description of each index is given.
Indices can be summarized in groups related to Gait, upper limbs, lower limbs, torso, strength and
dexterity-control. The latter group (dexterity-control) is almost always made of task-related
performance indicators.
In section 3 we give the indicators for able-bodied people (including anthropometric data).
In section 4 we give a detailed description of each disease, including a section for elder people,
and focusing on abstract modelling parameters.
In section 5 the abstract parameters and data are summarized in a table form.
Annexes report additional information like the prioritization tables (Annex A) and detail description
of metrics (Annex B).

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1. Spectrum and priority of diseases


There is a wide spectrum of diseases that can cause some kind of physical impairment in people.
These range from diseases of the nervous system to diseases of the musculoskeletal system and
connective tissues.

We organize physical impairments in four broad categories:


1) motor impairments;
2) visual impairments;
3) speech impairments;
4) hearing impairments.

The activity presented here (project activity A1.3.2) aims at defining and characterizing disabled
users by means of numerical values for specific parameter sets that model the disability.
A literature review is carried out to obtain the data about physical and motor impairments (in this
manner it is possible to characterize the disabled users and the relative pathologies).

1.1. Prioritization of motor diseases


The World Health Organization (WHO) [1] endorsed a classification of various diseases and other
health problems, called International Classification of Disease (ICD). From an overview of this
classification, it is clear that the number of disability types is very large. In addition, the category of
older people needs to be also considered. This is a transversal class, which, besides general aging
effects, can include one or more of the above diseases.
It is convenient to focus on a relatively small group of important pathologies, which have to be
considered with priority for the simulations and hence for the literature review. Thus, to define
which kinds of users have to be considered, the tables in Annex A.1 have been completed.
According to an Irish study [2], the causes of motor disabilities are due to illness and disease
(45%), Hereditary and Genetic (10%), Accidents, Injuries etc. (16%) and other causes (see graph
D1.3 od the cited paper).
Among the 45% due to illness, the most frequent ones are (see Figure 1.1):
Multiple sclerosis;
Cerebral palsy;
Stroke;
Arthritis (all forms);
Heart conditions.

Considering the above, we have put most of the efforts analyzing some blocks and diseases of the
ICD, which corresponds to most mobility problems due to illness and to some hereditary and
genetic causes. In particular we focused on the following blocks:
Block G: diseases of the nervous system;
Block M: diseases of musculoskeletal system and connective tissue.
Block I: Stroke.

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The other blocks such as the block S (Injury, poisoning and certain other consequences of external
causes) and the block Q (Congenital malformations, deformations and chromosomal
abnormalities) havent been considered.
We believe that coverage of M and G blocks, with associated kinematic, dynamic and control
related limitations (see below) indirectly covers also other types of functional limitations that can be
associated with the neglected causes.

Figure 1.1 Illness reported as the cause of Mobility and Dexterity disability

Prioritization tables.
The tables reported in Annex A.1 give the prioritization of various pathologies (taken from ICD
classifications) and includes:
diseases of the musculoskeletal system and connective tissues: these disorders directly
concern problems of some body parts (joints, muscles, tendons, etc);
diseases of the nervous system: these disorders concern problems at the motor control
level, but they have an important influence in the task that a certain body part have to
accomplish.
For the prioritization, the relative importance of every disease has been defined. First of all, data on
prevalence (how many people are affected in a specific population) of every disease was found
(Annex A.1). This parameter is indicative, because, for every pathology, it refers to different
countries, depending on the data found in the literature.
By the number of people affected in a population, it is possible to establish the relative importance
of the disease compared with the others.
The prioritization was accomplished block by block (i.e., the prioritization of each M, G, block is
independent from the other one). Each disease was assigned either high priority (marked with the
letter H) or low priority (marked with the letter L). The criterion used to establish the priority is
based on a threshold: if a pathology has a prevalence lower than 10% of the most frequent one,
then the disease is not taken into account.
From the completed column Priority of the tables in Annex A.1, it is possible to understand where
to put more efforts. For example, the pathologies with high priority (marked with the letter H)
indicate the types of disabilities that need to be characterized with the best accuracy.

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Annex A.1 report the tables for this prioritization. In Table 1.1, Table 1.2 and Table 1.3 the
pathologies with the highest priority levels for G, I and M blocks respectively are summarized.

Table 1.1 Pathologies of G block with the highest priority value


ICD 10 Code Pathology
G20 G22 Parkinsons Disease
G24 Dystonia
G35 Multiple Sclerosis
G60 Hereditary and idiopathic neuropathy
G80 G83 Cerebral Palsy

Table 1.2 Pathologies of I block with the highest priority value


ICD 10 Code Pathology
I64 Stroke

Table 1.3 Pathologies of M block with the highest priority value


ICD 10 Code Pathology
M05 M06 Rheumatoid Arthritis
M10 Gout
M16 Coxarthrosis (osteoarthritis of the hip)
M17 Gonarthrosis (osteoarthritis of the knee)
M18 Arthrosis of First Carpometacarpal Joint (hand osteoarthritis)
M40 Kyphosis and lordosis
M45 Ankylosing spondylitis
M50 M51 Cervical disc disorders and other intervertrebal disc disorders

In order to further reduce the number of diseases of the M block, cervical disc disorders (M50-51)
will not be studied in section 4. Conversely, data for Shoulder Adhesive Capsulitis, are reported
because they had already been collected before exclusion form the priority lists.

1.2. Prioritization of visual diseases


Using the classification of the International Statistical Classification of Diseases and Related Health
Problems 10th Revision (ICD-10) version 2007, the diseases pointed out in the table of Annex A.2
of the eye, which affect vision, are considered as relevant for the VERITAS project.

Infectious diseases, inflammatory conditions, conditions resulting as symptoms from other causes,
scars, injuries and as complications of surgeries are excluded.

In order to select the diseases for consideration in VERITAS, an algorithm has been implemented
based on three criteria. The reason for that is the prevalence alone is not enough to characterize a
visual disease. For example, refractory errors are very common, but they can be easily treated by
the prescription of glasses or contact lenses. Therefore, three criteria have been considered,
instead of just the prevalence, as follows. The criteria and the corresponding qualitative ratings are:
extent of visual impairment caused by the disease (light, moderate or severe);
prevalence of disease, that is frequency of occurrence in the population (rare or not rare);
availability of treatment (yes or no).
The priority of the disease for VERITAS is calculated according to the following algorithm:

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IF
Availability of treatment = YES
THEN
Priority = LOW
ELSE
IF Prevalence = RARE
THEN
Priority = LOW
ELSE
IF Extent of Impairment = MODERATE OR SEVERE
THEN
Priority = HIGH

According to the analysis, the conditions that are of priority HIGH for VERITAS are the Senile
macular degeneration, the Diabetic retinopathy, Glaucoma and Colour vision deficiencies.

Table 1.4 Pathologies of H block with the highest priority value


ICD 10 Code Pathology
H35.3 Senile macular degeneration
H36.0 Diabetic retinopathy
H40 Glaucoma
H53.5 Colour vision deficiencies

Indeed, according to the World Health Organization, in the middle income and industrialized
countries three eye conditions are the main threats for visual impairment. These conditions are
diabetic retinopathy, due to the increase of diabetes incidence among several population groups,
glaucoma which can not be easily diagnosed at an early state and often requires life long treatment
and senile or age-related macular degeneration, which is the primary cause of visual deficiency in
industrialized countries.
Colour vision deficiencies usually do not interfere significantly with daily activities. In some
vocational settings, the impact of minor colour vision deficiencies can be significant. This is the
case of VERITAS project, where colour may be used to convey information, so impairments
caused by colour vision defects should be considered.

1.3. Prioritization of speech diseases


According to the Telaid project, 10% of the disabled population suffers from speech disorders [3].
While the Australian Bureau of Statistics (ABS) estimates that at least 2% of Australians have a
speech disability including difficulties in pronunciation of sounds, projection and fluency problems
[4].
At the same time the New York Times state that disfluencies are from the rhythm disorders that are
usually characterized by the repetition of a sound, word, or phrase stuttering is perhaps the most
serious one.
The data from the National Institute on Deafness and Other Communication Disorders (NIDCD) of
USA come to verify the aforementioned. According to NIDCD, approximately 7.5 million people in
the United States have trouble using their voices and more than 15 million individuals in the world
stutter, most of who began stuttering at a very early age [5].
Because the speech pathologies aren't many, the prioritization could be neglected.

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The Table 1.5 reports the speech diseases considered in the analysis.

Table 1.5 Speech pathologies considered in the analysis


ICD 10 Code Pathology
F98.5 Stuttering
F98.6 Cluttering
H91.3 Muteness no speech
R47.0 Dysarthria
R48.2 Apraxia of speech

1.4. Prioritization of hearing diseases


Hearing impairment is difficult to be statistically defined among the population and this is why we
can find a wide range of results worldwide. Also there are different ways of identifying the hearing
impairment. In some cases they use stage of deafness; in other cases they use types of disability.
This can lead to false or corrupted data. In this chapter data form worldwide known and certified
organizations about disability and hearing impairments are presented, which give a picture of the
hearing impairments situation in US, EU and worldwide.
In USA, statistics are primarily maintained by two Federal agencies: The National Centre for Health
Statistics (NCHS) [6], which is under the Centers for Disease Control (CDC) [7], and the U.S.
Census Bureau [8].
The estimated demographic figure from these organizations has ranged from 22 million deaf and
hard of hearing to as high as 36 million deaf and hard of hearing, which means approximately 15%
of the whole USA population. Of these, only a few million are considered "deaf" and the remainder
is hard of hearing. Further muddying statistics is the fact that some "deaf" people may actually be
hard of hearing, and some "hard of hearing" people may actually be deaf. While most people with
hearing loss are elderly who have lost hearing with age, approximately 12 out of every 1,000
persons with hearing impairment in USA is under 18 years of age, based on the most recently
available NCHS statistics [9].
In Europe, Eurostat is the major statistical organization that includes all kind of statistical data, and
also statistical data about disabilities. From Eurostat document Statistics in Focus of 2002,
Employment of disabled people in Europe in 2002, we can see that 2.1% of all disabled
population suffer from difficulties in hearing in EU 15 [10].
Worldwide, the most well-known and active organization is the World Health Organization (WHO).
WHO recognizes that only in Europe, about 71 million adults aged 18 to 80 years have a hearing
loss greater than 25 dB [11]. According to 2005 estimates by the World Health Organization, about
278 million people worldwide had moderate to profound hearing impairment of which 80% of them
live in low-and middle-income countries.
Specifically in Europe, WHO states that there are 10.2 million hearing impaired people in Germany,
7.6 million in France, 7.2 million in Spain, 4.7 million in Poland and 2 million in Netherlands. In the
UK, the Royal National Institute for Deaf People, RNID, has found that there are 8.7 million deaf
and hard of hearing people.
In North America the figure is estimated at around 35 million. In developing countries the burden of
hearing impairment is estimated to be twice as large as in developed countries, probably because
of a lot of untreated ear infections. At the same time, in the developed countries, people suffer from
hearing loss at younger and younger ages primarily due to the increased exposure to excessive
noise.

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If one has a hearing loss, the odds are such that he probably has a sensorineural loss.
Sensorineural hearing loss (SNHL) accounts for about 90% of all hearing loss. If we do the math,
90% of 8% of the population with a hearing loss works out to about 7% of the population. Recently
there has been an attempt to separate "sensorineural" into "sensory" and "neural" types. However,
for the most part, the mixed term "sensorineural" is used.
In conductive hearing loss, the second most common form of hearing loss, sound is not transmitted
into inner ear. If we do the math again, as only 8% of the population has a hearing loss at all, and
90% of them are sensorineural, this means that only 0.8% of the population has a conductive
hearing loss. An example of conductive hearing loss is plugging up of the ear by ear wax. Other
things that cause conductive hearing losses are fluid in the middle ear, and disorders of the small
bones (ossicles) in the middle ear.
However, the actual severity of hearing loss is measured as follows:
Mild Hearing Loss
Moderate Hearing Loss
Severe Hearing Loss
Profound Hearing Loss
The explanation of each of the aforementioned terms will be explained at the following chapter.
The National Disability Survey of Ireland for 2006, showed that from all the population with hearing
disability, 61% reported a moderate level of difficulty, 36% severe level of difficulty and 3% could
not hear at all.
The Table 1.6 reports the hearing diseases considered in the analysis.

Table 1.6 Hearing pathologies considered in the analysis


ICD 10 Code Pathology
Conductive hearing loss, bilateral, unilateral with unrestricted
H90.0-H90.2
hearing on the contralateral side or unspecified
Sensorineural hearing loss, bilateral, unilateral with
H90.2-90.5
unrestricted hearing on the contralateral side or unspecified
Mixed hearing loss conductive and sensorineural hearing
H90.6-H90.8 loss, bilateral, unilateral with unrestricted hearing on the
contralateral side or unspecified
H91.9 Hearing loss, unspecified

1.5. Data storage table


For the purpose of the project parameters and data to build the Abstract user model have to be
defined.
These can be conveniently stored in an appropriate data structure, which is represented by the
table Disability Category reported in section 5.
The columns of the tables have the following meaning:
Disability Category: it represents the category of the impairment. Motor, visual, speech
and hearing are possible entries.
Block: it concerns a family of diseases with some similar characteristics;
Code and Pathology: it reports a sub-class of each block, with more specific pathologies;
Description: a short description of disease and its symptoms;
Priority: it is a qualitative value that represents the importance of each disease in
modelling phase. In VERITAS, we will consider only the pathologies with an high degree of
priority;

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Age related: it establishes if a disease is related to the age (progressive) or not;


Functional limitations: it reports the limitations caused by the disease, according to the
ICF classification of the WHO;
Quantitative disability metrics: this columns-group reports various parameters, which
values can potentially be required to define the user model. The columns of this group are:
o Type: it includes a group of parameters that describe a specific part/function of the
human body;
o Parameter: for every type, this column reports a series of associated parameters;
o Value: the specific numeric value (mean and standard deviation) of the considered
parameter from literature data.

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2. Metrics
2.1. Metrics for motor impairments
Taxonomy of motor impairments. A broad classification of motor impairments is given in the
following. This classification discriminates functional aspects, which, in turn, call for different
metrics (and later different modelling methods).

1) Kinematics functional limitations. Reduction in mobility of joints, velocity of joints,


(possibly geometry of joints and bones) and ultimately reach and dexterity abilities.
2) Dynamics functional limitations. Reduction in muscle strength and ultimately the ability
to produce useful forces.
3) Control Functional limitation. Neuromuscular deficiencies, which ultimately results in
difficulty of controlling movements.

Kinematics functional limitations arise mostly from reduction of joint range of motion (M block) or
from reduction in joint speed (G block). These limitations are easily described by range and speed
limitations of joint parameters. Joint range/speed are for the most part directly observable and they
will be later easy to map onto parameters of the chosen simulation models (e.g., shoulder
abduction can be measured, and transformed into parameters for the articulated kinematic chains
of simulation manikins). However not all joints can be observed: for example rotations of single
spine joints is not (easily) observable. Only the overall displacements are easy to measure and to
find in the literature. In addition kinematic data are not sufficient for reach analysis. In facts where
several different postures exist for the same reach, criteria for selection of the most likely posture
are also necessary (see ID1.3.2).
Aside from the range of motion and speed of joints, there might also be deformities of joints and
links (bones). These can be, in principle, modelled with parameters that describe the spatial
position of successive joints in the kinematic chain, as for example the Denavit-HartenBerg
notation [394,395].

Dynamics functional limitations means reduced muscle forces (M block) or reduced muscle control
(G block). Muscle forces cannot be easily observed directly. In facts, what can be measured is the
force applied by limbs (hands, feet, etc.). These have to be converted into joint parameter (forces
of single muscles) by means of some identification techniques. However the identification
technique is in principle quite easy for forces (it calls for an inverse dynamic analysis).

Control functional limitations are caused by deficiencies of motor neurons in any point of the chain
that goes from motor cortex to cerebellum to spine and to muscles. Such deficiencies can be
measured by task performance indices (as an example the gait parameters). In turn, depending on
the modelling techniques used, proper model parameters have to be found to reproduce such
performance indices.

According to the picture above, kinematic limitations are the easiest to observe, model and those
for which data (although incomplete) close to modelling need are more abundant and available.
Conversely, control deficiencies are more difficult to observe, are related to specific task and are
more difficult to map onto parameters of the simulation models.

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The metrics of motor impairments have been defined, partly from the contributuion of ID1.3.1
(kinematics) and partly here.
Basically we have the following groups of metrics::
Gait parameters;
Upper body kinematic parameters;
Lower body kinematic parameters.
Torso kinematic parameters;
Strength parameters
Dexterity and control, task-related, performance indicators.

Table 2.1 summarizes the most relevant metrics for motor impairments. Additional metrics used in
relation with specific disabilities (e.g. dexterity tests, clinical scales, etc.) are given in chapter 4
under the specific disability section. Additional explanations of each metrics for motor impairments
are given in Annex B.1.

Table 2.1 Most relevant metrics of motor impairments


(additional disease-specific indicators are given in chapter 4).
Parameter Unit
Step length m
Step width m
Stride length m
Gait parameters
Gait cycle time s
Cadence steps per minute or Hz
Velocity cm/s
Neck rotation rad
Neck extension rad
Neck lateral bend rad
Shoulder horizontal adduction/abduction rad
Shoulder rotation rad
Upper body parameters Shoulder flexion/extension rad
Elbow flexion/extension rad
Forearm supination/pronation rad
Wrist ulnar bend/radial bend rad
Wrist flexion/extension rad
Joint angular velocity for each of the above rad/s
Plantar flexion/dorsiflexion rad
Knee flexion rad
Hip flexion/extension rad
Lower body parameters
Hip adduction/abduction rad
Foot rotation rad
Joint angular velocity for each of the above rad/s
Sagittal flexion of torso rad
Torso parameters Lateral flexion of torso rad
Torsion of torso rad
Joint net-torque (for each of the above
Nm
joints)
Ligament force N
Muscle force N
Pull force N
Strength parameters Push force N
Up force N
Down force N
In force N
Out force N
Hand grip N

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Parameter Unit
Thumb-finger grip (palmer) N
Thumb-finger grip (tips) N
Torque strength supination Nm
Torque strength pronation Nm
Point to point motion tasks
Reaction time s
Movement time s
Path deviation in point to point motion mm or %
Movement speed m/s
Jerk m/s^3
Continuous tracking tasks
Percentage time in target (PTT) %
Dexterity/control Root Mean Square Error (RMSE) mm
Deviation to trajectory mm
Mean speed mm/s
Standard deviation speed mm/s
Mean error to hold the position mm
Standard deviation of holding position mm
Fittss law
a ms
b ms

2.2. Metrics for visual impairments


Visual skills assessment currently involves the assessment of:
Visual Acuity the ability to perceive details presented with good contrast;
Visual Field the ability to simultaneously perceive visual information from various parts of
the environment.
Measurement techniques for these two abilities have been well established and standardized.
Other visual functions that should be assessed are:
Contrast Sensitivity the ability to perceive patterns of poor contrast. Loss of this ability
can interfere significantly with many daily activities.
Glare sensitivity, including delayed Glare recovery, Photophobia and reduced or delayed
Light and Dark Adaptation are other functions that may interfere with proper contrast
perception.
Color vision deficiencies
Standardized measurement techniques have not yet been developed for all of these functions.
One can find a more complete explanation of these metrics in Annex B.2.

Table 2.2 Metrics of visual impairments


Metrics for visual impairments
Visual acuity
Visual field
Contrast sensitivity
Glare sensitivity
Color vision deficiencies

2.3. Metrics for speech impairments


The speech analysis is complex and has been disregarded for a long time. The speech disorders
are very personalized disabilities so the metrics used for their assessment are quite vague and the

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methods are empirical. The task is complex due to the inherent variability of the speech signal,
which varies for a given word both between speakers and for multiple utterances by the same
speaker. Indeed, many studies don't return specific analysis of the speech.
An issue is the diagnosis of the speech impairment, which is primarily based on the criteria severity
of involvement and pattern. Severity of involvement is often used to establish the need for
articulation and phonological treatment. Unfortunately, severity is determined differently by
counties, school districts, and sometimes even by clinicians in the same clinical setting, leading to
situations in which a patient might be deemed eligible for articulation and phonological services in
one community but not in another. Severity of articulation and phonological involvement is
measured by various means, each with its own strengths and limitations. Clinical judgment scales,
the most widely used severity assessment instruments, are simple and quick to use, but are highly
subjective. The best-researched procedure is the PCC, which is intended primarily for use with
clients with multiple substitutions and deletions. The value of the PCC is limited somewhat by its
dependence on spontaneous speech samples, which makes its use problematic in clinical settings
that cannot afford the time needed for data collection and analysis.
The ACI is a new measure of severity intended for use with people whose speech contains many
distortions. A limitation of the ACI is that, as its author notes, reliable data access do not exist to
identify various types of distortions [12].
As with the PCC, the ACI requires a spontaneous speech sample, which limits its potential
usefulness in clinical settings that cannot afford the time needed to perform data collection and
analysis. Percentage of development offers a relatively quick means to calculate severity, using
information that is obtained as part of the evaluation. The developmental theory, on which the
calculation is based, however, seems somewhat odd, because it is probably more accurate to say
that a personss speech is similar to a younger childs speech in some respects rather than saying
that the clients speech is a certain percentage younger than a childs chronological age.
Percentage of development also appears to ignore individual differences in childrens rate of
articulation and phonological development.
The metrics are summarized in Table 2.3.
A more detailed explanation of PCC and ACI indexes is given in the Annex B.

Table 2.3 Metrics of speech impairments


Metrics for speech impairments
PCC (Percentage of Consonants Correct)
ACI (Articulation Competence Index)

2.4. Metrics for hearing impairments


For hearing impairments the audiogram is a good indicator: it reports the hearing level in Decibels
versus the frequency of the signal.
The metric is summarized in Table 2.4.

Table 2.4 Metrics of hearing impairments


Metrics for hearing impairments
Decibel as function of Frequency

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3. Literature review about able-bodied people


This section deals with the anthropometric characterization of a person. Not all the disabilities
cause variations on the body structure of a person. Instead, it is common that pathologies affect
the functionality of the body, such as the range of motion of joints or the muscle strength. In this
case the difference between an able-bodied individual and a disabled subject may be restricted
only to the values of the parameters that define the model sharing the same underlying structure.
In other words, the same model could theoretically represent both kinds of people in a continuum
fashion, in the cases where a disease affects the functionality and not the anthropometry of a
subject.
Thus, the first step is here the definition of typical anthropometric data.

3.1. Anthropometric data


In this paragraph, anthropometric data for able-bodied people is given. The documentation
reported in the tables below has been extracted from [13]. The following pictures shows the body
dimensions, with the relative ID code. The tables report data (in cm or inch) for each ID code.

Figure 3.1 Body-size of 40-year-old Japanese female for year 2000 part 1

Table 3.1 - Body-size of 40-year-old Japanese female for year 2000 part 1
Notes No. Dimension 5th Percentile cm 50th Percentile cm 95th Percentile cm
(inches) (inches) (inches)
1 805 Stature 148.9 (58.6) 157.0 (61.8) 165.1 (65.0)
1 973 Wrist height 70.8 (27.9) 76.6 (30.2) 82.4 (32.4)
64 Ankle height 5.2 (2.0) 6.1 (2.4) 7.0 (2.8)
1 309 Elbow height 92.8 (36.5) 98.4 (38.8) 104.1 (41.0)
169 Bust depth 17.4 (6.8) 20.5 (8.1) 23.6 (9.3)
1 916 Vertical trunk circumfrence 136.9 (53.9) 146.0 (57.5) 155.2 (61.1)
1, 2 612 Midshoulder height, sitting
459 Hip breadth, sitting 30.4 (12.0) 33.7 (13.3) 37.0 (14.6)
1 921 Waist back 35.2 (13.9) 38.1 (15.0) 41.0 (16.1)
506 Interscye 32.4 (12.8) 35.7 (14.1) 39.0 (15.4)
639 Neck circumfrence 34.5 (13.6) 37.1 (14.6) 39.7 (15.6)
754 Shoulder length 11.3 (4.4) 13.1 (5.1) 14.8 (5.8)
General Notes:
(a) Gravity conditions the dimensions apply to a 1G condition only. Dimension expected to change
significantly due to microgravity are marked.
(b) Measurement data the number adjacent to each of the dimension are reference codes. The same codes

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Notes No. Dimension 5th Percentile cm 50th Percentile cm 95th Percentile cm


(inches) (inches) (inches)
are in NASA RP 1024, Volume 2. NASA RP 1024, Volume 2 provides additional data for these measurements
plus an explanation of the measurement technique.
Notes for application of dimensions to microgravity conditions:
(1) Stature increases approximately 3 percent over the first 3 to 4 days in weightlessness (See
NASASTD3000, Volume I, Figure 3.2.3.12, for information). Almost all of this change appears in the
spinal column and thus affects (increases) other related dimensions, such as sitting height (buttockvertex),
shoulder height sitting, eye height, sitting, and all dimensions that include the spine.
(2) Sitting height would be better named as buttockvertex in microgravity conditions, unless the crewmember
were measured with a firm pressure on shoulders pressing him or her against a fixed, flat sitting support
surface. All sitting dimensions (vertex, eye, shoulder, and elbow) increase in weightlessness by two
changes:
(a) Relief of pressure on the buttock surfaces (estimated increase of 1.3 to 2.0 cm (0.5 to 0.8 inches).
(b) Extension of the spinal column as explained in note (1) above (3 percent of stature on ground).

Figure 3.2 Body-size of 40-year-old American male for year 2000 part 1

Table 3.2 - Body-size of 40-year-old American male for year 2000 part 1
5th Percentile cm 50th Percentile cm 95th Percentile cm
Notes No. Dimension
(inches) (inches) (inches)
1 805 Stature 169.7 (68.8) 179.9 (70.8) 190.1 (74.8)
1 973 Wrist height
64 Ankle height 12.0 (4.7) 13.9 (5.5) 15.8 (6.2)
1 309 Elbow height
169 Bust depth 21.8 (8.6) 25.0 (9.8) 28.2 (11.1)
1 916 Vertical trunk circumfrence 158.7 (62.5) 170.7 (67.2) 182.6 (71.9)
1, 2 612 Midshoulder height, sitting 60.8 (23.9) 65.4 (25.7) 70.0 (27.5)
459 Hip breadth, sitting 34.6 (13.6) 38.4 (15.1) 42.3 (16.6)
1 921 Waist back 43.7 (17.2) 47.6 (18.8) 51.6 (20.3)
506 Interscye 32.9 (13.0) 39.2 (15.4) 45.4 (17.9)
639 Neck circumfrence 35.5 (14.0) 38.7 (15.2) 41.9 (16.5)
754 Shoulder length 14.8 (5.8) 16.9 (6.7) 19.0 (7.5)
378 Forearmforearm breadth 48.8 (19.2) 55.1 (21.7) 61.5 (24.2)
General Notes:
(a) Gravity conditions the dimensions apply to a 1G condition only. Dimension expected to change
significantly due to microgravity are marked.
(b) Measurement data the number adjacent to each of the dimension are reference codes. The same codes are
in NASA RP 1024, Volume 2. NASA RP 1024, Volume 2 provides additional data for these measurements
plus an explanation of the measurement technique.
Notes for application of dimensions to microgravity conditions:
(1) Stature increases approximately 3 percent over the first 3 to 4 days in weightlessness (See

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5th Percentile cm 50th Percentile cm 95th Percentile cm


Notes No. Dimension
(inches) (inches) (inches)
NASASTD3000, Volume I, Figure 3.2.3.12, for information). Almost all of this change appears in the
spinal column and thus affects (increases) other related dimensions, such as sitting height (buttockvertex),
shoulder height sitting, eye height, sitting, and all dimensions that include the spine.
(2) Sitting height would be better named as buttockvertex in microgravity conditions, unless the crewmember
were measured with a firm pressure on shoulders pressing him or her against a fixed, flat sitting support
surface. All sitting dimensions (vertex, eye, shoulder, and elbow) increase in weightlessness by two
changes:
(a) Relief of pressure on the buttock surfaces (estimated increase of 1.3 to 2.0 cm (0.5 to 0.8 inches).
(b) Extension of the spinal column as explained in note (1) above (3 percent of stature on ground).

Figure 3.3 - Body-size of 40-year-old Japanese female for year 2000 part 2

Table 3.3 - Body-size of 40-year-old Japanese female for year 2000 part 2
5th Percentile cm 50th Percentile cm 95th Percentile cm
Notes No. Dimension
(inches) (inches) (inches)
1, 2 758 Sitting height 78.3 (30.8) 84.8 (33.4) 91.2 (35.9)
1, 2 330 Eye height, sitting 68.1 (26.8) 73.8 (29.1) 79.8 (31.4)
4 529 Knee height, sitting 41.6 (16.4) 45.8 (16.4) 49.5 (19.5)
678 Popliteal height 34.7 (13.6) 38.3 (15.1) 41.9 (16.5)
751 Shoulderelbow length 27.2 (10.7) 29.8 (11.7) 32.4 (12.8)
184 Buttockknee length 48.9 (19.2) 53.3 (21.0) 57.8 (22.7)
420 Hand length 15.8 (6.2) 17.2 (6.8) 18.7 (7.3)
411 Hand breadth 6.9 (2.7) 7.8 (3.1) 8.6 (3.4)
416 Hand circumference 17.9 (6.5) 17.9 (7.0) 19.3 (7.6)
General Notes:
(a) Gravity conditions the dimensions apply to a 1G condition only. Dimension expected to change
significantly due to microgravity are marked.
(b) Measurement data the number adjacent to each of the dimension are reference codes. The same codes
are
in NASA RP 1024, Volume 2. NASA RP 1024, Volume 2 provides additional data for these measurements
plus an explanation of the measurement technique.
Notes for application of dimensions to microgravity conditions:
(1) Stature increases approximately 3 percent over the first 3 to 4 days in weightlessness (See
NASASTD3000, Volume I, Figure 3.2.3.12, for information). Almost all of this change appears in the
spinal column and thus affects (increases) other related dimensions, such as sitting height (buttockvertex),
shoulder height sitting, eye height, sitting, and all dimensions that include the spine.
(2) Sitting height would be better named as buttockvertex in microgravity conditions, unless the crewmember
were measured with a firm pressure on shoulders pressing him or her against a fixed, flat sitting support
surface. All sitting dimensions (vertex, eye, shoulder, and elbow) increase in weightlessness by two
changes:
(a) Relief of pressure on the buttock surfaces (estimated increase of 1.3 to 2.0 cm (0.5 to 0.8 inches).
(b) Extension of the spinal column as explained in note (1) above (3 percent of stature on ground).
(4) Knee heightsitting may increase slightly in microgravity due to relief of the pressure on the heel which it

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5th Percentile cm 50th Percentile cm 95th Percentile cm


Notes No. Dimension
(inches) (inches) (inches)
occurs when it is measured on the ground. The increase is probably not more than 2 to 3 mm (0.1 inch).

Figure 3.4 - Body-size of 40-year-old American male for year 2000 part 2

Table 3.4 - Body-size of 40-year-old American male for year 2000 part 2
5th Percentile cm 50th Percentile cm 95th Percentile cm
Notes No. Dimension
(inches) (inches) (inches)
1, 2 758 Sitting height 88.9 (35.0) 94.2 (37.1) 99.5 (39.2)
1, 2 330 Eye height, sitting 76.8 (30.3) 81.9 (32.2) 86.9 (34.2)
4 529 Knee height, sitting 52.6 (20.7) 56.7 (22.3) 60.9 (24.0)
678 Popliteal height 40.6 (16.0) 44.4 (17.5) 48.1 (19.0)
751 Shoulderelbow length 33.7 (13.3) 36.6 (14.4) 39.4 (15.5)
184 Buttockknee length 56.8 (22.4) 61.3 (24.1) 65.8 (25,9)
420 Hand length 17.9 (7.0) 19.3 (7.6) 20.6 (8.1)
411 Hand breadth 8.2 (3.2) 8.9 (3.5) 9.6 (3.8)
416 Hand circumference 20.3 (8.0) 21.8 (8.6) 23.4 (9.2)
General Notes:
(a) Gravity conditions the dimensions apply to a 1G condition only. Dimension expected to change
significantly due to microgravity are marked.
(b) Measurement data the number adjacent to each of the dimension are reference codes. The same codes are
in NASA RP 1024, Volume 2. NASA RP 1024, Volume 2 provides additional data for these measurements
plus an explanation of the measurement technique.
Notes for application of dimensions to microgravity conditions:
(1) Stature increases approximately 3 percent over the first 3 to 4 days in weightlessness (See
NASASTD3000, Volume I, Figure 3.2.3.12, for information). Almost all of this change appears in the
spinal column and thus affects (increases) other related dimensions, such as sitting height (buttockvertex),
shoulder height sitting, eye height, sitting, and all dimensions that include the spine.
(2) Sitting height would be better named as buttockvertex in microgravity conditions, unless the crewmember
were measured with a firm pressure on shoulders pressing him or her against a fixed, flat sitting support
surface. All sitting dimensions (vertex, eye, shoulder, and elbow) increase in weightlessness by two
changes:
(a) Relief of pressure on the buttock surfaces (estimated increase of 1.3 to 2.0 cm (0.5 to 0.8 inches).
(b) Extension of the spinal column as explained in note (1) above (3 percent of stature on ground).
(4) Knee heightsitting may increase slightly in microgravity due to relief of the pressure on the heel which it
occurs when it is measured on the ground. The increase is probably not more than 2 to 3 mm (0.1 inch).

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Figure 3.5 - Body-size of 40-year-old Japanese female for year 2000 part 3

Table 3.5 - Body-size of 40-year-old Japanese female for year 2000 part 3
5th Percentile cm 50th Percentile cm 95th Percentile cm
Notes No. Dimension
(inches) (inches) (inches)
949 Waist height 90.1 (35.5) 96.7 (38.1) 103.4 (40.7)
249 Crotch height 65.2 (25.7) 70.8 (27.8) 76.1 (30.0)
215 Calf height 25.5 (10.0) 28.9 (11.4) 32.3 (12.7)
103 Biacromial breadth 32.4 (12.8) 35.7 (14.1) 39.0 (15.40
1 946 Waist front
735 Scye circumference 32.3 (12.7) 36.1 (14.2) 39.8 (15.7)
178 Buttock circumference 79.9 (31.5) 87.1 (34.3) 94.3 (37.1)
1, 2 312 Elbow rest height 20.7 (8.2) 25.0 (9.9) 29.3 (11.5)
856 Thigh clearance 11.2 (4.4) 12.9 (5.1) 14.5 (5.7)
381 Forearmhand length 37.3 (14.7) 41.7 (18.4) 44.6 (17.6)
200 Buttockpopliteal length 37.9 (14.9) 41.7 (18.4) 45.5 (17.9)
General Notes:
(a) Gravity conditions the dimensions apply to a 1G condition only. Dimension expected to change
significantly due to microgravity are marked.
(b) Measurement data the number adjacent to each of the dimension are reference codes. The same codes are
in NASA RP 1024, Volume 2. NASA RP 1024, Volume 2, provides additional data for these measurements
plus an explanation of the measurement technique.
Notes for application of dimensions to microgravity conditions:
(1) Stature increases approximately 3 percent over the first 3 to 4 days in weightlessness (See
NASASTD3000, Volume I, Figure 3.2.3.12, for information). Almost all of this change appears in the
spinal column and thus affects (increases) other related dimensions, such as sitting height (buttockvertex),
shoulder height sitting, eye height, sitting, and all dimensions that include the spine.
(2) Sitting height would be better named as buttockvertex in microgravity conditions, unless the crewmember
were measured with a firm pressure on shoulders pressing him or her against a fixed, flat sitting support
surface. All sitting dimensions (vertex, eye, shoulder, and elbow) increase in weightlessness by two
changes:
(a) Relief of pressure on the buttock surfaces (estimated increase of 1.3 to 2.0 cm (0.5 to 0.8 inches).
(b) Extension of the spinal column as explained in note (1) above (3 percent of stature on ground).

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Figure 3.6 - Body-size of 40-year-old American male for year 2000 part 3

Table 3.6 - Body-size of 40-year-old American male for year 2000 part 3
5th Percentile cm 50th Percentile cm 95th Percentile cm
Notes No. Dimension
(inches) (inches) (inches)
949 Waist height 100.4 (39.5) 108.3 (42.6) 116.2 (45.7)
249 Crotch height 79.4 (31.3) 85.4 (34.0) 93.3 (36.7)
215 Calf height 32.5 (12.8) 36.2 (14.3) 40.0 (15.7)
103 Biacromial breadth 37.9 (14.9) 41.1 (16.2) 44.3 (17.5)
1 946 Waist front 37.2 (14.6) 40.9 (16.1) 44.6 (17.5)
735 Scye circumference 44.4 (17.5) 49.0 (19.3) 53.6 (21.1)
178 Buttock circumference 91.0 (35.8) 100.2 (39.4) 109.4 (43.1)
1, 2 312 Elbow rest height 21.1 (8.3) 25.4 (10.0) 29.7 (11.7)
856 Thigh clearance 14.5 (5.7) 16.8 (6.6) 19.1 (7.5)
381 Forearmhand length
200 Buttockpopliteal length 46.9 (18.5) 51.2 (20.2) 55.5 (21.9)
General Notes:
(a) Gravity conditions the dimensions apply to a 1G condition only. Dimension expected to change
significantly due to microgravity are marked.
(b) Measurement data the number adjacent to each of the dimension are reference codes. The same codes are
in NASA RP 1024, Volume 2. NASA RP 1024, Volume 2 provides additional data for these measurements
plus an explanation of the measurement technique.
Notes for application of dimensions to microgravity conditions:
(1) Stature increases approximately 3 percent over the first 3 to 4 days in weightlessness (See
NASASTD3000, Volume I, Figure 3.2.3.12, for information). Almost all of this change appears in the
spinal column and thus affects (increases) other related dimensions, such as sitting height (buttockvertex),
shoulder height sitting, eye height, sitting, and all dimensions that include the spine.
(2) Sitting height would be better named as buttockvertex in microgravity conditions, unless the crewmember
were measured with a firm pressure on shoulders pressing him or her against a fixed, flat sitting support
surface. All sitting dimensions (vertex, eye, shoulder, and elbow) increase in weightlessness by two
changes:
(a) Relief of pressure on the buttock surfaces (estimated increase of 1.3 to 2.0 cm (0.5 to 0.8 inches).
(b) Extension of the spinal column as explained in note (1) above (3 percent of stature on ground).

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Figure 3.7 - Body-size of 40-year-old Japanese female for year 2000 part 4

Table 3.7 - Body-size of 40-year-old Japanese female for year 2000 part 4
5th Percentile cm 50th Percentile cm 95th Percentile cm
Notes No. Dimension
(inches) (inches) (inches)
1, 3 23 Acromial (shoulder) height 119.6 (47.1) 127.1 (50.0) 134.5 (53.0)
894 Trochanteric height 71.0 (28.0 76.7 (30.2) 82.4 (32.5)
873 Tibiale height 35.9 (14.1) 39.3 (15.5) 42.7 (16.8)
122 Bideltoid (shoulder) height 35.6 (14.0) 38.9 (15.3) 42.1 (16.6)
223 Chest breadth 24.5 (9.7) 26.8 (10.5) 29.0 (11.4)
457 Hip breadth 30.5 (12.0) 32.9 (12.9) 35.3 (13.9)
165 Bizygomatic (face) breadth 13.3 (5.2) 14.5 (5.7) 15.7 (6.2)
427 Head breadth 14.4 (5.7) 15.6 (6.1) 16.8 (6.6)
General Notes:
(a) Gravity conditions the dimensions apply to a 1G condition only. Dimension expected to change
significantly due to microgravity are marked.
(b) Measurement data the number adjacent to each of the dimension are reference codes. The same codes are
in NASA RP 1024, Volume 2. NASA RP 1024, Volume 2 provides additional data for these measurements
plus an explanation of the measurement technique.
Notes for application of dimensions to microgravity conditions:
(1) Stature increases approximately 3 percent over the first 3 to 4 days in weightlessness (See
NASASTD3000, Volume I, Figure 3.2.3.12, for information). Almost all of this change appears in the
spinal column and thus affects (increases) other related dimensions, such as sitting height (buttockvertex),
shoulder height sitting, eye height, sitting, and all dimensions that include the spine.
(3) Shoulder or acromial height, sitting or standing, increases during weightlessness due to two factors:
(a) Removal of the gravitational pull on the arms
(b) Extension of the spinal column as explained in Note (1) above (3 percent of stature on ground).

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Figure 3.8 - Body-size of 40-year-old American male for year 2000 part 4

Table 3.8 - Body-size of 40-year-old American male for year 2000 part 4
5th Percentile cm 50th Percentile cm 95th Percentile cm
Notes No. Dimension
(inches) (inches) (inches)
1, 3 23 Acromial (shoulder) height 138.0 (54.3) 147.6 (58.1) 157.3 (61.9)
894 Trochanteric height 88.3 (34.8) 96.6 (37.6) 102.9 (40.5)
873 Tibiale height x x x
122 Bideltoid (shoulder) height 44.6 (17.6) 48.9 (19.3) 53.2 (20.9)
223 Chest breadth 29.7 (11.7) 33.2 (13.1) 36.7 (14.4)
457 Hip breadth 32.7 (12.9) 35.8 (14.1) 39.0 (15.4)
165 Bizygomatic (face) breadth 13.4 (5.3) 14.3 (5.6) 15.1 (6.0)
427 Head breadth 14.8 (5.8) 15.7 (6.2) 16.5 (6.5)
General Notes:
(a) Gravity conditions the dimensions apply to a 1G condition only. Dimension expected to change
significantly due to microgravity are marked.
(b) Measurement data the number adjacent to each of the dimension are reference codes. The same codes are
in NASA RP 1024, Volume 2. NASA RP 1024, Volume 2 provides additional data for these measurements
plus an explanation of the measurement technique.
Notes for application of dimensions to microgravity conditions:
(1) Stature increases approximately 3 percent over the first 3 to 4 days in weightlessness (See
NASASTD3000, Volume I, Figure 3.2.3.12, for information). Almost all of this change appears in the
spinal column and thus affects (increases) other related dimensions, such as sitting height (buttockvertex),
shoulder height sitting, eye height, sitting, and all dimensions that include the spine.
(3) Shoulder or acromial height, sitting or standing, increases during weightlessness due to two factors:
(a) Removal of the gravitational pull on the arms
(b) Extension of the spinal column as explained in Note (1) above (3 percent of stature on ground).

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Figure 3.9 - Body-size of 40-year-old Japanese female for year 2000 part 5

5th Percentile cm 50th Percentile cm 95th Percentile cm


Notes No. Dimension
(inches) (inches) (inches)
747 Shoulder circumference x x x
230 Chest circumference 73.2 (28.8) 82.1 (32.3) 90.9 (35.8)
6 931 Waist circumference 55.3 (21.8) 63.2 (24.9) 71.2 (28.0)
5 852 Thigh circumference 45.6 (17.9) 51.6 (20.3) 57.7 (22.7)
5 515 Knee circumference 31.0 (12.2) 34.6 (13.6) 38.2 (15.0)
5 207 Calf circumference 30.3 (11.9) 34.1 (13.4) 37.8 (14.9)
113 Biceps circumference, relaxed 21.8 (8.8) 25.5 (10.1) 29.3 (11.5)
967 Wrist circumference 13.7 (5.4) 15.0 (5.9) 16.2 (6.4)
111 Biceps circumference, flexed x x x
369 Forarm circumference, relaxed 19.9 (7.8) 22.0 (8.7) 24.1 (9.5)
General Notes:
(a) Gravity conditions the dimensions apply to a 1G condition only. Dimension expected to change
significantly due to microgravity are marked.
(b) Measurement data the number adjacent to each of the dimension are reference codes. The same codes are
in NASA RP 1024, Volume 2. NASA RP 1024, Volume 2 provides additional data for these measurements
plus an explanation of the measurement technique.
Notes for application of dimensions to microgravity conditions:
(5) Leg circumferences and diameters significantly decrease during the first day in microgravity. See NASA
RP 1024, Volume 1, appendix C, for details and measurements of actual persons.
(6) Waist circumference will decrease in microgravity due to fluid shifts to the upper torso. See Figure 3.2.3.1
2 for measurements on actual persons.

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Figure 3.10 - Body-size of 40-year-old American male for year 2000 part 5

Table 3.9 - Body-size of 40-year-old American male for year 2000 part 5
5th Percentile cm 50th Percentile cm 95th Percentile cm
Notes No. Dimension
(inches) (inches) (inches)
747 Shoulder circumference 109.5 (43.1) 119.2 (46.9) 128.8 (50.7)
230 Chest circumference 89.4 (35.2) 100.0 (39.4) 110.6 (43.6)
6 931 Waist circumference 77.1 (30.3) 89.5 (35.2) 101.9 (40.1)
5 852 Thigh circumference 52.5 (20.7) 60.0 (23.6) 67.4 (26.5)
5 515 Knee circumference 35.9 (14.1) 39.4 (15.5) 42.9 (16.9)
5 207 Calf circumference 33.9 (13.3) 37.6 (14.8) 41.4 (16.3)
113 Biceps circumference, relaxed 27.3 (10.7) 31.2 (12.3) 35.1 (13.8)
967 Wrist circumference 16.2 (6.4) 17.7 (7.0) 19.3 (7.6)
111 Biceps circumference, flexed 29.4 (11.6) 33.2 (13.1) 36.9 (14.5)
369 Forarm circumference, relaxed 27.4 (10.8) 30.1 (11.8) 32.7 (12.9)
General Notes:
(a) Gravity conditions the dimensions apply to a 1G condition only. Dimension expected to change
significantly due to microgravity are marked.
(b) Measurement data the number adjacent to each of the dimension are reference codes. The same codes are
in NASA RP 1024, Volume 2. NASA RP 1024, Volume 2 provides additional data for these measurements
plus an explanation of the measurement technique.
Notes for application of dimensions to microgravity conditions:
(5) Leg circumferences and diameters significantly decrease during the first day in microgravity. See NASA
RP 1024, Volume 1, appendix C, for details and measurements of actual persons.
(6) Waist circumference will decrease in microgravity due to fluid shifts to the upper torso. See Figur3.2.3.12
for measurements on actual persons.

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Figure 3.11 - Body-size of 40-year-old Japanese female for year 2000 part 6

Table 3.10 - Body-size of 40-year-old Japanese female for year 2000 part 6
5th Percentile cm 50th Percentile cm 95th Percentile cm
Notes No. Dimension
(inches) (inches) (inches)
67 Thumbtip reach 65.2 (25.7) 71.6 (28.2) 78.0 (30.7)
772 Sleeve length x x x
441 Head length 16.7 (6.6) 18.2 (7.2) 19.6 (7.7)
430 Head circumference 53.2 (20.9) 55.2 (21.7) 57.2 (22.5)
586 Mentonsellion (face) length 9.0 (3.5) 10.8 (4.2) 12.6 (5.0)
362 Foot length 21.3 (8.4) 22.9 (9.0) 24.4 (9.6)
356 Foot breadth 8.6 (3.4) 9.3 (3.7) 10.0 (3.9)
97 Ball of foot circumference 21.0 (8.3) 22.7 (8.9) 24.3 (9.6)
General Notes:
(a) Gravity conditions the dimensions apply to a 1G condition only. Dimension expected to change
significantly due to microgravity are marked.
(b) Measurement data the number adjacent to each of the dimension are reference codes. The same codes
are in NASA RP 1024, Volume 2. NASA RP 1024, Volume 2 provides additional data for these
measurements plus an explanation of the measurement technique.

Figure 3.12 - Body-size of 40-year-old American male for year 2000 part 6

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5th Percentile cm 50th Percentile cm 95th Percentile cm


Notes No. Dimension
(inches) (inches) (inches)
67 Thumbtip reach 74.9 (29.5) 81.6 (32.1) 88.2 (34.7)
772 Sleeve length 86.2 (33.9) 92.0 (36.2) 97.9 (38.5)
441 Head length 18.8 (7.4) 20.0 (7.9) 21.1 (8.3)
430 Head circumference 55.5 (21.8) 57.8 (22.8) 60.2 (23.7)
586 Mentonsellion (face) length 11.1 (4.4) 12.1 (4.8) 13.1 (5.2)
362 Foot length 25.4 (10.0) 27.3 (10.8) 29.3 (11.5)
356 Foot breadth 9.0 (3.6) 9.9 (3.9) 10.7 (4.2)
97 Ball of foot circumference 23.1 (9.1) 25.1 (9.9) 27.2 (10.7)
General Notes:
(a) Gravity conditions the dimensions apply to a 1G condition only. Dimension expected to change
significantly due to microgravity are marked.
(b) Measurement data the number adjacent to each of the dimension are reference codes. The same codes are
in NASA RP 1024, Volume 2. NASA RP 1024, Volume 2 provides additional data for these measurements
plus an explanation of the measurement technique.

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3.2. Mobility of the body


Each joint of the body has a range of motion (ROM) throughout which the joint normally operates.
The range of motion of each joint varies from person to person.
Table 3.11 reports the ranges of movement at the joints for air force personnel (able bodied
people). The column Figure refers to Figure 3.13 and Figure 3.14, which depicts the articoulation
of joints for which the ROM is defined.

Table 3.11 - Joint movement ranges for males and females


Range of motion (degrees)
Males (1) Female (1)
Notes

Joint movement (2) 5th percentile 95th percentile 5th percentile 95th percentile

Neck, rotation right 73.3 99.6 74.9 108.8


1
Neck, rotation left 74.3 99.1 72.2 109.0

2 34.5 71.0 46.0 84.4


Neck, flexion
65.4 103.0 64.9 103.0
Neck, extension Neck, lateral right Neck,
34.9 63.5 37.0 63.2
lateral left
3 35.5 63.5 29.1 77.2

4
173.2 188.7 172.6 192.9
5 Shoulder, abduction 46.3 96.7 53.8 85.8
Shoulder, rotation lat Shoulder, rotation med 90.5 126.6 95.8 130.9
Shoulder, flexion Shoulder, extension 164.4 210.9 152.0 217.0
6 39.6 83.3 33.7 87.9

7 Elbow, flexion 140.5 159.0 144.9 165.9

Forearm, pronation 78.2 116.1 82.3 118.9


8
Forearm, supination 83.4 125.8 90.4 139.5

9
16.9 36.7 16.1 36.1
Wrist, radial 18.6 47.9 21.5 43.0
Wrist, ulnar Wrist, flexion Wrist, extension 61.5 94.8 68.3 98.1
10
40.1 78.0 42.3 74.7
11 Hip, flexion 116.5 148.0 118.5 145.0
12 Hip, abduction 26.8 53.5 27.2 55.9

13 Knee, flexion 118.4 145.6 125.2 145.2

Ankle, plantar 36.1 79.6 44.2 91.1


14
Ankle, dorsiflexion 8.1 19.9 6.9 17.4

Notes:
(1) Data was taken 1979 and 1980 at NASAJSC by Dr. William Thornton and John Jackson. The study was
made using 192 males (mean age 33) 22 females (mean age 30) astronaut candidates (see SP286L064).
(2) Limb range is average of right and left limb movement.

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Figure 3.13 - Joint movements - part 1

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Figure 3.14 - Joint movements - part 2

3.3. Strength Data


The following tables report: grip strength, arm strength, hand-finger strength and upper arm torque
strength according NASA document [13]. Fig. 3.15 gives a visual description of arm and grip
strength parameters.
Additional data about grip strength can be found also in paper [397]. The paper provides data for
able-bodied people measured using different equipment: a Grippit electronic dynamometer
(Grippit; AB Detektor, Goteborg, Sweden) and a Jamar hydraulic dynamometer (Jamar; Smith and
Nephew, Memphis, TN). The two different measuring systems give different results (probably due
to slight different way of gripping). The paper provides data for males (254 subjects) and females,
(286 subjects) and for different age classes from 18 to 97 years, so that it may be also useful for
the characterization of elder people. Tables 3.16 and 3.17 reports grip strength for women and
men measured with the Grippit system. The Jamar dynamometer produced results that were on
average (mean difference) 22 N greater (Jamar - Grippit) and limits of agreement of ranged
between -86 to +129 N (mean, 2 SD, Fig. 3 paper [397]),.

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Table 3.12 - Grip strength for females [13]


Percentiles, N (lbf)
Population
5th 50th 95th Population SD
U.S. Navy personnel
258 (58) 325 (73) 387 (87) 39.1 (8.8)
Mean of both hands
U.S. Industrial workers
254 (57) 329 (74) 405 (91) 45.8 (10.3)
Preferred hand

Figure 3.15 Arm strength movements

th
Table 3.13 - Arm strength (5 percentile male data) [13]
Arm strength (N)
(1) (2) (3) (4) (5) (6) (7)
Degree of elbow flexion Pull Push Up Down In Out
(rad) L R L R L R L R L R L R
222 231 187 222 40 62 58 76 58 89 36 62
5/6 187 249 133 187 67 80 80 89 67 89 36 67
2/3 151 187 116 160 76 107 93 116 89 98 45 67
142 165 98 160 76 89 93 116 71 80 45 71
1/3 116 107 96 151 67 89 80 89 76 89 53 76
Hand and thumbfinger strength (N)
(8) (9) (10)
Hand grip
L R Thumbfinger grip (Palmer) Thumbfinger grip (tips)
Momentary hold 250 260 60 60
Sustained hold 145 155 35 35
Arm strength (lb)
(1) (2) (3) (4) (5) (6) (7)
Degree of elbow flexion Pull Push Up Down In Out
(deg) L R L R L R L R L R L R
180 50 52 42 50 9 14 13 17 13 20 8 14
150 42 56 30 42 15 18 18 20 15 20 8 15
120 34 42 26 36 17 24 21 26 20 22 10 15
90 32 37 22 36 17 20 21 26 16 18 10 16
60 26 24 22 34 15 20 18 20 17 20 12 17

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Table 3.14 - Hand and thumb/finger strength (5th male data) [13]
Hand and thumbfinger strength (lb)
(8) (9) (10)
Hand grip
L R Thumbfinger grip (Palmer) Thumbfinger grip (tips)
Momentary hold 56 59 13 13
Sustained hold 33 35 8 8
L = Left; R = Right
* Elbow angle shown in radians

Table 3.15 Torque strength for the upper arm [13]


Mean (Nm) Standard Deviation (Nm)
Torque strength supination 13.73 3.41
Torque strength pronation 17.39 5.08

Table 3.16 Grippit Dynamometer [397]: Hand-Grip Strength Ranges for Women
Age Range (y) Number Hand Peak (N) Average* (N) Final (N)
1824 24 R 163389 121326 86313
L 133362 89292 45290
2534 35 R 166466 94417 79400
L 145386 43425 37419
3544 42 R 137433 100368 100368
L 145459 76309 99329
4554 33 R 137408 98325 73301
L 141366 43298 43298
5564 26 R 148332 99288 79276
L 126332 79269 25269
6574 21 R 83298 56238 36223
L 60282 41218 27199
75+ 36 R 51253 28198 22182
L 39251 21195 18180
*Average grip strength over the 10-second recording period.
Grip strength recorded at the end of the 10-second recording period.

Table 3.17 Grippit Dynamometer [397]: Hand-Grip Strength Ranges for Men
Age Range (y) Number Hand Peak (N) Average* (N) Final (N)
1824 24 R 262-714 203-655 171-631
L 233-709 175-639 159-611
2534 35 R 369-733 184-672 190-670
L 264-688 375-535 163-610
3544 42 R 268-728 196-418 172-624
L 277-677 200-628 122-610
4554 33 R 249-697 187-614 171-632
L 291-639 224-572 135-147
5564 26 R 189-574 135-492 139-489
L 192-584 135-511 108-600
6574 21 R 215-503 169-425 109-435
L 207-491 161-417 96-424
75+ 36 R 87-378 81-381 37-373
L 126-450 83-195 76-346
*Average grip strength over the 10-second recording period.
Grip strength recorded at the end of the 10-second recording period.

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3.4. Dexterity/control data


Neuromuscular skills, i.e., the ability to control movement, have been traditionally described by a
number of clinical scales. For example, the Unified Parkinsons Disease Rating Scale (UPDRS) or
the Fugl-Meyer Assessment scale for stroke. Clinical scales are useful to rate the degree of
disability, but are based on subjective judgment and do not provide useful quantitative indicators
for modelling purposes. In recent years (last 5 years) a number of quantitative indicators have
been proposed to objectively assess the degree of a disability, which may be (somewhat) useful
also for modelling the effects of disabilities in VERITAS.
These indicators are based on the observations of how a set of tasks is accomplished. Most tasks
are specific of each disease (and also each researcher proposed his own variation of test tasks).
We can roughly divide indicators into:
Tasks related to the movement of upper limbs. These tasks typically involve point-to-point
aiming tests, or continuous tracking tests, or holding position against disturbance forces, or
executing dexterity tests (e.g., inserting pegs in a pegboard) or controlling force devices, etc..
From the observation of the execution of these tasks, indicators are derived which can be
classified as related to movement time (possibly broken down into initiation, execution, reaction
time), movement accuracy, force control accuracy etc.
Tasks related to gait. These tasks involve observation of gait (mostly straight course, but
some studies also address stairs, turning, freezing, etc.). From the observation of gait, a
number of parameters are derived, which are step and stride length, speed, gait asymmetry,
etc.

Since most of the test tasks are specific of each disease (e.g., the spiral test in Parkinsons
Disease) they will be described in each disease section, where also data for able-bodied people
are given for comparison.
In the following we introduce the Fittss test and gate parameters for able-bodied people, because
of their transversal value for many diseases.

3.4.1. Fitts law.

Fittss law is a model of human movements. It describes the time needed to complete the task of
aiming specific spots. It was initially introduced for Human Computer Interaction studies, but it has
been proposed also for the assessment of several upper and lower limb motor disabilities. It is a
quite simple test, which combines movement time and accuracy in a unique indicator.
A justification of Fittss law has been given in terms of information theory: namely the control of a
movement needs transmission of information. The channels that carry information in human beings
have a limited throughput, which limits the speed at which a target can be met.
Paper [14] gives a review of Fitts law: its theoretical foundations, the original experiment and the
extensions and revisions, competing models, and applications.
There also exists an online live demonstration that is very effective to explain the law [15].
In brief, the classical form of Fittss law is the following:

(1)

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It gives the time (MT) needed to move from a spot onto a target of width W and distance A. The
original law was deduced for movements in one dimension, but extensions to two dimensions have
been introduced later. The term log2(2A/W) is called the Index of Difficulty (ID) and combines the
size and distance of the target to be pointed:

(2)

Constants a and b depends on the type of pointing device. For hands a=13 ms and b=95 ms. the
inverse of b is a measure of pointing performance (IP):

(3)

Fitts' law is an effective quantitative method of modelling user performance in rapid, aimed
movements, where one appendage (like a hand) starts at rest at a specific start position, and
moves to rest within a target area. Movement is sometimes decomposed in three phases: reaction
time, ballistic movement, and homing phase, which means the time needed to start the movement,
the quick approaching to the target and the final fine positioning onto the target (e.g., we will see
that elder people have different changes in each of these phases).
A Fitts test is quite easy to carry out. Although the law has been mainly used to assist in the design
of user interface, it has been indeed successfully used also to summarise the degradation of
performance for some diseases like post-Stroke motor disability, Parkinsons disease, etc. .

According to the original Fittss experiment (moving a stylus between two targets, i.e., Fitts
paradigm), the law parameter (see also appendix B) for able-bodied people are reported in the
following Table.

Table 3.18 Fitts parameters a and b for able-bodied person


Fitts parameters
a [ms] b [ms]
12.8 94.7

The same paper cited above reports data for other devices (mouse, joystick, foot pedal, etc.). The
Table 3.19 lists the most important ones.

Table 3.19 - Fitts' law parameters for various pointing devices (able bodied people)
Intercept a Slope b
Device Study IP [bit/s] Error [%] Comment
[ms] [ms/bit]
Eye tracker Ware and Mikaelian (1987) 680 73 13.7 - 8.5 Hardware button
Foot pedal Drury (1975) 187 85 11.8 0.97 <3.3 Experiment 2
Hand Fitts (1954) 12.8 94.7 10.6 0.98 1.8 Tapping, 1-oz stylus
Card, English and Burr
Mouse 1030 96 10.4 0.91 5
(1978)
Eye tracker Ware and Mikaelian (1987) 790 97 10.3 - 22 On-screen button
Eye Tracker Ware and Mikaelian (1987) 680 107 9.3 - 12 Dwell time
Helmet sight Jagacinski and Monk 1985 -268 199 5.0 0.99 0
Joystick Jagacinski and Monk 1985 -303 199 5.0 0.99 0 Isometric; position control
Card, English and Burr
Joystick 990 220 4.5 0.94 12 Isometric; velocity control
(1978)

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Intercept a Slope b
Device Study IP [bit/s] Error [%] Comment
[ms] [ms/bit]
Joystick Kantowitz and Elvers (1988) -328 297 3.4 0.62 25 Isometric, position, high gain
Joystick Kantowitz and Elvers (1988) -447 297 3.4 0.76 25 Isometric, position, low gain
Trackball Epps (1986) 282 347 2.9 0.93 0
Mouse Epps (1986) 108 392 2.6 0.83 0
Touchpad Epps (1986) 181 434 2.3 0.74 0 Absolute positioning
Joystick Kantowitz and Elvers (1988) -846 449 2.2 0.84 25 Isometric, velocity, high gain
Joystick Kantowitz and Elvers (1988) -880 449 2.2 0.85 25 Isometric,velocity, low gain
Touchpad Epps (1986) -194 609 1.6 0.70 0 Relative positioning
Joystick Epps (1986) -587 861 1.2 0.81 0 Isometric; velocity control
Joystick Epps (1986) -560 919 1.1 0.86 0 Displacement; velocity control

3.4.2. Gait metrics

Gait pattern is influenced by many types of disabilities and by aging. Able-bodied people also
exhibit good bilateral coordination and symmetrical gait [16], which degrades in many disorders.
Able-bodied subjects are indeed able to control each leg separately to a remarkable degree, while
this ability declines with diseases and is an important sign for gait disorder diagnosis.
The neuronal mechanisms responsible for limbs control are located in spinal loco-motor centres,
which consist of central pattern generators (CPGs), i.e., local neuronal circuits that generate
rhythmic stepping movements by alternating activity between groups of flexor and extensor
muscles of a limb [17].
Besides neural causes, there can also be orthopaedic causes affecting gait (e.g., arthritis).

Gait Clinical Scale. Gait Abnormality Rating Scale (GARS) [18] is a videotape-based analysis of
16 aspects of human gait. It has been evaluated as a screening tool for gait evaluation and to
identify patients at risk for injury from falls [19].

Gait Parameters. The major indicators for gait are:


Step length. Step length is defined as the anterior displacement of the foot from foot strike to
contralateral foot strike. In both cases the same given point on foot is measured, usually is the
midpoint of the distance between the most posterior part of the calcaneus and the 1st or 5th
caput metatarsal. During normal walking speed (1.2 to 2.2 m/s) able-bodied people have a step
length of about 0.7 and 0.8m, respectively.
Step width. Step width is the lateral distance between the feet. It is measured as the distance,
perpendicular to the direction of progression, between a point on one foot (usually at its initial
contact) and the same point on the other foot at the subsequent contact. The width depends on
which point is chosen. The centre of the heel is often used, although again this may not be
appropriate for some pathological gait patterns. Other studies have used the centres of mass of
the feet, ankle joint centres or outside borders of the feet. Step width has a value of a few
centimetres for normal subjects, while for patients with balance problems, such as cerebellar
ataxia or athetoid form of cerebral palsy, it can increase to as much as 15 or 20 cm. Step width
variability may relate to fall risk [20]. Older individuals who tend to walk more slowly and have a
shorter stride/step length displayed a higher falls risk score [21].
Stride length. Stride length is the distance between two successive placements of the same
foot, consisting of two step-lengths. In other words it is the distance travelled by one person

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during one cycle. With normal subjects, the two step-lengths will be approximately equal, but
with certain patients there will be an asymmetry between the left and right sides.
Stride length is an important component of speed (speed = stride length / cycle time). Stride
length depends on strong leg muscles and a good range of motion in joints, especially those of
the hip and knee. The mix of joint mobility, muscle strength, neural control and energy leads to
a customary walking speed, stride length and step rate. Time and distance factors combined
with swing and stance times, constitute the persons stride characteristics [22]. Stride length for
normal persons averages 1.41 meters [22].
Gait Cycle time. The time between any two identical events in the walking or running cycle.
There are two main phases in gait: a) Stance phase, during which the foot is on the ground and
b) swing phase where the same foot is no longer in contact with the ground and the leg and the
leg is swinging in preparation for the next foot strike. Double stance is the phase when both
feet are on the ground. The transition from walking to running is marked by elimination of
double support.
Cadence (steps per minute). Cadence represents the number of steps in the unit time in
analogy with cycling where cadence represents the number of rotation per minute. It is related
to gait cycle time: in fact it is the inverse of half gait cycle time. Cadence, together with step
length, are the two means people use to regulate walking velocity. Able-bodied people have
cadence in the range 70-155 min-1 while walking and 33-214 min-1 while running.
Velocity. Velocity represents the displacement per unit time (m/s) and rigorously speaking it is
a vector quantity (actually the time derivative of position a point). The mean scalar velocity in
gait is the stride length divided by the cycle time. Able-bodied people walking speed range
walking speeds ranging from 4.51 km/h to 4.75 km/h for older individuals to 5.32 km/h to 5.43
km/h for younger individuals [23].

3.5. Other miscellaneous data


The following table reports additional data related to the range of motion, strength and dexterity
with a miscellaneous source.
Note that there may be some difference with data reported above, due to heterogeneity of
methods, environments, subjects, etc.

Table 3.20 Kinematic, dynamic and dexterity data from miscellaneous sources.
Parameters Value for able-bodied people

Upper limb abilities:

1. Hand Function Strength: Averages of grip strength (kgf), (standing elbow in extension, Dominant
o Strength (Power hand, min-max: 38-160 (kgf)
Grip/Power Grip Mean S.D:86.0624.71
strenght) Pincer Grip strength (kgf), Dominant hand, min-max: 4.5-13.5 (7.822.10) (kgf) [433].
(Study: 149 volunteers, age: 24-60 years, grip strength measured using a standard
Jamar dynamometer at standing position with shoulder adducted and neutrally rotated
and elbow in full extension).
2. Fingers (thumb, index Reference posture: neutral position- the extended finger equals:0
finger, middle finger, ring
finger and little finger) Flexion and extension (first carpometacarpal joint): 0- (20-50)
2.1 Thumb Abduction: 0- (30- 40)
o Flexion Adduction:((40-30)-0
o Extension Opposition

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o Grip IP (interphalangeal joint): Flexion: 90, Extension:0


o Abduction Metacarpal phalangeal joint flexion: 80 to 90, Extension: 0, Hyprextension:0 -20
o Adduction Flexion /Extension (proximal interphalangeal joint): 90 to 100 to 0 .
o Opposition
Flexion and extension (distal interphalangeal joint): 70 to
rotation of the
thumb 90 to 0
3. Wrist Reference posture:neutral position. Hands straight equals 0.

o Flexion Flexion: 0 -(50-60)


o Extension Movement dorsally extension : 0 -(35-60)
o Radial deviation Radial deviation : 0 -(25-30)
o Ulnar deviation
Ulnar deviation : 0 -(30-40)
4. Forearm Rotation -starting position of elbow: 90 against the body. The axis of the wrist joint
vertical.
Internal rotation (pronation): 0 (80-90)
External rotation (supination): 0 (80-90)
5. Elbow Reference posture: neutral position. Full extension equals 0.

Flexion: 0 (135-150)
Extension: 0
Hyperextension:10
6. Shoulder The shoulder joint, the scapulaflexed in a neutral position, the extended armhangs at a
position of 0)

Forward flexion: 0- (70-90)


Full flexion:0- (150-170)
Backwards extension:0- 40.
Abduction:0-( 80-90)/Maximun elevation (abduction): 0-180/Adduction: 0-(20-
40)
Horizontal flexion (arm in 90 abduction): 0-135/Horizontal extension:0-(40 -50)
Internal rotation: 0-(70, 90)/External rotation: 0-(40-50) (the upper arm held
snugly in to the side of the body)
Internal rotation: 0-70/External rotation: 0-70 (upper arm position in 90
abduction).

Lower limb abilities:


1. Hip Reference posture: neutral position, full extension:0 (in supine position).
o Full flexion
o Hyperextension Full flexion: 0 (130-140), Hyperxtension:10
o Abduction Abduction: 0(30-45),
o Adduction
Adduction: 0-20-30
o Internal rotation
o External rotation Internal rotation: 0(40-50),
External rotation:0 (30-40) (position: extension).
Internal rotation: 0 (30-45), External rotation: 0 (40-50) (position: flexion).
2. Knee Reference posture: neutral position, knee extended
o Flexion
o Extension Flexion: 0 (120, to 150), Extension: 0, Hyperextension: 5-10
o Hyperextension Internal-External rotation: 20,
o Internal rotation
o External rotation

3. Ankle Reference posture: Foot in a right angle: x=0


o Plantarflexion
o Dorsiflexion or Plantarflexion: 0 (40-50)
extension Dorsiflexion or extension: 0 (20-30)

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4. Toe joints Reference posture: neutral position


Sub-talar joint
o Inversion Sub-talar joint.
(supination) Inversion (supination): 0 -30
o Eversion Eversion (pronation): 0 (30-35)
(pronation)
Metatarso-phalangeal joints
Metatarso-phalangeal joints
Extension: 0 (30-40)
Flexion: 0 (30-40)
o Extensiom
o Flexion
5. Movements of the head Reference posture: neutral position: upright, head straight = 0.
and the neck
o Flexion Flexion:0 (35-45),
o Extension Extension: 0 (35-45)
o Lateral bending to Lateral Bending to the right: 0-45,
the right
Lateral Bending to the left: 0- 45
o Lateral bending to
the left Rotation Right: 0 (60 to 80), Rotation left: 0 (60 to 80)
6. Movements of the spinal Lateral bending: 20-30
column
o Lateral bending Forward bending, flexion: 0-90, Backwards bending (extension): 0-30
o Forward bending, Lateral rotation: 0-30
(flexion)
o Backwards bending
(extension)
o Lateral rotation
Gait:
1. Step length During normal walking speed (1.2 and 2.2 m/s) healthy populations have a step length
of about 0.7 and 0.8m, respectively.

2. Stride width (walking 5-10cm


base)

3. Stride length Males:158cm, Females:132


With normal subjects, the two step lengths will be approximately equal, but with certain
patients there will be an asymmetry between the left and right sides. Similar to step
length it is measured either in (m) or (cm).
4. Cadence 70 steps/min at the lowest speed and 155 steps/min at the highest speed.

For males:117 (60-132), for females:117 (60-132).


5. Velocity (centimeters per Normal free gait velocity on a smooth level surface averages 82 meters per minute
second) (m/min) for adults.

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4. Literature review about disabled people


This section reports the abstract user models for the disabilities that have been previously defined
in the prioritization section (section 2). For each disability we provide a brief description, a list of
metrics (and when useful the relevant clinical scales, protocols, etc.) and data that can be found in
the literature for people with that disability in comparison with able-bodied persons. The papers
from which data have been obtained are mentioned.

4.1. Literature review about motor impairments


This paragraph concerns motor impairments. According to A1.3.1 (the VERITAS survey of
modelling techniques), each pathology reported below is studied considering the possible
simulation models, in the sense that we searched parameters for functional limitation as close as
possible to the modelling tools that will be likely used.

4.1.1. Rheumatoid arthritis

Rheumatoid arthritis is a highly inflammatory polyarthritis, often leading to joint destruction,


deformity and loss of function.
In general, patients develop seropositive rheumatoid factor within one year of developing
symptoms. Overall, patients who are seropositive have a more severe disease course with more
joint deformities, x-ray damage, disability and inflammation outside of the joints. However, there
are many exceptions to these rules.

Neck. Now we consider the neck affected by rheumatoid arthritis. Figure 4.1 depicts the typical
movements of the neck, which are the rotation, flexion/extension and lateral bend (lateral flexion)
movements.

Figure 4.1 - Neck movements description

Data about muscle strength and mobility of the cervical spine in rheumatoid arthritis (RA) patients
are reported below, according to reference [24]. The population, from which the data have been
extracted, has the characteristics reported in the Table 4.1.

Table 4.1 - Descriptive statistics for a group of 94 people with cervical RA


Value
Number of women [%] 75
Age [years] 60 (11)
Duration of disease [years] 16 (11)
Data are expressed as mean (1SD)

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The mobility of Cervical Spine, for men and women, is reported in Table 4.2.

Table 4.2 - Mobility of cervical spine in a group of 94 people with RA


Women Men
Mean Standard deviation Mean Standard deviation
[deg] [deg] [deg] [deg]
Extension 64 16 69 14
Flexion 46 10 46 6
Rotation 132 22 137 20
Lateral flexion 66 15 70 15

The data about isometric neck muscle strength (it is a static test, where there is no movement at
the joint) are reported in Table 4.3. The strength (in N) refers to the cervical strength of flexor,
extensor and rotator muscles (see paper for details of test procedure).

Table 4.3 - Isometric neck muscle strength in a group of 94 people with RA


Women Men
Mean Standard deviation Mean Standard deviation
Extension [N] 122 43 221 73
Flexion [N] 60 24 125 37
Rotation [Nm] 4.4 2.1 10.7 4.5

Hand. The working space of the hand (i.e., the difference between the volume enclosed by the
hand in extension and the volume enclosed by the hand in flexion), reflects the space available
within the rheumatoid hand, and incorporates the effect of deformity and stiffness present in the
whole hand. The reference [25] reports a study on the working space of the hands of a rheumatic
population. The circles which best fits the hand model for the radial and ulnar digit in full extension
and full flexion are first assessed (see Figure 4.2)

Figure 4.2 Examples of hand in extension (a and b) and in flexion (c and d)

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The working space of the hand is then computed using the above circles and the palm width,
according to Figure 4.3, which depicts the approximated shape of the hand workspace. Table 4.4
reports a statistic description of the considered group of patients. Data about hand working space
(for hand deformity groups) are reported in Table 4.5. for different types of deformities.

Figure 4.3 - Volume (cone segment) representing the hand workspace

Table 4.4 - Descriptive statistics for a group of 54 people with hand RA


Sex Age Hand disease duration
Deformity
Male Female [years] [years]
None 4 15 61.7 (2.9) 14.2 (2.7)
Boutonnire 0 11 64.2 (2.6) 6.8 (1.7)
Ulnar deviation 1 4 67.6 (1.7) 11.4 (1.9)
Swan neck 0 8 56.1 (3.5) 12.8 (3.7)
Combined 1 10 61.5 (3.3) 19.2 (2.7)
Total 54 61.9 (1.4) 13.2 (1.4)
Data are expressed as mean (1SD)

Table 4.5 - Hand working space for deformity groups in hand RA patients
Working space
Deformity Number of patients
[cm3]
None 19 4920 (111.0)
Boutonnire 11 3842 (292.2)
Ulnar deviation 5 3861 (324.5)
Swan neck 8 3270 (499.3)
Combined 11 1154 (333.8)
Total 54 3602 (154.7)
Data are expressed as mean (1SD)

The reference [26] reports some functional data for hands characterized by the destruction and
dislocation of the metacarpophalangeal (MCP) joints (that is quite common in subjects affected by
rheumatoid arthritis). These are reported in Table 4.6.
The JebsenTaylor test mentioned there, simulates activities of daily living and consists of 7
components:
1. Writing a short sentence;
2. Turning over 3- by 5-inches cards;
3. Picking up small objects and placing them in a container;
4. Stacking checkers;
5. Simulated eating;
6. Moving large empty cans;
7. Moving large weighting cans.
For each component, the time required in seconds to complete the task is recorded.

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Table 4.6 - Functional scores in 16 patients with destruction of the MCP joint
Parameter Mean Standard deviation

Grip strength [Kg] 5.9 4.6


Key (lateral) pinch [Kg] 5.5 3.4
2-point (tip) pinch [Kg] 3.3 2.8
Three jaw (palmar) pinch [Kg] 3.8 3.2
Jebsen-Taylor [s] 44.8 13.8

Paper [27], reports some functional indicators for a group of 50 patients with hand rheumatoid
arthritis.
Table 4.7 Grip and Pinch strength in 50 patients with hand RA
Parameter Mean Standard deviation

Grip strength [N] 103.80 69.41


Pinch strength [N] 32.80 22.17

Knee. Paper [28] reports data about the range of motion, peak torque, peak torque angle, power,
total work, peak torque acceleration time, set total work, torque acceleration energy (explosion)
and endurance of the knee for a control group CG and a group of subjects with rheumatoid
arthritis RA. The ranges of motion are reported in Table 4.8.

Table 4.8 - Values of knee range of motion in a group of 50 people with RA


Right side Left side
Movement
Control group Rheumatoid arthritis Control group Rheumatoid arthritis
Flexion [deg] 130 (0) 126.8 [120-130] (4.6) 130 (0) 127 [120-130] (4.4)
Extension [deg] 0 (0) 1.3 [0 to -10] (2.9) 0 (0) 1.1 [0 to -10] (2.7)
Data are expressed as mean [maximum and minimum] (1SD)

In the isokinetic test, the same subjects performed ve repeated movements (exion and
extension) at the two prescribed velocities and 30 repetitions at a third angular velocity, and the
parameters evaluated in all 3 velocity cases were: peak torque, peak torque angle, power, total
work, peak torque acceleration time, set total work, torque acceleration energy (explosion) and
endurance. The parameters have the meaning explained below:
Peak torque: it is the highest torque value seen from all points in the range of motion
(ROM), expressed in [Nm];
Total work: it represents the action of a torque during all its amplitude; it may be computed
as the area under the torque curve, and physically it can be seen as the energy developed
by the muscle, expressed in Joules [J];
Power: it stands for the pattern of realized work, and can be expressed in watts [W]; it can
be seen as the total work divided by the actual contraction time;
Endurance: it is the capacity of a muscle to produce force over a series of consecutive
isokinetic contractions. The endurance of a contraction is expressed as a percentage of the
precedent contraction;
Peak torque angle: it is the point where the highest torque was achieved, expressed in
grades;
Set total work: it is the sum of the work obtained after each series of contractions,
expressed in joules [J];

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Acceleration energy of the torque: it is the explosion, and it represents the work
performed in the rst 1/8 second of the muscular contraction. It indicates the muscular
explosiveness, and is expressed in joules [J].
Moreover a distinction between flexors and extensors movements has been made. Table 4.9
reports the numeric data for the parameters just explained.

Table 4.9 - Values of knee isokinetic parameters in a group of 50 people with RA


Movement Flexors Extensors
Angular velocity
60 180 300 60 180 300
[deg/s]
Side Right Left Right Left Right Left Right Left Right Left Right Left
Peak Torque 42 39 30 30 18 17 81 80 49 50 33 35
[Nm] (12) (12) (11) (11) (12) (11) (25) (23) (16) (17) (14) (14)
Peak Torque 39 41 36 38 47 45 59 56 54 53 52
58 (9)
Angle [deg] (14) (17) (15) (17) (17) (13) (10) (12) (10) (13) (12)
Peak Torque 0.10 0.10 0.09 0.09 0.15 0.16 0.06 0.06 0.08 0.08 0.11 0.11
Acc. Time [s] (0.06) (0.07) (0.05) (0.04) (0.08) (0.08) (0.04) (0.03) (0.04) (0.04) (0.05) (0.05)
Power 52 48 34 27 48 50 84 90 69 76
29 (9) 27 (9)
[W] (23) (20) (30) (25) (15) (15) (30) (36) (40) (40)
Total Work 49 44 32 29 13 84 84 53 55 28 30
10 (9)
[J] (16) (15) (14) (12) (12) (27) (24) (18) (19) (15) (14)
Set total work 214 192 138 124 355 247 374 377 231 241 637 692
[J] (75) (70) (67) (55) (234) (211) (127) (116) (86) (87) (300) (248)
Explosion 2.2 2.1 8.3 8.0 8.2 7.2 3.4 3.7 12.1 12.7 15.3 16.5
[J] (1.2) (1.1) (3.2) (3.1) (5.5) (5.1) (1.5) (1.7) (4.4) (4.5) (6.3) (6.5)
Endurance 132 139 89 88
- - - - - - - -
[%] (76) (95) (29) (24)
Data are expressed as mean (1SD)

Gait. According to [29], the kinematic parameters for the range of motion of the knee during gait
assume the value reported in the Table 4.10.

Table 4.10 - Kinematic parameters of knee joint in rheumatoid arthritis


Parameter Unit Mean Value Standard deviation value

Knee maximum extension (flexion angle) deg 21 13

Knee maximum flexion deg 36 13

Knee range deg 15 14

Knee flexion rate deg/sec 82 79

Knee extension rate deg/sec 83 88

Paper [30] reports data about gait parameters of a group of 22 patients with feet rheumatoid
arthritis (RA). The group has the descriptive statistics reported in Table 4.11, The gait parameters
are reported in Table 4.12.

Table 4.11 - Descriptive statistics for a group of 22 people with feet RA


Value
Number of subjects 22 (29 feet)
Age [years] 54 (range 17-76)
Sex 2 men and 20 women
Affected side 11 right and 18 left

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Table 4.12 - Gait parameters for a group of 22 people with feet RA


Parameter Unit Mean Value Standard Deviation Value

Stride length m 0.96 0.17

Cadence Steps/min 104.8 8.8

Stance duration mm 65.7 2.5

Walking speed m/s 0.89 0.25

4.1.2. Gout

Gout is a common form of inflammatory arthritis, and its prevalence among older patients is
especially rising [31]. Acute gout is a common cause of arthritis [32]. The joints that are commonly
involved are:
Metatarsal joint;
The base of the big toe;
Knee joint;
Wrist joint;
Joints of the fingers.
Paper [33] reports a set of values for spatiotemporal parameters of the gait. Table 4.13
summarizes those parameters.

Table 4.13 Spatiotemporal parameters of gait in subjects affected by Gout


Left side Right side
Parameter Unit
Control Group Gout patients Control Group Gout patients
Step length [m] 0.66 (0.1) 0.57 (0.1) 0.66 (0.1) 0.57 (0.1)
Stride length [m] 1.32 (0.2) 1.14 (0.2) 1.32 (0.2) 1.13 (0.3)
Single leg support [s] 0.42 (0.1) 0.41 (0.1) 0.42 (0.1) 0.57 (0.8)
Double leg support [s] 0.19 (0.1) 0.19 (0.1) 0.16 (0.1) 0.20 (0.1)
Stance phase [s] 0.75 (0.1) 0.99 (0.8) 0.75 (0.1) 1.1 (1.2)
Swing phase [s] 0.41 (0.1) 0.48 (0.3) 0.41 (0.1) 0.41 (0.1)
Velocity [m/s] 0.90 (0.3) 1.10 (0.3) - -
Cadence [steps/min] 113.6 (36.9) 93.7 (16.9) - -
Values are expressed as Mean (Standard Deviation)

4.1.3. Kyphosis and lordosis

Kyphosis, also called hunchback, is a common condition of a curvature of the upper spine. It can
be either the result of degenerative diseases (such as arthritis), developmental
problems, osteoporosis with compression fractures of the vertebrae, and/or trauma.
Lordosis is a medical term used to describe an inward curvature of a portion of the vertebral
column. Lordosis may also increase at puberty sometimes not becoming evident until the early or
mid-20s. Imbalances in muscle strength and length are also a cause, such as weak hamstrings, or
tight hip flexors. Figure 4.4 shows the difference between a normal spine and a spine with
excessive kyphosis and lordosis curvature.

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Figure 4.4 - Normal spine and spine with excessive kyphosis and lordosis

KYPHOSIS
There are several kinds of Kyphosis. Paper [34] reports data about the thoracic Kyphosis curvature
for old population (summarized in Table 4.14), while the Figure 4.4 depicts the thoracic Kyphosis
angle.

Figure 4.5 - Tx kyphosis angle

Table 4.14 - Descriptive statistics for a group of 15 people


Value
Height [cm] 160.6 (1.5)
Weight [Kg] 68.6 (2.8)
Age [years] 67.2 (2.5)
Tx Kyphosis [deg] 58.8 (3.2)
Data are expressed as mean (1SD)

As for what concerns gait parameters we refer to [35], which takes into account the effect of sagittal
trunk posture on the gait of able-body subjects. Understanding the effect of trunk posture on gait is
of interest since alterations in trunk posture often occur with age or in the presence of spinal

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pathologies, such as Kyphosis. Table 4.15 reports the spatial and temporal parameters of the gait
(with dependence on the trunk flexion), while Table 4.16 shows the kinematic data during gait.

Table 4.15 - Spatial and temporal gait parameters, dependent on the trunk flexion
Slow walking speed Normal walking speed Fast walking speed
257 507 257 507 257 507
Upright trunk trunk Upright trunk trunk Upright trunk trunk
[deg] flexion flexion [deg] flexion flexion [deg] flexion flexion
[deg] [deg] [deg] [deg] [deg] [deg]
Average
0.77 0.76 0.81 1.20 1.11 1.19 1.80 1.78 1.79
walking
0.19 0.19 0.21 0.20 0.17 0.25 0.29 0.37 0.37
speed [m/s]
Average
82.7 86.0 93.3 104.5 104.2 111.1 125.2 129.6 135.6
cadence
10.7 10.8 10.4 10.6 10.1 10.9 10.4 13.1 11.9
[steps/min]
Normalized
step length 0.32 0.30 0.30 0.40 0.37 0.37 0.49 0.47 0.45
[step 0.04 0.05 0.05 0.03 0.04 0.05 0.05 0.06 0.07
length/height]
Single
35.72 36.15 36.00 39.25 39.39 39.62 41.74 42.23 42.29
support [% of
3.73 1.60 1.96 1.72 3.49 3.11 1.80 2.07 2.18
gait cycle]
Double
15.11 14.08 14.81 11.86 11.94 11.03 8.26 8.18 7.92
support [% of
2.01 1.58 4.07 3.55 2.56 2.08 2.21 1.64 2.12
gait cycle]
The values mean 1SD

Table 4.16 - Kinematic data during gait, dependent on the trunk flexion
Slow walking speed Normal walking speed Fast walking speed
257 507 257 507 257 507
Upright trunk trunk Upright trunk trunk Upright trunk trunk
[deg] flexion flexion [deg] flexion flexion [deg] flexion flexion
[deg] [deg] [deg] [deg] [deg] [deg]
Ankle
maximum 11.3 3.1 13.9 2.8 16.9 3.8 10.1 3.6 13.6 3.0 17.4 4.2 10.1 3.6 12.8 3.1 17.4 4.3
dorsiflexion
Ankle
-14.1 -16.6 -11.2 -16.6 -12.0
maximum -9.7 3.3 -7.7 2.7 -7.9 3.2 -7.5 3.6
4.0 3.8 3.5 3.8 3.7
plantarflexion
Ankle ROM 25.5 4.3 24.9 3.2 26.5 3.8 29.3 3.6 26.7 3.0 27.2 3.2 29.3 3.6 27.4 3.2 28.0 3.7
Knee
61.0
maximum 55.1 4.1 56.3 4.4 61.2 8.4 54.7 5.2 58.5 4.6 62.8 8.9 54.7 5.2 57.3 4.6
11.1
flexion
Knee ROM 60.7 5.8 59.4 5.9 59.9 4.2 65.6 3.8 65.1 4.1 65.4 4.1 65.6 3.8 65.9 3.8 67.7 4.7
Hip maximum
28.4 6.4 34.1 7.2 46.7 9.4 32.4 8.1 35.8 7.2 48.8 8.9 32.4 8.1 36.8 7.5 48.2 9.9
flexion
40.8
Hip ROM 34.6 4.0 29.1 6.7 21.9 5.1 51.2 6.3 35.6 6.3 30.0 7.9 51.2 6.3 47.3 8.2
11.3
The values are mean degrees 1SD

For the kinematic data of the lower limbs in Kyphosis, we can refer to [36], whose results are
summarized in Table 4.17.

Table 4.17 - Kinematic data about lower limb for Kyphosis disease
Group 1 Group 2
Mean Standard deviation Mean Standard deviation
[deg] [deg] [deg] [deg]
Right hip extension 12.60 5.32 14.62 7.40
Left hip extension 12.20 5.59 13.23 7.47
Right knee flexion 91.13 1.36 98.54 1.29

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Group 1 Group 2
Mean Standard deviation Mean Standard deviation
[deg] [deg] [deg] [deg]
Left knee flexion 92.27 3.83 98.46 2.70
Right knee extension 3.00 3.56 2.85 4.56
Left knee extension 3.27 3.32 2.08 2.87
Right ankle dorsiflexion 4.47 6.06 6.69 4.75
Left ankle dorsiflexion 4.53 8.09 6.00 3.76

Based on the reference [36], Table 4.18 reports some dynamic data for Kyphosis disease.

Table 4.18 - Dynamic data for Kyphosis disease


Group 1 Group 2
Mean Standard deviation Mean Standard deviation
[N] [N] [N] [N]
Spine extensors 4.21 0.89 4.31 1.18
Abdominals 3.80 1.52 3.54 1.45

LORDOSIS
Concerning lordosis, we first introduce the angle used to assess the disease: it is depicted in
Figure 4.6 and is representative of the lumbar lordosis.

Figure 4.6 - Cobb angle (or L1-S1 angle)

Reference [37] reports the Cobb-angle for a group of 29 patients, as summarized in Table 4.19.

Table 4.19 - Cobb-angle in lumbar lordosis for a group of 29 patients


Value
Age [years] 53.7 (11.7)
Cobb (L1-S1) angle [deg] 58.8 (3.2)
Data are expressed as mean (1SD)

4.1.4. Ankylosing spondylitis

Ankylosing spondylitis (AS) is defined as the formation of a stiff joint by consolidation of the
articulating surfaces and inflammation of the vertebral column. In AS, the spine becomes rigid from
the occiput to the sacrum. This leads to a stooped position, with inability to see the horizon and a
shock absorption decrease [38].

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Gait. As reported in [38], Table 4.20 reports some numeric values of the joint parameters, involved
during gait cycle.

Table 4.20 - Joints parameters during gait cycle in Ankylosing Spondylitis


Mean Standard deviation Mean Standard deviation
Parameter
(Normal subjects) (Normal subjects) (SA subjects) (SA subjects)
Trunk ROM [deg] 3.17 0.95 5.49 1.64
Right hip ROM [deg] 44.36 4.08 34.92 6.99
Right knee ROM [deg] 64.38 8.0 65.69 7.77
Right ankle ROM [deg] 28.32 5.5 29.37 8.42
Left hip ROM [deg] 41.93 1.9 33.18 6.41
Left knee ROM [deg] 58.87 9.0 66.39 3.53
Left ankle ROM [deg] 28.65 10.35 30.19 11.22
Stride length [m] 1.16 0.08 0.89 0.19

Spine movements. Some of the parameters (from [38], [39] and[40]) used to assess the disease
are:
Pelvic incidence (PI): angle between a line drawn from center of the hip axis to the center of
the superior endplate of S1 and perpendicular to the endplate (Figure 4.7);
Sacral Slope (SS): angle formed between the sacral endplate and the horizontal plane
(Figure 4.7);
Pelvic Tilt (PT): angle between the vertical plane and a straight line joining the centers of
the femoral heads and the center of the sacral endplate (Figure 4.7);
C7 Tilt (C7T): The L line is defined by the line joining the center of C7 and the center of the
sacral endplate). The C7 tilt (C7T) is the angle formed between the L line and the horizontal
plane (Figure 4.8);
Spino-Sacral Angle (SSA): it was the angle between the L line and the sacral endplate
(Figure 4.8);
Kyphosis Tilt Angle (KTA): defined as reported Figure 4.9;
Chest expansion: using a tape, it consists in the change in circumference of the patients
chest at the level of the 4th intercostal space;
Cervical spine posture: it is measured with a pair of compasses and a ruler as the distance
from C7 to the wall;
Thoracic spine posture: it is measured by means of Debrunners kyphometer, between
Th23 and Th1112;
Lumbar spine posture: it is measured by means of Debrunners kyphometer, between
Th1112 and S12;
Cervical rotation: Distance between tip of nose and ACJ in neutral and maximal ipsilateral
rotation. Difference between two positions calculated for right/left rotation. Smaller
difference indicates a more restricted range. Measured with plastic tape measure;
Fingertip-to-floor distance: distance between tip of right middle finger and the floor following
maximal lumbar flexion, whilst maintaining knee extension; smaller distance indicates
greater movement. Measured with a retractable steel tape measure;
Lumbar lateral flexion (LLF): distance between tip of ipsilateral middle finger and floor
following maximal LLF, maintaining heel contact with floor and without trunk rotation.
Smaller distance indicates greater movement. Measured with a rectractable steel tape
measure;

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Modified Schober index (15 cm): Distance between two marks placed 15 cm apart in
standing (10 cm proximal and 5 cm distal to the PSIS) following maximal forward flexion of
the spine. Larger difference indicates greater lumbar movement. Measured with a plastic
tape measure;
Tragus-to-wall distance (TWD): horizontal distance between right tragus and wall, standing
with heels and buttocks against the wall (to prevent pivoting), knees extend and chin drawn
in. Larger distance indicates worse spinal/upper cervical posture. Measured with a
retractable steel tape measure.

Figure 4.7 - PI, SS and PT angles

Figure 4.8 - C7T and SSA angles

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Figure 4.9 - KTA angle

Reference [41] is a study about Ankylosing Spondylitis patients with severe kyphotic deformity. The
result is a comparison with able-bodied people (control group). Data are summarized in Table 4.21.

Table 4.21 - Ankylosing Spondylitis patients with severe kyphotic deformity


Parameter Control group AS patients
PI [deg] 50.6 5.2 61.9 13.7
SS [deg] 39.5 7.6 23.9 11.3
PT [deg] 11.1 5.8 38.5 10.9
C7T [deg] 95.4 1.4 72.6 14.7
SSA [deg] 135.2 3.8 96.4 17.8
KTA [deg] 93.4 2.4 74.9 12.7
Data are expressed as mean 1SD

Paper [39] reports additional data, listed here in Table 4.22.

Table 4.22 - Data for two groups of patients with Ankylosing Spondylitis
Parameter Group 1 Group 2
Chest expansion [cm] 4.5 1.3 4.2 1.7
Posture cervical spine [cm] 5.1 2.5 5.2 1.8
Posture thoracic spine [deg] 37.3 10.3 39.3 8.3
Posture lumbar spine [deg] 21.2 6.8 23.6 6.4
Sagittal thoracic spine flexion [deg] 14.0 8.3 13.3 6.5
Sagittal thoracic spine extension [deg] 4.7 5.2 6.6 6.0
Sagittal thoracic spine ROM [deg] 18.7 9.5 19.8 6.2
Lumbar thoracic spine flexion [deg] 36.9 14.5 37.5 6.7
Lumbar thoracic spine extension [deg] 7.3 5.7 7.9 6.7
Lumbar thoracic spine ROM [deg] 44.2 17.7 45.4 10.1
Data are expressed as mean 1SD

More data are reported in [40] and summarized in Table 4.23.

Table 4.23 - Data for a group of patients with Ankylosing Spondylitis


Parameter Mean [cm] Standard deviation [cm]
Cervical rotation left 7.36 3.74
Cervical rotation right 7.28 3.57
Fingertip-to-floor distance 19.71 15.73
Lateral lumbar flexion left 53.10 6.59
Lateral lumbar flexion right 52.21 6.30
Modified Schober index (15 cm) 4.02 2.30
Tragus-to-wall distance 17.94 7.11
Data are expressed as mean 1SD

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Other studies with data about Ankylosing Spondylitis disease are reported in [42] and [43].

4.1.5. Hand Osteoarthirtis (incl. arthrosis of first carpometacarpal joint)

Osteoarthritis (OA) is the most common joint disorder, affecting abut 12% of people. Osteoarthritis
can be classified into either primary or secondary. Primary OA is degenerative disorder correlated
to age, but not caused by aging (there are people that are not affected). The cartilage covering the
ends of the bones forming a joint gradually deteriorates. Contact between bones, inflammation and
outgrow of spurs can happen. Overall joints become stiffer, cause pain, and have reduced range of
motion, causing disabilities like reduced strength and mobility.
Secondary OA is caused by diseases like diabetes, by injuries, joint overload due to obesity and a
number of other syndromes.

The most affected joints are hands, feet, knees and hips. This section deals with the hand OA, the
following sections will deal with knee and hip.

Hand osteoarthritis typically involves the distal interphalangeal joints (DIP), the proximal
interphalangeal joints (PIP), and the first carpometacarpal (CMC) joints, and affect up to 75% of
women aged 60 to 70 years.

Clinical scales. There are many clinical scales used to assess hand function in osteoarthritis.
For example Arthritis Hand Function Test (AHFT), Grip Ability Test (GAT), Jebsen Test of Hand
Function, and The Rheumatoid Hand Functional Disability Scale (The Duruoz Hand Index, DHI)
[398].
A review of measures to evaluate disability for hand problems in older persons is given in [399].
The purpose of the study was to identify valid questionnaires to evaluate hand osteoarthritis (HOA)
in the general population. The paper selected 5 scales: Algofunctional Index (FIHOA), Arthritis
Impact Measurement Scale 2 (AIMS2), Stanford Health Assessment Questionnaire (HAQ),
Australian/Canadian Osteoarthritis Hand Index (AUSCAN), Cochin. Overall, the AIMS2 and
AUSCAN were more highly rated.

AUSCAN. The Australian/Canadian Osteoarthritis Hand Index. Paper [400] studied the
acceptability and measurement properties of the AUSCAN scale on 2113 community-dwelling
population of older adults with hand problems. 55 of them participated to a complete clinical
assessment in a second stage. AUSCN is a questionnaire which focus on three subscales:
- Pain subscale (amount of pain experienced in hands in the last week): At rest; Gripping objects;
Lifting objects; Turning objects; Squeezing objects.
- Stiffness subscale: Morning stiffness.
- Function subscale (degree of difficulty in the last week due to): Turning taps; Turning round
doorknob or handle; Buttons; Fastening jewelry; Opening new jar; Carrying full pot (e.g.,
saucepan); Peeling vegetables/fruits; Picking up large heavy objects; Wringing out washcloths
(e.g., squeezing wet sponge or flannel).

Paper [401] is a study carried out on 87 women with hand osteoarthritis with age between 50 and
70 years (mean 62.7 SD 5.4). Disease duration was mean 14.5 years (SD 6.9 years). Comorbidity
was present in 44% of cases. 61% had also knees osteoarthritis and 32% hip osteoarthritis. Self

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efficacy (evaluated with a clinical scale) was 70.8%. The AUSCA function was mean 1.8 (SD 0.92)
in a 0-4 scale range.
The most important clinical characteristics of hand osteoarthritis are pain and reduced joint mobility
and grip force. The following measures were chosen to reflect these characteristics at the
impairment level.
1) Joint mobility of both hands was measured as follows:
flexion deficit of digits II-V as the distance in mm from the distal palmar crease to the distal
point of the digits;
extension deficits of digits II-V as the distance in mm from the distal point of the nailbed of
the extended fingers to a table where the patients rested their hand in a supinated position;
opposition deficit of digit I as the distance between the tip of the thumb and the base of digit
V;
radial abduction of the thumb as the angle between the metacarpal bones of the thumb and
the digit II parallel to the plane of the palm.
2) For hands, grip strength and three-pod pinch strength (thumb, index and long finger) were
measured in Newtons (N) by the Grippit electronic instrument. The mean force in 10 second test
duration was recorded.
3) Pain was measured immediately following each assessment of grip force, on a 100 mm visual
analogue (VAS) scales ranging from 0 = no pain to 100 = maximal pain, by asking the patient to
mark the amount of pain experienced during the resisted motion in respectively grip strength and
pinch strength for each hand.
The following table lists the findings.

Table 4.24 Hand Osteoarthritis parameters [401]


Impairment variable Right hand Left hand
Flexion deficit II (mm) 4.2 (9.9) 4.2 (10.2)
III 3.5 (9.5) 4.0 (12.5)
IV 3.0 (8.2) 3.7 (9.4)
V 1.4 (5.4) 2.2 (6.9)
Extension deficit II (mm) 2.1 (4.9) 1.6 (4.0)
III 3.7 (7.0) 2.1 (4.4) *
IV 3.4 (6.8) 1.5 (3.9) *
V 2.2 (4.5) 1.2 (3.5)
Opposition deficit thumb (mm) 6.5 (12.8) 6.2 (11.6)
Radial abduction thumb () 60.0 (13.3) 62.5 (14.8)
Grip strength (N)** 113.9 (74.1) 104.0 (67.4)
Proportion of normal grip strength (%) 57 (37) 58 (39)
Pinch strength (N) 19.4 (10.9) 20.0 (10.9)
Pain resisted grip (mm) 35.6 (26.1) 35.4 (26.4)
Pain resisted pinch (mm) 31.3 (27.5) 31.0 (26.2)
Values are mean (SD). *Statistically meaningful differences between right and left hand. ** Average grip strength
(considered here) of the right and left hand for healthy women: 206/194 N (age 5059) and 197/173 N (age 6069).

4.1.6. Gonarthrosis (osteoarthritis of the knee)

Gonarthrosis is osteoarthritis of the knee joint, generally implying early joint surface damage of any
kind. This causes the joint movability to decrease.
The angles in knee are defined as Figure 4.10. A possible model, could be similar to that depicted
in Figure 4.11, extracted by [44].

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Figure 4.10 - Description of the knee range of motion

Figure 4.11 - A model of the muscle-tendon function in human lower limb

As reported in paper [45], the effects are listed in Table 4.25. The study was done on a population
of 12 women and 8 men, aged 45-93 with unilateral gonarthritis. The control group was 12 women
and 8 Men aged 52-84.

Table 4.25 - Effects of knee joint in Gonarthrosis Mean (SD).


Parameter Unit Control Patients

Cadence step/min 94.5 (20.7) 97.04 (8.1)

Step length mm 934.7 (110.7) 903.1 (80.5)

Walking base mm 27.9 (8.7) 27.8 (5.2)

Double support phase % of gait cycle 20.9 (1.9) 18.2 (1.7)

Swing phase percent of gait cycle 30.9 (5.5) 31.4 (2.8)

According to paper [46], the range of motion of the joint are reported (for a population of 198
subjects) in Table 4.26. The Range of Motion is more meaningful than the mean and standard
deviation, showing that there are people who cannot reach the straight position.

Table 4.26 - Kinematic parameters of knee joint in Gonarthrosis


Left Right
Parameter
Mean (SD) [deg] Range [deg] Mean (SD) [deg] Range [deg]
Knee flexion 136.3 (11.4) 65 to 155 136.3 (10.6) 90 to 153
Knee extension 0.3 (5.3) -20 to 13 0.2 (5.2) -19 to 12

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4.1.7. Coxarthrosis (osteoarthritis of the hip)

This is a non-inflammatory degenerative disease of the hip joint which usually appears in late
middle or old age. It is characterized by growth or maturational disturbances in the femoral neck
and head, as well as acetabular dysplasia. A dominant symptom is pain on weight-bearing or
motion.
The Table 4.27 reports the values of kinematic parameters for the Coxarthrosis disease, according
to [46].

Table 4.27 - Kinematic parameters of hip joint in Coxarthrosis


Left Right
Parameter Standard Deviation Standard Deviation
Mean [deg] Mean [deg]
[deg] [deg]
Hip flexion 115.4 12.3 115.3 11.7
Hip extension 2.3 7.3 2.2 7.6
Hip adduction 11.8 4.7 12.2 4.6
Hip abduction 18.3 6.9 17.2 7.5
Hip internal rotation 29.4 9.5 28.6 10.2
Hip external rotation 34.8 9.6 34.5 9.2

4.1.8. Shoulder adhesive capsulitis

Note. This disease has been excluded by the list of priorities in revision 6. However some data had
already been collected. In the following the collected data are reported anyway.

Frozen shoulder, medically referred to as adhesive capsulitis, is a disorder in which


the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder,
becomes inflamed and stiff, and grows together with abnormal bands of tissue, called adhesions,
greatly restricting motion and causing chronic pain. Adhesive capsulitis is a painful and disabling
condition. Certain movements can cause sudden onset of tremendous pain and cramping that can
last several minutes.
Figure 4.12 represents the movements at the shoulder joint, while Figure 4.13 depicts the normal
shoulder elevation movement.

Figure 4.12 - Shoulder movements

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Figure 4.13 - Shoulder elevation movement

Figure 4.14 depicts a model of the shoulder complex, as explained in [47].

Figure 4.14 - A serial model of the human shoulder complex

The angles sF, sA e sR represent the shoulder flexion-extension, the shoulder abduction-adduction
and the shoulder rotation. The angles gF, gA e gR are the upper arm flexion-extension, the upper
arm adduction-abduction and the upper arm rotation. Linear coordinate sT is the shoulder
translation.
According to paper [48], values of the kinematic parameters for the disease are reported in Table
4.28.

Table 4.28 - Kinematic parameters of shoulder joint in adhesive capsulitis


Left Right
Standard Range Standard Range
Pathology type Parameter Mean Mean
Deviation (median) Deviation (median)
[deg] [deg]
[deg] [deg] [deg] [deg]
Abduction 170.33 4.69 170 132.88 15.72 130
Right shoulder
adhesive Internal Rotation 71.64 3.49 70 32 13.79 30
capsulitis
External Rotation 89.28 1.72 90 64.71 13.41 70

Abduction 123.75 15.9 125 170.56 4.03 170


Left shoulder
adhesive Internal Rotation 22.81 14.37 20 72.06 4.4 71.5
capsulitis
External Rotation 52.18 12.1 50 88.75 2.88 90

Bilateral shoulder Abduction 129.58 17.44 135 123.91 14.06 127

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Left Right
Standard Range Standard Range
Pathology type Parameter Mean Mean
Deviation (median) Deviation (median)
[deg] [deg]
[deg] [deg] [deg] [deg]
adhesive Internal Rotation 28.33 13.64 30 22.7 15.53 20
capsulitis
External Rotation 54.58 13.74 50 51.25 14.23 50

4.1.9. Parkinsons disease

Parkinson's disease (abbreviation PD) is an age-related, progressive, degenerative brain disorder,


related to insufficient generation of dopamine in the midbrain. It affects several cognitive and motor
functions.
As for what concerns motor functions there are the following signs:
Tremor. Tremors of limbs, which occur mostly at rest and which is more pronounced at
farthest extremities. Tremor develops unilaterally, and progresses as bilateral tremor.
During aimed motion tremor disappears [49].
Rigidity. Rigidity is due to increased muscle tone, which is apparent when moving the
limbs passively [49].
Bradykinesia. Bradykinesia is slowness of movements, which affects not only the
execution of movements but also movement initiation (akinesia). It reduces also the ability
to execute sequential and simultaneous movements. Bradykinesia is the most impairing
aspect of PD at the earlier stages [50], [51].
Postural instability. Postural instability, balance problems and falls are effects usually
observed in the later stages [49].
Gait disorders. Gait disorders are also known as parkinsonian gait for the typical pattern
they have, which include forward flexed posture, small steps, slow walking speed, flat foot
stride, etc.
Other clinical features include secondary motor symptoms (e.g. Hypomania, dysarthria, dysphagia,
sialorrhoea, micrographia, shuffling gait, festination, freezing, dystonia, glabellar reflexes), non-
motor symptoms (e.g. Autonomic dysfunction, cognitive/neurobehavioral abnormalities, sleep
disorders and sensory abnormalities such as anosmia, paresthesias and pain) [49]. Reaction time
and the accuracy of steering are studied in [396].

Metrics.
The Unified Parkinsons Disease Rating Scale (UPDRS) is a clinical scale that, based on the
above symptoms can be used by expert motor disorder specialists to grade the severity of PD [52],
[53], [54], [55], [56].
However, besides being examiner-dependent, it is of little usefulness for modelling virtual PD
users.

As for what concerns the modelling needs of VERITAS (i.e., the tasks that have to be simulated)
Bradykinesia and Gait disorders are the symptoms that must be modelled. Objective kinematic
indicators related to movement execution are thus necessary.

As explained in section 3.4, a large variety of disease-dependent indicators have been proposed in
the literature. These are based on observation of the execution for specific tasks.

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The following are typical tasks and indicators used for upper limb metrics in Parkinsons Disease.
Examples of tasks that are related to these are: reaction time and the accuracy of steering [57], as
well as difficulty to enter the car or reach the radio due to tremor.

Modelling and simulation of PD motion patterns. Modelling the complex movement patterns of
persons with PD is quite a challenging task. A few papers addressed this by approaching the
modelling of basal ganglia activity.
Paper [434] describes the motion planning that occurs in the deep brain by means of a set of
Hamiltonian equations. The model successfully reproduced in a two-arm robot manipulator the
characteristic patterns of PD such as bradykinesia and hyperkinesia.
Another paper dealing with such modelling aspects is [435]. The paper presents a computational
model of handwriting generation that highlights the role of Basal Ganglia. Handwriting produced by
the model reproduced the characteristic PD handwriting distortions like micrographia and velocity
fluctuations.
A further model of Basal Ganglia functioning and its role in PD is give in a PhD dissertation [436]
and a following paper [437]. In Paper [438] the validity of the neural network model proposed in
said PhD dissertation is tested in a reciprocal aiming task (eg a FITTs task). In PD, slowness of
movement (i.e. bradykinesia) can be explained by a hypoactive disinhibition of the direct pathway,
which, results in decreased firing activity of neurons in cortical areas. Pause or hesitation to initiate
the next movement in the sequence (i.e. akinesia) may be due to a hyperactive inhibition of the
indirect pathway.

Spiral analysis is recommended by the Movement Disorder Society [58] as a test to assess
tremor and hypokinesia (bradykinesia and akynesia) in PD and in other related diseases like
Essential Tremor (ICD-10 G25, not included in this survey) and multiple sclerosis. Paper [59] gives
an overview of the complete guidelines and standards, as well as some insight into mathematical
modelling of tremor. Original spirals from Bain and Finley [60] can be used to cross check results
obtained with new methods.
Spiral analysis is a test where a person is asked to draw a spiral, while measuring trajectory and
force. Post processing of these data permit to derive a number of indicators that reflect the motor
disability [61], [62]. In particular, 4 indicators (first order crossing, second order smoothness, mean
speed and Degree of Severity) were found to correlate fairly well with the UPDRS scale [62].
An improved methodology is used in [63], where wavelet transforms are used to process spiral
data collected on a PDA, and to derive an overall spiral score which is found to agree with PD
specialists scores. Supplementary tapping tests are also used. The purpose of the spiral drawing
task was to assess the drawing impairment caused by involuntary movements, such as tremor and
dyskinesia, as well as bradykinesia. The latter drawing task in [63] consisted of tracking (not
drawing freely) a pre-drawn spiral on a touch screen. Wavelet transform filters were used to
decompose spiral in large-scale and small-scale deviations. Ultimately a score denoted WSTS was
produced. In addition the standard deviation of the frequency-filtered drawing velocity (the SDDV
score) was computed to assess the involuntary movements. It was concluded that the WSTS
indicator had the best agreement with expert UPDRS scores. Other literature indicators are also
discussed and compared.
Overall spiral analysis is a good tool for early diagnosis and to monitor the progress of PD.
However it seems still far from providing the information that is needed to model virtual PD users
except for some modelling hints given in [59]. Spiral drawing times (essentially movement time)
have been found to be in correlation with Bradykinesia in [64]: The spiral drawing time was

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significantly longer in PD patients when compared to normal controls (p<0.001). The bradykinesia
assessment using the spiral drawing time showed a significant correlation with the clinical ratings
score of the UPDRS (R = 0.64, p = 0.001) and with the results of other instrumental methods.

Advanced Sensing for Assessment of Parkinson's disease (ASAP). A novel approach, called
Advanced Sensing for Assessment of Parkinson's disease has been introduced in [65]. A suite of
sensors and proper defined procedures are combined to obtain a quantitative and reliable measure
of motor impairment in early to moderate PD. The protocol measures grip force as an individual
tracks a sinusoidal or pseudorandom target force. This produces several indicators. A regression
to combine these indicators into a synthetic UPDRS-like score is finally given (with a mean
prediction error of 3.5 UPDRS points). This is again a method for early diagnosis and disease
progress monitoring than a method for modelling virtual users.

Overall, no data have been found for ASAP and Spiral analysis (only correlation coefficient with the
UPDRS score, consistently with the purpose of early prediction and monitoring). However the
metrics and protocols could in principle be adopted, but this calls for measuring all data.

Eurythmokinesimeter (EKM). This tool is similar in concept to the Fitts test [66]. Besides the
Fittss law parameters, it computes additional indicators named: precision, imprecision, contact
duration, unsureness, tremor, transit time, irregularity, and speed. The method requires the subject
to touch alternately the centre of near and far targets with a stylus. Target has three concentric
circles of radius is 1.4 mm, 4,4 mm and 10.5 mm, dividing the contact area in 4 zones A, B, C, D.
The distance is 30 cm (not clearly declared). Stylus contact is classified according to the contact
zone. Multiple contacts occur in case of sliding contacts.
A control group of 30 able-bodied people and 21 persons with PD were involved. No data about
their UPDRS score are however given. Thus results are only indicative because a dependency on
the UPDRS exists.

The Table 4.29 following table is an excerpt from table 5 of paper [66], which compares the control
group and the PD group on the basis of the nine indicators (Fitts parameter b; a forced to 0).
Numbers are the mean and standard deviation (in parenthesis). ANOVA indicated that tremor,
Fitts parameter and irregularity are the most statistical significant indicators (paper [66], table 9).

Table 4.29 - EKM parameters in Parkinsons Disease


Transit Contact Fitts
Speed Precision Imprecision Sureness Tremor Irregularity
Time time constant
Control 1.285 0.683 0.870 2.125 0.367 0.652 0.188 0.119 0.112
subjects (0.361) (0.208) (0.149) (0.457) (0.278) (0.194) (0.076) (0.029) (0.055)
PD 0.968 0.728 0.823 2.288 0.578 0.939 0.280 0.168 0.181
subjects (0.399) (0.257) (0.204) (0.807) (0.616) (0.462) (0.220) (0.071) (0.135)

- Speed is the number of contacts per second. A speed drop from 1.285 to 0.968 touches per
seconds is observed for the PD group.
- Precision is the fraction of hits in A zone.
- Imprecision is the fraction of hits in B+C+D zone.
- Sureness is the average number of contacts per event (typically 2.2 zones ate touched).
- Tremor is the number of extra contacts per event (excluding side slip). Tremor is higher for PD
people (from 0.367 to 0.578, with an increase of standard deviation too).

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- Transit time is the average duration of transit from a target on one side to the other side
(seconds). Transit time is much worse for PD people (from 0.652 to 0.939, with a meaningful
increase of standard deviation too).
- Contact time is the average duration of contact on the target (s). Both mean and standard
deviation increases from the control group to the PD group.
- Fitts constant is the b constant in Fitts law (a is set to zero). Mean b value change from 0.119 for
the control group to 0.168 for the PD group. Standard deviation increases more than twice (to
0.071).
- Irregularity is the standard deviation of intervals between events. Irregularity of PD group is nearly
twice the control group.

Manipulation of objects. Some of the fine-motor control problems in PD patients are caused by a
reduced capability to coordinate the fingers and wrist and by reduced control of wrist flexion[67].
Metrics and data for these are listed below:
Arm/Shoulder angles during grasp to reach movement [68]. Angular motions of the
shoulder and elbow joints, Fig. 4, pp 635.
Wrist [69]
Movement delay (ms): 127
Time to maximum grip aperture (ms): 631
Finger [70]
Flexion amplitude (mm): Mean=59.32 for control subjects, Mean= 44.08 for patients
Extension amplitude (mm): Mean=60.24 for control subjects, Mean=42.52 for patients
Flexion duration (msec): Mean=100.99 for control subjects, Mean=190.13 for patients
Extension duration (msec): Mean=159.01 for controls, Mean=206.44 for patients.
Finger angle (deg): Fingers started opening at 20% of the normalized movement time and
reached a maximum around 60% Fig.4, pp. 88, [71].
Time to maximum grip aperture (ms): 97.

Gait disorders. Gait and posture impairment, are the most common motor problems associated
with aging [72]. In the parkinsonian gait pattern, improvement in gait usually means a decrease in
cadence [73]. Slowness of movements and reduced stride length are the prominent functional
limitation of PD [74]. Sometimes the phenomenon of frozen gait is also observed.
Table 1, from paper [74], is reported below. It shows a comparison between 29 able-bodied people
(15 young and 14 elder) and 21 PD patients. Statistically significant differences are observed for
gait speed and stride length. In addition people with PD show variability and asymmetry. The
average disease degree is also listed (35.8 UPDRS score). The paper also introduces a Phase
Coordination Indicator, PCI, (a new index) and shows it effectiveness in diagnosis of PD (Table 2,
and Fig.2).
Table 4.30 - Gait parameters in Parkinsons Disease
Youg adults (n=15) Elderly subjects (n=14) PD (n=21)
Age (years) 26.3 0.5 69.1 1.3 71.9 1.5
Gender (m/f) 7/8 7/7 16/5
Gait speed (m/s) 1.35 0.03 1.36 0.04 1.05 0.05
Stride length (m) 1.45 0.03 1.42 0.03 1.11 0.05
Stride time variability (%) 1.86 0.14 1.65 0.11 2.09 0.16
Gait asymmetry 0.84 0.19 1.52 0.26 5.17 1.64
Hoehn & Yahr stage - - 2.3 0.1
UPDRS score - - 35.8 2.6
* And # denote statistically significant difference (P<0.05) between the older adults and the patients with PD and between the older adults and the
youg adults, respectively, based on two tailed t-test comparisons except for Chi square comparison for gender. Entries are mean SE, except for

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gender. UPDRS: Unified Parkinsons disease rating scale.

Additional data, namely kinematic data for pelvis, hip, knee and ankle), can be found in paper [75],
table 2, which considers also the effect of medicaments (L-dopa). The same paper shows recorded
history of these variables as function of gait cycle phase (Fig.1 and Fig.2). The following is an
excerpt of Table 3 from the above paper, which summarizes the gait indicators. The range of
disease degrees spans the interval 12-57 UPDRS scores.

Table 4.31 - Gait parameters in Parkinsons Disease [75]


Control (preferred
PD off L-dopa PD off L-dopa + cues PD on L-dopa PD on L-dopa + cues
gait)
a a a
Stride length (m) 1.46 (0.08) 0.96 (0.19) 1.39 (0.06) 1.26 (0.10) 1.44 (0.07)
Speed (m/second) 1.51 (0.15) 0.94 (0.20)a 1.28 (0.08)a 1.25 (0.09)a 1.39 (0.21)
Cadence
124.1 (12.6) 118.3 (15.3) 110.4 (5.6)a 118.4 (6.8) 116.1 (15.4)
(steps/minute)
Gait cycle in double
18.5 (2.3) 24.7 (4.8)a 18.1 (3.9) 19.3 (3.3) 16.7 (4.8)
limb support (%)
Values are expressed as mean (SD)
a
P<0.05 compared to Control (preferred gait condition)

4.1.10. Dystonia

Dystonia is a neurological disorder characterised by involuntary, abnormal muscle contractions


that result in sustained abnormal postures, twisting, or both, and repetitive movements of body
parts. It arises from dysfunction of the motor control system within the central nervous system [76].
Heredodegenerative dystonia is a kind of dystonia, that is a sign associated with neurological
conditions, such as Parkinson's Disease and Huntingtons Disease.
Dystonia is, therefore, best conceptualized as a motor circuit disorder, rather than an abnormalcy
of a particular brain structure [77].
The clinical diagnosis of dystonia is based on the hallmark features of the abnormal, involuntary,
and prolonged muscle contractions with consistent directionality that lead to an abnormal posture
of the area affected. There is no definitive diagnostic test for dystonia. Investigation typically
involves history and clinical examination.
Severe generalized dystonia is frequently a prominent symptom and can be very disabling,
causing:
Gait impairment [78];
Pain [78];
Respiratory distress [78];
Lack of dexterity [79];
Abnormal posturing [79]
In dystonia, the fundamental problem involves excessive involuntary muscle contractions [80].
Muscles involved in an intended movement contract excessively, and there is overflow contraction
of nearby muscles not needed for the movement. The overflow sometimes includes muscles that
oppose the primary muscles, leading to co-contraction of agonist and antagonist muscles. The
appearance of the movements depends on the strengths and combinations of muscles involved.

Lower body parameters.


In Paper [81], some biomechanical characteristics of knee joint of motion and walking are pointed
out. The main outcome measures include the resistance of the knee joint at different velocities and

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positions, the maximum muscle activation, maximum isometric flexion and extension torques and
the velocity of walking. The purpose is the characterization of the relation between the torque and
the angle at the knee joint.
Table 4.32 reports the general characteristics of the limbs of patients with Dystonia. The outcome
parameters mean:
0: knee position at fully extension (by definition is 0);
MVCflex: maximal isometric torques in flexion;
COFLEX: co-contraction ratios during voluntary flexion;
MVCext: maximal isometric torques in extension;
COEXT: co-contraction ratios during voluntary extension.

Table 4.32 General characteristics of the limbs of patients with Dystonia


Parameter Unit Median Min Max
0 [rad] 1.22 0.97 1.31
MVCflex [N/m3] 0.60 0.00 2.11
COFLEX [%] 55 20 100
MVCext [N/m3] 3.9 15 5.12
COEXT [%] 52.50 20 80

The same article provides other parameters, reported in Table 4.33. The parameters mean:
CATCH_EXT: position when the torque sign changed from positive to negative during
extension;
TQ_CATCH_EXT: torque when the torque sign changed from positive to negative during
extension;
R2_EXT: position when the torque sign changed from negative to positive during extension;
TQ_R2_EXT: torque when the torque sign changed from negative to positive during
extension;
CATCH_FLEX: position when the torque sign changed from positive to negative during
flexion;
TQ_CATCH_FLEX: torque when the torque sign changed from positive to negative during
flexion;
R2_FLEX: position when the torque sign changed from negative to positive during flexion;
TQ_R2_FLEX: torque when the torque sign changed from negative to positive during
extension.

Table 4.33 The Tardieu scale characteristics in the limbs of patients with Dystonia
Parameter Unit Median Min Max
CATCH_EXT [rad] 1.00 0.75 1.08
TQ_CATCH_EXT [N/m3] -1.40 -2.30 -0.99
R2_EXT [rad] 0.47 0.27 0.70
TQ_R2_EXT [N/m3] -1.07 -2.23 -0.82
CATCH_FLEX [rad] 1.42 0.92 1.75
TQ_CATCH_FLEX [N/m3] 1.17 0.22 2.19
R2_FLEX [rad] 1.65 0.92 2.00
TQ_R2_FLEX [N/m3] 1.02 0.04 2.46

The same paper, also provides some values of spatiotemporal parameters (reported in Table
4.34). The gait characteristics mean:
FLEXin: knee angular position at the beginning of the stance phase;
STANCEmin: minimum knee angle during stance phase;

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SWINGmax: maximum knee angle during the swing phase;


ROMstance: knee ROM during stance phase;
ROMswing: knee ROM during swing phase;
Velocity: the walking velocity.

Table 4.34 The gait characteristics in the limbs of patients with Dystonia
Parameter Unit Median Min Max
FLEXin [deg] 35 5 55
STANCEmin [deg] 25 0 35
SWINGmax [deg] 46.5 5 75
ROMstance [deg] 9 0 20
ROMswing [deg] 8.50 0 23
Velocity [m/s] 0.37 0.13 0.50

Upper body parameters


Head. Paper [82] presents a protocol for the assessment of neck movements in patients affected
by cervical dystonia, by using an electromagnetic system.
Cervical Dystonia (CD) causes slowness and a lack of selectivity in the execution of voluntary head
movements. In paper [83] the kinematic features in cervical dystonia patients are evaluated. In
order to evaluate the head Range of Motion (ROM) in the space, all subjects performed six
independent active head and neck movements (flexion, extension, right rotation, left rotation, right
lateral flexion and left lateral flexion). Each of the voluntary movements started from a neutral
position and ended to the extreme range of excursion. The results of these tests are reported in
Table 4.35 and Table 4.36.

Table 4.35 - Range of motions of head and neck in patients with Cervical Dystonia (CD)
Plane Parameter Cervical dystonia Able-bodied people
Rest in sagittal plane [deg] 4.45 18.49 -0.21 4.38
Sagittal Flexion [deg] 37.47 15.08 58.91 10.83
Extension [deg] 49.87 40.01 74.87 6.24
Rest in axial plane [deg] 1.21 26.42 -1.07 2.82
Axial Right rotation [deg] 38.21 28.65 64.92 4.69
Left rotation [deg] 41.73 30.65 61.41 5.19
Rest in coronal plane [deg] 4.13 19.80 -1.10 1.72
Coronal Rigth lateral tilting [deg] 33.72 21.54 45.58 6.22
Left lateral tilting [deg] 30.24 23.60 47.22 3.36
Values are expressed as Mean Standard Deviation

Table 4.36 Coupled movements in patients with Cervical Dystonia (CD)


Main movement Coupled movement Cervical dystonia Able-bodied people
Axial [deg] 2.06 18.35 -0.51 3.60
Flexion
Coronal [deg] 1.08 12.88 -0.81 3.89
Axial [deg] -2.48 22.41 0.95 4.21
Extension
Coronal [deg] 1.90 34.22 -1.11 7.81
Sagittal [deg] 11.56 17.79 5.35 5.26
Right rotation
Coronal [deg] -4.26 20.35 -2.18 5.94
Sagittal [deg] 10.52 14.50 3.14 3.47
Left rotation
Coronal [deg] 3.03 20.19 2.84 7.91
Sagittal [deg] 5.12 19.49 1.06 14.49
Rigth lateral tilting
Axial [deg] 7.69 23.14 7.23 12.70
Sagittal [deg] 22.54 19.21 5.27 11.81
Left lateral tilting
Axial [deg] 4.70 20.44 -12.59 8.31
Values are expressed as Mean Standard Deviation

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Hand. Paper [84] compares the neuromusculoskeletal characteristics of subjects affected by focal
hand dystonia, a sort of cramp typical of writers (WC) and musicians (MC). 27 people participated
to a 8 weeks of supervised therapy. Table 4.37 reports some observed physical parameters, the
mean of which is better explained in [84]. In particular, CAFE40 is a physical function
questionnaire. Posture is related to a posture scale. UE ROM stands for upper extremity range of
motion and is given as a percentage of total possible.

Table 4.37 Physical parameters for musician and writer cramps


Parameter Unit Dystonia in MC Dystonia in WC
Posture score [% normal] 78.91 (11.54) 64.63 (20.14)
Upper Extremity Range of Motion
[% normal] 81.31 (9.86) 66.78 (18.27)
(UE ROM)
CAFE 40 [% normal] 89.96 (8.63) 79.08 (13.04)
Ordinal work [% normal] 67.14 (30.93) 68.75 (37.30)
Lumbrical strength [Ft-lbs] 2.00 (1.09) 6.80 (4.20)
FDP strength [Ft-lbs] 9.93 (4.80) 14.29 (8.22)
Strength ratio - 0.22 (0.08) 0.48 (0.21)
Values are expressed as Mean (Standard Deviation)

The paper also reports a set of sensory parameters, as summarized in Table 4.38.

Table 4.38 Sensory parameters for musician and write cramps


Parameter Unit Dystonia in MC Dystonia in WC
Graphesthesia [% Wrong] 33.85 (13.72) 53.23 (26.45)
Localization [cm off target] 15.67 (6.69) 20.82 (12.13)
Kinesthesia [mm off target per digit] 3.87 (2.10) 14.00 (17.51)
Stereognosis accuracy [% Wrong] 55.15 (27.81) 32.79 (18.04)
Stereognosis time [s] 118.10 (66.85) 117.72 (68.16)
Values are expressed as Mean (Standard Deviation)

4.1.11. Multiple sclerosis

Multiple sclerosis (MS) is one of the most common diseases of the central nervous system [85].
MS is the result of damage to myelin - a protective sheath surrounding nerve fibres of the central
nervous system. When myelin is damaged, this interferes with propagation of messages between
the brain and other parts of the body.
Symptoms vary widely and include:
Difficulty walking or performing tasks that require coordination [86];
Loss of sensation [86];
Fatigue and/or weakness [86];
Tremors [87];
Spasticity [88].
For some people, MS is characterized by periods of relapse and remission while for others it has a
progressive pattern. For everyone, it makes life unpredictable.
Tremor is estimated to occur in about 25 to 60 per cent of patients with multiple sclerosis. Tremor
in MS can involve some body parts directly related to movements: head, neck, trunk and limbs. In
MS, the two most prevalent tremor forms are postural tremor (tremor present whilst voluntarily
maintaining a position against gravity) and intention tremor (tremor occurring during target directed
movement where tremor amplitude increases during visually guided movements towards the
target).

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Rest tremor is often assessed with the tremor subscale of the Unified Parkinsons Disease Rating
Scale (UPDRS). Moreover, accelerometry and polarized light goniometry are neurophysiologic
methods of tremor assessment [87].

Gait parameters
Paper [89] reports the outcomes from some tests, executed in the context of a gait analysis
session of 21 patients with unilateral (or unilateral predominant) hip flexor weakness, with an ability
to walk with or without a walking aid a minimum distance of 30 m. The results are reported in Table
4.39. The T25FW is a test of walking speed on a short distance: subjects are instructed to walk 25
feet (7.5m) as fast as possible but safely. The time needed is reported (hence the fast walking
speed can be derived). The 6MWT assesses walking endurance. The distance walked over 6
minutes is recorded. The TUG measures the time needed to stand up, walk 3m, turn 180, walk
back 3m, turn 180 again, and return to a sitting position. The TUG associates balance and gait
performance components. The MCGT is a gait course reproducing the diversity of terrains,
obstacles, and manoeuvres encountered in real life. If the subject is able to complete the whole
course, the time needed to complete is recorded.

Table 4.39 - Outcomes from a gait analysis session for MS patients


Test Unit Mean Standard Deviation
T25FW [s] 18.9 19.1
6MWT [m] 647.7 423.6
TUG [s] 24.5 19.4
MCGT time to complete [s] 97.5 66.9

Paper [90] aims to evaluate gait kinematics of MS patients before and after an 8-week progressive
resistance-training intervention. The kinematic gait parameters include the knee range of motion,
duration of stance, swing, double support-phase, and the other reported in Table 4.40 and in Table
4.41.
Table 4.40 Values for some gait characteristics of MS patients (part 1)
Most-affected limb Least-affected limb
Parameter Unit Pre-intervention Post-intervention Pre-intervention Post-intervention
Knee ROM [deg] 52.8 6.4 51.7 6.1 53.8 8.2 52.3 4.9
Stride time [s] 1.22 0.22 1.20 0.18 1.23 0.18 1.21 0.18
Stance time [s] 0.83 0.18 0.80 0.17 0.84 0.15 0.82 0.15
Stance* [%] 67.4 3.9 66.4 3.9 67.4 2.7 67.7 2.7
Swing time [s] 0.39 0.04 0.4 0.03 0.4 0.04 0.39 0.05
Swing* [%] 32.6 3.7 33.6 3.9 32.6 2.7 32.3 2.7
Step length* [m] 0.53 0.09 0.58 0.07 0.53 0.07 0.56 0.07
Foot angle* [deg] 13.9 9.1 9.82 7.0 10.7 5.4 10.7 5.4
Toe clearance* [m] 0.16 0.03 0.14 0.05 0.17 0.06 0.17 0.06
Values are axpressed as Mean Standard Deviaiton
* Significant difference between pretest and posttest in at least 1 limb (P<0.05)

Table 4.41 - Values for some gait characteristics of MS patients (part 2)


Parameter Unit Pre-intervention Post-intervetion
Double support time* [s] 0.23 0.07 0.21 0.06
Double support* [%] 18.3 2.8 16.8 2.8
Stride length* [m] 1.06 0.16 1.14 0.12
Velocity [m/s] 0.91 0.23 0.98 0.22
Step width [m] 0.19 0.04 0.22 0.09
Values are axpressed as Mean Standard Deviaiton
* Significant difference between pretest and posttest in at least 1 limb (P<0.05)

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Other data about the same kind of parameters are reported in [91], and summarized in Table 4.42.

Table 4.42 - Other spatiotemporal parameters of the gait analysis for MS patients
Parameter Unit Normal Multiple Sclerosis
Cadence [steps/min] 114 9 102 6*
Velocity [m/s] 1.30 0.2 0.98 0.1*
Stride length [m] 1.35 0.12 1.06 0.21*
Stance phase [% gait cycle] 60.8 2.3 71.2 3.5*
Double stance [% gait cycle] 10.1 1.4 15.6 2.7*
Values are axpressed as Mean Standard Deviaiton
* All spatiotemporal parameters were found to be significantly different between the two groups (P<0.05)

Paper [92] aims to perform a full biomechanical characterization of gait in people with multiple
sclerosis. Kinematic and kinetic data were collected using a motion capture system. Table 4.43
summarizes some of the numeric values.

Table 4.43 Values for movements at hip, knee and ankle joints during gait of MS patients
MS Patients Control Group
Standard Standard
Parameter Unit Mean Mean
Deviation Deviation
Min hip flexion [deg] -6.86* 7.4* -15.6* 3.8*
Min knee flexion at toe off [deg] 6.24* 6.8* -0.14* 3.2*
Max knee flexion [deg] 63.23 12.8 65.44 8.7
Peak ankle plantarflexion [deg] -12.22* 11.5* -24.47* 7.3*
* indicates a statistically significant difference between control subjects and MS patients at p<0.05

Paper [93] gives some information about the balance of MS patients. The balance is expressed as
the measure of the anteroposterior and mediolateral sway, and the velocity sway. The postural and
velocity sway have been calculated by the centre of pressure of the foot against a force platform.
Other outcomes from gait tests are also reported in [94].

Strength parameters
Paper [95] characterizes passive mechanical properties of gastrocnemius, obtaining the passive
ankle torque as function of the ankle and knee angles. The equation that results from this study is:

(4.1)

where:
The left side is the passive torque at the ankle, which is function of both ankle and knee
joint angles;
The first term at the right side is the torque due to single-joint structures on the plantar
aspect of the ankle;
The second term at the right side is the torque due to single-joint structures on the dorsal
aspect of the ankle;
The third term at the right side is the torque due to the gastrocnemius;

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and are ankle angle and knee angle respectively;


are parameters that determine the stiffness of structures of the ankle;
are ankle angles at which plantar flexors and dorsiflexors are slack respectively;
is the moment arm of gastrocnemius at the ankle;
is the length of the gastrocnemius muscle-tendon unit;
is the slack length of the gastrocnemius muscle-tendon unit.

For other information about the parameters and the computing of them, see the Paper [95].
In the same paper, there are some data about various strength parameters, as reported in Table
4.44. The table reports the slack lengths and the maximal strains of the muscle-tendon unit (MTU),
muscle fascicles and tendon, and the areas under the passive length-tension curves across the
length in vivo from 7 pairs of subjects with multiple sclerosis (MS) and healthy controls.

Table 4.44 - Strength data of lower limb for patients with MS


MS Patients Control Group
Standard Standard
Parameter Unit Mean Mean
Deviation Deviation
MTU slack length [cm] 42.7 3.4 41.4 2.4
Maximal strain of MTU [%] 17.7 2.6 18.3 4.6
Muscle fascicle slack length [cm] 3.8 0.3 3.9 0.2
Maximal strain of muscle fascicles [%] 79.2 12.5 78.7 22.8
Tendon slack length [cm] 39.3 3.4 37.9 2.5
Maximal strain of tendon [%] 11.2 2.0 11.4 3.0
Area under passive length-tension curves [Nm] 2.6 0.5 3.0 0.6

In summary, the paper showed that passive mechanical properties of gastrocnemius in people with
multiple sclerosis who are ambulant but without clinical signs of contracture do not differ from those
in neurologically normal people.
Paper [90] gives the isometric strengths before and after an 8-week resistance-training program.
The outcomes are summarized in Table 4.45.

Table 4.45 Isometric strengths at knee and ankle joints in MS patients


Parameter Unit Pre-intervention Post-intervetion
Knee extension* [Nm] 74.7 20.6 80.1 20.7
Knee flexion [Nm] 39.3 10.9 45.6 24.1
Plantarflexion* [Nm] 60.2 20.3 93.4 45.3
Dorsiflexion [Nm] 29.1 9.9 29.1 11.6
Values are axpressed as Mean Standard Deviaiton
* Significant difference between pretest and posttest in at least 1 limb (P<0.05)

In [96], an approach consisting of measuring force vectors at the fingertips of the impaired hand is
presented.
In paper [97], the ataxia (disorder or confusion of the movements) and dysmetria of MS patients
are measured. The main outcome measures were the average radial distance away from the target
(mean R) and the mean directional error (mean V) of 10 contact time from a defined target. The
patients were asked to touch the target 10 times for both hands and grasping a pen.
The parameter R represents the average distance from the target of all 10 points. The parameter V
is a measure of the tendency to veer (this parameter gives an information about the presence of a
directionally preponderant dysmetria). The MS patients were also divided in groups, according on
their upper limb symptoms. The Table 4.46 reports the outcomes for the radial distances from the
target, whereas Table 4.47 reports the mean directional error.

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Table 4.46 - Radial distances R from the target


Right hand Left hand
Group Standard Standard
Mean [mm] Range [mm] Mean [mm] Range [mm]
Deviation [mm] Deviation [mm]
Healthy controls 2.9 1.2 1.2-6.2 3.2 1.2 1.6-7.0
MS Controls 3.6 1.1 2.6-6.0 5.0 1.4 2.4-7.8
MS tremor 4.4 1.9 2.9-8.4 5.9 3.3 2.2-13.3
MS dysmetria 12.0 4.7 7.0-18.3 16.7 11.0 6.8-35.3
MS mixed 20.1 32.6 2.5-149.1 26.1 37.0 3.1-162.6

Table 4.47 - Mean directional error V


Right hand Left hand
Group Standard Standard
Mean [mm] Range [mm] Mean [mm] Range [mm]
Deviation [mm] Deviation [mm]
Healthy controls 1.6 1.0 0.3-4.2 1.4 1.2 0.2-4.1
MS Controls 1.7 1.0 0.1-3.8 2.2 1.1 2.2-4.0
MS tremor 1.8 0.8 0.7-3.4 2.7 2.7 0.9-9.3
MS dysmetria 7.1 4.2 3.1-14.8 13.0 1.80 2.5-31.5
MS mixed 14.0 28.4 0.5-132.3 15.7 26.3 0.1-97.9

4.1.12. Cerebral palsy

Cerebral Palsy (CP) [98] is a broad set of motor disorders which are caused by damages to the
cerebellum and its connections to the motor cortex, which occur during pregnancy, birth or in the
very first years of life (up to three years). No cure is known for any of the different types and
subtypes of CP. The disease is non-progressive as for what concerns the neurological aspects, but
it is progressive as for what concerns the orthopaedic aspects (due to permanent muscle
contraction).
CP may be accompanied by disturbances of sensation, perception, cognition, speech, behaviour
and/or by a seizure disorders.

CP is classified according to following types (which reflects different damaged brain areas):

Spastic CP: spastic CP is the most frequent type (~80%). It is caused by damages to the
upper motor neurons and to the corticospinal tract, which in turn becomes no longer able to
regulate muscle tone. Consequently, the group of muscles that depend on the damaged brain
structures result constantly contracted and become hypertonic (i.e., they present a velocity-
dependent increasing stretch resistance). There are subtypes of Spastic CP, depending on the
affected limbs:
o Spastic hemiplegia occurs when one side is affected (this is the worst clinical case).
o Spastic diplegia is when both lower limbs are affected (this is the most common type).
Spastic diplegia impairs gait. A gait pattern called scissor gait is typical of this disease.
o Spastic monoplegia, triplegia and quadriplegia occurs when one, three or four limbs
are respectively affected.
The affected limbs may present violent uncontrolled movements (clonus) and involuntary
contractions (spasms). Pain and early tendinitis and arthritis may be caused by continuous
muscle contraction and is managed with physical activity or medications.
Voluntary and passive movements are difficult because of the excessive muscle tone. People
affected by Spastic CP experience a strong resistance to movements of the affected limbs.

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The degree of spasticity varies widely from person to person.

Ataxia: it is the least frequent case (~10%). It is caused by damages in the cerebellum that
lead to hypotonia and tremors and lack of muscle coordination. Thus many manual tasks like
object handling, pointing, writing, etc. is difficult for these people. Also balance problems while
walking are reported.

Dyskinetic CP: it occurs in 10-20% of cases. It causes mixed muscle tones, which in turn
cause difficulty to achieve coordinate motion [99]. For example walking, sitting, holding objects
and reaching specific spots to grasp objects. Involuntary movements can also occur.

Hypotonic CP: it causes insufficient muscle tone. People with hypotonic CP can move very
little.

Overall, the effects of CP span a large spectrum of symptoms, which range from slight clumsiness
to severe movement coordination deficit (fine and gross motion), speech, hearing vision and
cognition which impacts on many aspects of person life [100].
Muscle tone [101] and reflexes [102], [103] are abnormal, which in turn affects motor coordination.
In addition, the development of bones and joints may be influenced by muscle contractures,
leading to deformities. In fact, people with CP exhibit different degrees of deformities of bones and
joints. Joint cartilage atrophy may be caused by scarce use. Musculoskeletal aspects are reviewed
in [104].
Gait is affected by CP in several aspects: unsteady gait and balance problems, scissor walking, toe
walking, equinus gait are the most common effects.
Speech disorders are frequent in people with Cerebral Palsy. Dysarthria is estimated to range from
31% to 88%. Speech problems are caused by poor respiratory control and reduced movement
control in the oral-facial muscles. The speech characteristics are: imprecise consonants, irregular
articulatory breakdown, distorted vowels, excess and equal stress, prolonged phonemes, slow
rate, monopitch, monoloudness and harsh voice (see also speech section for metrics).

Metrics.

The Manual Ability Classification System (MACS) is a clinical scale, which assess the ability of
children with CP in handling (with their hands) objects in their daily activities[105]. The scale gives
a classification in 5 levels.

The Modified Ashworth Scale is a six-point rating scale with good validity and interrater reliability
for grading spasticity [106].

The Zancolli Classification of Voluntary Grasp and Release Patterns of the Hand, Wrist, and
Fingers is a 3 level scale (with two subgroups at level 2) [107].

The Gross Motion Function Classification System (GMFCS) is another 5 level clinical scale
related to gross motion skills (i.e., sit, stand, walk and climb stairs). The scale range from level 1,
which corresponds to mild disabilities (reduced speed, balance and coordination) to level 5, where
self-mobility is severely limited even with the aid of assistive technology [108].

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The Gross Motor Function Measure (GMFM) [109],[110] is a criterion-based quantification scale.
The GMFM score consists of 88 items grouped into 5 dimensions: lying and rolling (17 items),
sitting (20 items), crawling and kneeling (14 items), standing (13 items), and walking, running, and
jumping (24 items).
Paper [108] provides the expected GMFM as function of age for the 5 GMFCS levels, as shown in
the following figure.

Figure 4.15 - Gross Motor Function Measure (GMFM) scores as function of age, for each of the 5
GMFCS levels.

The paper reports also fitting curve equations. For age greater than 2-3 years, curves tend to a
horizontal asymptote. The GMFM score tend to stabilize at:
96.8 2.6 for level I;
89.3 5.5 for level II;
61.3 2.9 for level III;
36.1 2.9 for level IV;
12.9 3.0 for level V.
Given the GMFM score, paper [108] gives the probability of passing motor tasks of various
difficulties, as shown in the following table.

Table 4.48 Chance of passing motor tasks.


GMFM Total Score
GMFM Item at Which the Chance
Gross Motor Skill
and Score(s) of Passing Is
50 % 95 %
(#8 or #9=3) From supine, con roll prone to right or left side 18.8 46.1
(#24=3) From Sitting, can maintain sitting position with arms free for 3+ seconds 23.5 41.7
From sitting on a bench, can maintaining sitting position with arms free but feet supported for 10+
(#34=2 or 3) 29.8 54.3
seconds
(#67=3) From standing, can walk forward 10+ steps with hands held 40.8 63.6
(#44=3) From 4-point, can crawl or hitch 6+ feet 43.6 61.4
(#45=3) From 4-point, can crawl reciprocally 6+ feet forward 53.6 75.5
(#36=3) From the floor, can sit on a bench 55.6 68.6
(#35=3) From standing, can sit on a bench 56.1 72.0
(#56=2 or 3) From standing, can maintain standing for 3+ seconds with arms free 66.5 86.8
(#69=3) From standing, can walk forward 10+ steps with arms free 69.6 87.0
(#59=3) From sitting on a bench, can stand with arms free 71.8 88.7
(#84=1, 2 or 3) From standing, can walk up 2+ steps, same foot leading, while holding one rail 71.4 87.7
(#70=3) From standing, can walk 10 steps, turn and walk back 72.0 87.3

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GMFM Total Score


GMFM Item at Which the Chance
Gross Motor Skill
and Score(s) of Passing Is
50 % 95 %
(#77=3) From standing, can run 15 feet, stop and run back 83.7 98.8
85.3 98.2
(#86=1,2 or 3) From standing, can walk up 2+ steps, same foot leading, with arms free 86.6 97.8

The House classification was developed for the evaluation of function in the affected hand after
surgery for thumb-in-palm deformity in children with spastic hemiplegic CP [111]. The classification
consists of 9 grades ranging from a hand that is not used at all (grade 0) to 1 that is used
spontaneously and independently from the other hand (grade 8)

The Life-H questionnaire [112] was developed, from the WHOs international classification of
functioning, to measure the level of participation of disabled people to life situations. It comprises
62 items grouped into 11 domains covering both daily activities and social roles. The study [100] is
a large-scale international survey involving 818 children of 9 European regions. The study provides
statistical data concerning gross motion functions, fine motor skills, intellectual impairment, vision,
hearing, seizures, feeding, communication, subtype of CP, pain (Table 2). An excerpt of table 2
concerning physical and cognitive impairments is here reported.
Further tables are provided in the study, giving statistic information on the success rate in several
type of daily tasks (table 3,4): mealtimes, health hygiene, personal care, communication, home life
and getting about; responsibilities, relationships, community life, school and recreation. Further
tables investigate the relation between impairment type and degree, and the effect on the level of
participation in daily and social life (tables 5-7). These tables can provide a first qualitative
assessment of the success rate of children with CP on the execution of daily life activity and could
be used as qualitative rules in the virtual user model.

Table 4.49 Type and level of disability from survey [100]


Function No (%)
Gross motor function
1 Walks and climb stairs, without limitation 257 (31)
2 Walks with limitations 164 (20)
3 Walks with assistive devices 139 (17)
4 Unable to walk, limited self mobility 113 (14)
5 Unable to walk, severely limited self mobility 145 (18)
Fine motor skills:
1 Without limitation 281 (34)
2 Both hands limited in fine skills 205 (25)
3 Needs help with tasks 131 (16)
4 Needs help and adapted equipment 91 (11)
5 Needs total human assistance 110 (13)
Intellectual impairment
None or mild (IQ>70) 385 (47)
Moderate (IQ 50-70) 186 (23)
Severe (IQ<50) 242 (30)
Information not available 5 (1)
Vision
Has useful vision 759 (93)
Blind or no useful vision 59 (7)
Hearing
Does not need hearing aids 799 (98)
Needs hearing aids (>70 decibel loss) 18 (2)
Information not available 1(0)

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Sitting and Posture. Children with cerebral palsy tend to sit with the center of pressure forward.
When sitting with the arms on a table and with the line of gravity anterior to the ischial tuberosities,
weight is also distributed through the arms [113].
Unstable seating affects negatively the upper extremity motor control. Anteriorly tilting the seats
may disturb postural stability, without improving performance of the upper extremity. [114].
Dysfunctions are present in the modulation of the response pattern of ventral muscles during
forward translations [115].
Arm performance is affected substantially by sitting posture [116]. The effect of body inclination
(seating from 30 backward to 15 forward) on a simple motion task is studied in [117]. The task
was to move the arm from the starting position (shoulder abduction) to the midline position
(shoulder adduction) to touch a switch on cue from the video monitor and to withdraw their hand as
quickly as possible. The mean performance time as a function of seat inclination is given for
athetoid and spastic CP. No data about the degree of disease (GMFCS or GMFM) are however
given, so the results are difficult to interpret.

In Wheelchairs, pressing against one or both armrests and /or one or both footplates the trunk is
assisted or pushed to an extended position [118]. The trunk is moved to behind the position it
should have had if it was upright [118].

Deficits in head stability in the sagittal plane and deficits in trunk control that affect head stability in
the frontal plane are also reported [119]. The paper compares sway motion for children with CP
with able-bodied (Typical Development) children according to 4 different metrics (which were
defined in [120]): root mean square of displacement (RMS), mean velocity (MV), root mean square
for velocity RMSV, and the frequency which contains 95% of signal power (P95). Children with
GMFCS I-III are considered.
The following figure reports results from the paper, for sway movements in sagittal (on the left of
the figure) and frontal planes (on right of the figure), planes that are quite similar.
CP subjects show significant differences in root mean square of displacement (RMS), mean
velocity (MV), root mean square for velocity RMSV, but not in the frequency content (P95).
The aggregated CP subjects show mean velocity (MV) approximately 1 cm/s, twice the value of
able-body children in the age 4-6, and several times (~5) the value of adults. Of the CP subjects
those with dyskinetic CP show twice the sway than the aggregated CP group (nearly 2 cm/s). The
root mean square of velocity RMSV gives similar results. Also similar conclusions are drawn from
the analysis of the root mean square displacement (RMS).

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Figure 4.16 - Group means for sway parameters in sagittal (left) and frontal (right) planes. Head
movement for control group (light gray bars) and children with CP grouped by age (dark gray bars)
or grouped by movement disorder (white bars). Error bars, intersubject SE. Asterisk indicates p <
0.05.

Manual abilities.

Impaired manual dexterities [101] affect writing, personal care, use of equipment like telephone,
computer, audiovisual devices, personal care etc. [100]. Arm and hand loss of sensation is
described in [102], [103].

Reach and Grasp. Assessments of reach and grasp motor skills is carried out in [121]. The paper
compares 10 able-bodied children to 10 subjects with CP of different types. The degree of disease
is rated according to the Modified Ashworth scale, which was found to be significantly correlated to
normalized jerk. The test tasks consisted in reaching and grasping two different sizes of buttons
(one with accuracy constraint and the other with non-accuracy constraint). Motion was analyzed
and a number of indicators were derived. Three indicators were found to be statistically significant
of the disability: movement time (MT), jerk (NJS) and number of movement units (NMU).
Jerk is measured with the following power indicator:

(4.1)

where T is the motion time, L the displacement and j(t) is the recorded jerk (the derivative of
acceleration).
The number of movement units is defined as the number of minima to maxima transitions in speed
velocity (exceeding a certain threshold). This indicator is similar to the number of speed maxima in
the section of stroke.

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The following table summarizes the findings. It can be concluded that, in case of precise
movements (small button) for CP subjects the movement time is 36% greater and jerk is 3.7 times
greater. For less precise reach (large button) the disadvantage reduces to 18% for movement time
and to 2.3 times for jerk.

Table 4.50 Movement time and jerk in reach and grasp tasks
Parameter Small Button Large Button
Mean (SD) Able-Bodied CP Able-Bodied CP
MT (s) 0.67 (0.11) 0.91 (0.31) 0.66 (0.12) 0.78 (0.23)
NJS 40.7 (17.6) 150.6 (134.7) 41.1 (22.9) 92.9 (65.7)
NMU 1.40 (0.47) 3.00 (1.3) 1.63 (0.6) 2.86 (1.10)

Fitts Law. A number of papers considered the use of the Fitts law to model pointing skills in
CP[122], [123], [124], [125], [126], [127], [128],[129], [130], [131], [132]. The use of Fitts law is
controversial in paper [127], according to which movement times had no significant adherence to
Fitts' law (but high error rates that could be the result of oculomotor problems among the subject
group were noted).
Paper [125] reviews the work above and redesigned a test for children with hemiplegic CP.
Because of great motor coordination problems of CP subjects, traditional input devices were not
used and thje Fitts test was carried out on a LCD screen using direct hand pointing (holding a
puppet that had to land onto specific spots on the screen). Another difference was that movement
did not have to be made by the fingers, which are usually most constrained in hemiplegic patients.
Test span index of difficulty (ID) range from 2 to 4 bits. Children had a degree of disability rated
with the Zancolli scale with score I, IIA, and IIB (mild and moderate hand dysfunction).
The conclusion was that the intercept a of the Fitts law, corresponding to the time required to
realize a tapping movement, was (about 300 ms) higher in the affected hand of the children in the
CP group.
(4.2)

However, the slope b (which reflects the sensitivity of the motor system to a change in difficulty of
the task) was similar in both CP and control groups.
Overall the movement time was much longer (~60 and 80%, respectively) for movements made by
the children with hemiplegic CP.
A study that concerns the use of Joysticks (a force Joystick and a position Joystick) is given in
[128]. The study considered three groups of CP subjects classified as mild, moderate and
severe (with no indication of any clinical scale) and a control group. The overall processing rate,
defined as ID/MT is reported as in the following table for the two types of Joystick.

Table 4.51 Processing rate: Mean (SD), (bits/s)


Subjects Force Joystick Position Joystick
Able-Bodied 5.41 (0.94) 7.25 (0.91)
Mild CP 2.21 (0.91) 3.81 (0.89)
Moderate CP 2.08 (0.87) 3.49 (0.86)
Severe CP 0.47 (0.64) 1.32 (0.54)

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Hand function. A study on hand function in 367 children with CP (several subtypes) is reported in
[133]. The study reports the distribution between MACS levels in the total population. Of the 367
children, 236 (64%) were independent in age-relevant manual activities (MACS I and II), whereas
53 children (14%) did not have any active hand function and were totally dependent on others in
their daily occupations (MACS V). Data are here reported per CP subtype in the following table.

Table 4.52 Distribution of MACS levels in study [133]


Total Number
CP Subtype MACS 1 MACS 2 MACS 3 MACS 4 MACS 5 Missing Data
of Children
Spastic
71 41 10 4 0 2 128
Hemiplegia
Spastic
0 0 1 1 13 0 15
tetraplegia
Spastic
68 32 23 11 9 2 145
diplegia
Dyskinetic 5 5 4 12 23 0 49
Ataxic 9 1 3 2 2 0 17
Unclassified or
2 2 1 2 6 0 13
mixed
Total 155 81 42 32 53 4 367

In order to use the above data, the functional limitations that occur with each MACS level are
reported in the following table.

Table 4.53 MACS levels functional limitations.


MACS Level Description
1 Handles objects easily and successfully
2 Handles most objects but with somewhat reduced quality or speed of achievment
3 Handles objects with difficulty; needs help to prepare or modify activities
4 Handles a limited selection of easily managed objects in adapted situations
5 Does not handle objects and has severely limited ability to perform even simple actions
Children in MACS l and II are considered to be independent in age-relevant daily activities

Similar data are reported for the House and Zancolli scales (see paper for further details).

Paper[134] is a study of hand impairments and manual abilities in children with CP. Hand motor
impairments are assessed with 3 tests, which are: grip strength (Jamar dynamometer), gross
manual dexterity (Box and Block Test) and fine finger dexterity (Purdue Pegboard Test). Hand
sensory impairments are assessed with 3 other tests: tactile pressure detection (Semmes-
Weinstein aesthesiometer), stereognosis (Manual Form Perception Test) and proprioception
(passive mobilization of the metacarpophalangeal joints). The paper focuses on the relation
between hand impairments and manual abilities (measured with a standardized questionnaire) and
does not report raw data, which are converted in a score scale (thus of little usefulness for
VERITAS). Fig.1 of the paper reports the distribution of scores (z-score) for grip strength, gross
manual dexterity and fine finger dexterity.

Grasp, Pinch and dexterity. Paper [135] reports data about grasp force, pinch force and dexterity
(measured with a 9 peg board test) for children with moderate spastic hemiplegia (no level on any
clinical scale is specified). Data are reported with bare hand and with splints (a static and a
dynamic splint). The following able reports the grip force, the lateral pinch force and time to
complete the peg dexterity test for both the dominant and non-dominant hand.

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Table 4.54 Hand metrics in children with spastic hemiplegia.


Control Group CP Group
Nondominant
Measure Splint Dominant (n=5) R Hemi (n=5) L Hemi (n=5) Overall p-Value
(n=5)
No 23.5 (6.9)* 22 (8.9)* 7.9 (16.1) 1.7 (2.1) <0.001
Grip [lb] Dynamic 20.1 (6.8)* 18.2 (6.8) 10.8 (11.8) 1.6 (1.2) 0.002
Static 23.5 (7.6)* 18.4 (6.5)* 5.4 (8.4) 0.6 (0.4) <0.001
No 9.7 (1.8) 9.8 (0.9) 6.1 (5.4) 2.4 (2.7) 0.01
Lateral Pinch [lb] Dynamic 9.8 (1.6)* 9.0 (1.6)* 5.3 (5.6) 1.6 (1.5) 0.002
Static 9.8 (0.7)* 8.2 (2.8)* 4.1 (4.7) 1.1 (1.1) 0.002
No 5.7 (1.8)* 6.9 (1.9)* 36.5 (31.7) 51.3 (24.3) <0.001
Peg Dexterity
Dynamic 5.3 (1.7)* 6.7 (1.6) 29.2 (28.6) 41.7 (26.0) 0.003
[sec]
Static 6.1 (2.0)* 6.9 (1.6)* 29.6 (27.2) 47.9 (21.4) 0.001
CP = children with cerebral palsy; L = left; Hemi = Hemiplegia; R = right
Note: Significances reflect analyses on lof transformed data.
* Scores are significantly higher on grip and pinch and/or lower on pegs than both groups of children with CP.
Scores are significantly higher on grip and pinch and/or lower on pegs than children in L Hemiplegia CP group only.

A study on fingertip force control (with data) can be found in[136].

Rigid and awkward movement performance in grasping objects is described in [137]. Awkwardness
ratings are given in paper table 4 (no measurable data).

Upper limbs functions. A study the relationship between neuromuscular body function and elbow,
forearm, and hand activity in children adolescents with CP is [138]. Twenty-three participants
(mean age 13y, range 818y) with spastic CP (21 with hemiplegia, 2 with diplegia) at Manual
Ability Classification System levels I to III participated in the study. Neuromuscular body function
measures were (1) muscle strength in the elbow, forearm, and grip, (2) muscle tone in elbow
flexors and forearm supinators, (3) active supination range and elbow extension range, and (4)
force control at submaximal level in elbow flexion. These data were correlated with hand activity
(assessed with two specific clinical scales: Assisting Hand Assessment and Melbourne
Assessment of Unilateral Upper Limb Function). Paper found that limited active supination range
and difficulties in generating and modulating force are strongly related to limitations in hand
activity.
The following table reports the parameter that were measured (mean and SD) and the grades
according to the two chosen clinical scales. As for what concerns the range of motion, it was
reduced more in the forearm than in the elbow: twelve out of 23 participants had full extension
range in the elbow, whereas only two had full supination range.
Force control capacity was evaluated through a force modulation task. The participants were
instructed to follow a target force by isometrically flexing the elbow. The target signal consisted of a
linear increase followed by a linear decrease between 0 and 40% maximal voluntary contractions
in 30 seconds. Online visual feedback of both the target force and the force actually generated was
provided on a monitor (full screen) placed at a convenient distance in front of the participant. The
elbow angle was set to 60 (from full extension). The table below reports the root mean square
(rms) and the coefficient of variation (CV) of the difference between the applied force and the
target force were calculated.

Table 4.55 Upper limb metrics in children/adolescent according to [138].


Variables Unit Mean SD
Flexion torque elbow [Nm] 7.83 4.96
Extension torque elbow [Nm] 10.83 6.78

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Variables Unit Mean SD


Supination torque forearm [Nm] 0.69 0.65
Pronation torque forearm [Nm] 1.17 0.84
Grip force [N] 104.83 66.50
Resistance torque elbow extension [Nm] 2.33 1.16
Resistance torque forearm supination [Nm] 0.35 0.20
AROM elbow extension [deg] -9.34 13.43
AROM forearm supination [deg] -55.21 39.21
Force control 0-40 rms [%] 4.75 4.36
Force control 40-0 rms [%] 6.11 5.09
Force control 0-40 CV [%] 0.19 0.19
Force control 40-0 CV [%] 0.53 0.99
Melbourne Assessment [%] 80.78 15.23
AHA [%] 62.91 22.70
N=23 for all variables except force control (n=20). AROM, active range
of motion; rms, root mean square; CV, coefficient of variation; AHA,
Assisting Hand Assessment

Gait and Ankle. A large number of studies can be found in the literature about gait in CP. Among
those that report data we selected a few.

Gait patterns in spastic hemiplegia have been classified by Winters, Gage and Hicks [139]; see
also [104] Fig.2 and Fig.3. Groups I and II include children with distal involvement expressed as
equinus contracture and drop foot. Group III and IV involve also proximal joints (jump knee/hip
flexion).

Paper [140] reports ankle torque-rotation characteristics. With a rotational dynamometer,


moment-angle relations were measured at: (1) the angle at 0 Nm (neutral), (2) the angle at -4 Nm
(plantar), (3) the angle at 4 Nm (dorsal), (4) the moment at the angle halfway between angles 1
and 2 (half plantar), and (5) the moment at the angle halfway between angles 1 and 3 (half dorsal).
The following table reports the findings (note that there are no units! However presumably units are
in SI; note also that the definition of half-plantar and half-dorsal are quite unclear).

Table 4.56 The mean (SD) angles and moments measured in the control group (CTD) and CP
children (CCP) group for the study. As neutral, plantar and dorsal angles were always measured at
the same moment, the SD of these measurements is zero.
Group Parameter Measurement
Neutral Plantar Dorsal Half Plantar Half Dorsal
CTD Angle -6.0 (7.7) -60.0 (9.1) 26.0 (7.3) -35.0 (6.4) 9.5 (8.0)
Moment 0.0 (0.0) -4.0 (0.0) 4.0 (0.0) -1.6 (0.4) 1.2 (0.7)
CCP Angle -10.0 (6.1) -57.0 (12.2) 8.0 (5.3) -30.5 (10.1) -2.0 (9.0)
Moment 0.0 (0.0) 0.0 (0.0) 4.0 (0.0) -1.2 (1.1) 0.8 (0.9)

Passive stiffness characteristics of ankle plantar flexors in hemiplegia is investigated in [141].


Since the characteristic is non-linear, the paper reports fitting polynomials.

A Fourier series analysis of the foot to ground reaction force is given in paper [142]. The paper
also reports average walking speed and stance time (however the degree of disability, e.g.,
GMFCS score, is not declared). Subjects were hemiplegics and mild diplegics (a precise clinical
scale rating is not given). The following table reports the observed walking speed and stance
phase.

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Table 4.57 Walking speed and stance phase in study [142].


Subjects Walking speed (m/s) Stance phase less affect leg Stance phase more affected
(s) side (s)
Control Group 1.38 m/s 0.55 s
CP Group 1.05 m/s 0.59 s 0.62 s

A correlation between the GMFM score and gait parameters is investigated in [143]. The study
involved 26 children with CP and 4 with other head injuries aged 1-8 (mean 4.2, SD 2.2). Half were
capable of walking independently, half needed assistance from a therapist (these latter were on
average younger and quadriplegic). A correlation of 0.899 is obtained between gait velocity and the
total GMFM score. Fitting equation is not declared but can be estimated from paper Fig.2 as:
(4.3)

where v is the velocity in m/s (GMFM=92 @1 m/s, GMFM=48 @0.1m/s). The inverse equation
could be used to estimate a corrective coefficient as a function of the GMFM score. Fitting curves
are found also for cadence and stride length but the paper reports only the correlation coefficient
and no data for the fitting equations!
A comparison with typical development children of the same age is given in paper Fig.5. Data
estimated from that figure are reported here below.

Table 4.58 Gait parameters for age groups


CP age<4y Control age<4y CP age>4y Control age>4y
Velocity (cm/s) 32 85 90 110
Cadence (steps/min) 90 160 140 150
Step Length (cm) 19 32 37 45

Dependence on the age (via the GMFM score) is also pointed out.
The following table reports the average and standard deviation for the whole group and for the sub
groups that were independent and non-independent walkers. The GMFM total score, as well as the
A-E sub scores is also reported.

Table 4.59 Gait parameters and GMFM scores for children with CP [143].
Total group With support Without Support
(N = 30) (N = 15) (N = 15)
FMFM
Global (%) 74 (23) 56 (18) 92 (5)
A (%) 95 (7) 92 (8) 98 (3)
B (%) 89 (20) 78 (25) 99 (2)
C (%) 79 (31) 61 (35) 97 (6)
D (%) 60 (33) 32 (22) 88 (5)
E (%) 47 (35) 15 (9) 80 (15)
STM
Velocity (cm/s) 59 (39) 23 (13) 95 (17)
Stride length (m) 56 (27) 33 (10) 79 (15)
Cycle duration (s) 1.422 (1.168) 2.006 (1.444) 838 (110)
Cadence (steps/min) 113 (43) 80 (33) 146 (20)
Values are means SD in parentheses

A study [144] investigates differences in the variability and symmetry of spatiotemporal gait
characteristics during the early years of walking in children with bilateral spastic CP compared to
children with similar amounts of walking experience and typical development (TD). The study

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focuses on young walkers with an average walking experience of 28.5 months. All primary
spatiotemporal parameters (velocity, cadence, step length and single support duration) were
reduced in the CP group, who also demonstrated greater stride-to-stride variability, compared to
the TD group. Additionally musculoskeletal parameter are also reported (range of motion of joints
and degrees of spasticity).
Muscular activity in early walkers with and without CP is later compared in[145].
Spatiotemporal gait parameters (including repeatability) for two groups of children aged 6-13 (one
able-bodied another hemiplegic) is described in [146]. Children with hemiplegia were independent
walkers with grade 1 of the Ashworth scale. The following tables are extracted from tables 2-4 of
the paper.

Table 4.60 Gait parameters (mean and SD) according to [146] tables 2-3
Typical development CP
Velocity (m/s) 1.02 (0.14) 0.81 (0.14)
Velocity/Height (m/s/m) 0.77 (0.06) 0.62 (0.11)
Cadence (steps/min) 122. (11.5) 113.4 (15.1)
Gait cycle time (s) 0.99 (0.09) 1.08 (0.14)
Stance phase (s) 0.63 (0.06) 0.65 (0.09)
Swing phase (s) 0.37 (0.04) 0.43 (0.06)
Stride length (m) 1.01 (0.18) 0.86 (0.15)
Stride length/Height (%) 76.6 (6.7) 66.1 (6.3)

Table 4.61 Mean (SD) of stride length (absolute and normalized values) according to [146] table 4
Typical development Right CP Plegic Stride (m) CP Nonplegic Stride (m)
Stride (m)
Absolute value 0.52 (0.09) 0.43 (0.08) 0.43 (0.08)
Normalized value (% of Height) 39.3 (3.4) 33 (3.2) 33.2 (3.5)

4.1.13. Hereditary and idiopathic neuropathies

Idiopathic neuropathy is a disorder that affects the peripheral nerves and has no identifiable
primary cause. According to this definition, a third of all neuropathies can be classified as idiopathic
neuropathies [147]. Despite this apparently high prevalence, there has been little research focused
on understanding idiopathic neuropathy [148].
The common symptoms are numbness, tingling and pain; more rarely there could be tremors [149].
Hereditary motor and sensory neuropathy (HMSN) (ICD-10 G60.0), also called Charcot-Marie-
Tooth disease (CMT) is a family of nerve pathologies among the most frequent inherited diseases.
CharcotMarieTooth disease is due to mutations that cause defects in neuronal proteins, which in
turn affect the propagation of signals in the neuronal axons and synapses. There are several sub
types: type I primary demyelinating neuropathies (CMT1, CMT3, and CMT4) and type II primary
axonal neuropathies (CMT2), with frequent overlap.
Its effects are loss of muscle tissue and touch sensation, predominantly in the feet and legs but
also in the hands and arms in the advanced stages of disease. Symptoms usually begin in late
childhood or early adulthood. Wasting of muscle tissue of the lower parts of the legs may give rise
to "stork leg" or "inverted bottle" appearance. Weakness in the hands and forearms occurs in many
people later in life as the disease progresses. Breathing, hearing, vision and the neck and shoulder
muscles can be affected sometimes. Scoliosis is common. Hip sockets can be malformed. Tremor
can develop as muscles waste.

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Hand Function. A PhD thesis, which collects a number of papers about hand function is available
online [150].
The general clinical picture of CMT, type 1A, is that of a distal length-related neuropathy affecting
the lower limbs to a greater extent than the upper limbs, and motor function more than sensory
function. There is a remarkable diversity in clinical presentation in CMT1A, ranging from severe
distal weakness and atrophy resulting in deformities of the feet and hands to slightly affected or
even asymptomatic individuals [151].
When the upper limbs are involved, loss of hand strength and manual dexterity are common
symptoms. Patients with CMT1A may have difficulties with the manipulation of small objects such
as coins or buttons or with grasping large, heavy objects.
Intrinsic minus-hand (without intrinsic muscle function), a mild clawing position of the fingers,
abducted resting position of the little finger, dyskinetic finger flexion (altered sequence of finger
flexion), loss of thumb function and weak pinch are typical signs.
Manual dexterity is compromised in CMT. Evaluation of manual dexterity can be obtained with
specific dexterity tests.

Paper [152] measured strength and endurance in a study, which involved 20 subjects with HMSN
and 20 control people. Maximal voluntary isometric grip force, indicated as peak force of grip
(PFgrip), was calculated as the mean grip force in three repetitions. To quantify endurance, a
fatigue index (FI) was calculated as the relative decline in PFgrip from the first battery to the 11 th
battery. The maximal voluntary isometric force of the two-point (tip) and lateral (key) pinch were
measured, as described by Mathiowetz et al [153].
The following table reports the Grip strength and Fatigue Index (%decline).

Table 4.62 - PFgrip and Fatigue Index in HMSN and Control Subjects
HMSN Subjects Control Subjects
227 130 339 109
PF grip [N]
39-501 128-545
34 18 40 16
FI [%]
0-81 3-64

Table 4.63 Mean Values of 2-Point and Lateral Pinch


2-Point Pinch Lateral Pinch
No. valid 17 20
No. Missing 3 0
Mean pinch force SD [N] 47.9 24.5 68.9 32.1

A study including dexterity test, tactile sensation and grip and pinch force, is [154]. This study used
universal dexterity tests: the Box and Block Test, which is a simple, well-documented unilateral
dexterity test [155], [156], [157], and The Nine-Hole Peg Test, which is one of the most commonly
used tools for assessing dexterity [158].
The Box and Block Test is a standardized test [155], [156], [157], which measures numbers
of blocks picked in 1 minute. The subject grasps wooden blocks (2.54 cm3) from a box with two
sections and transports them one at a time from one compartment of the box to the other.
The Nine-Hole-Peg Test is a standardized test [158], which consists of a square board with
nine holes and a container with nine wooden pegs (3.2 cm long, 0.64 cm across) are used. It is
a time-monitored test where pegs are picked up from the container one by one, put into the
holes and then returned to the container as quickly as possible.

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Twenty subjects (9 men, 11 women) aged 24-73 years participated to the study; 11 (55%) were
diagnosed with type I, five (25%) with type II, one with type 4c, while the subtype of the disease
was unidentified in three people.
The following table lists the results of the dexterity tests.

Table 4.64 Dexterity tests


Measurement N Reliability Analysis Mean diff
Mean (test I Mean diff (test II 95% limits of CR CV (%) ICC (95% CI) norm SD
+ II) SD test I) (95% CI) agreement
BBT [b/min] R 20 53.1 17.5 4.7* (2.0-7.4) -6.8-16.2 11.5 8.4 0.95 (0.87-0.98) 24.7 17.4
BBT [b/min] L 20 51 15.4 3.2* (1.0-5.3) -6.2-12.5 9.3 6.4 0.96 (0.89-0.98) 24.9 15.7
NHP [s] R 18 29.6 14.8 -0.3 (-1.4-0.8) -4.6-3.9 4.3 3.9 0.99 (0.97-1.00) -11.3 14.9
NHP [s] L 19 38.9 27.8 -5.1 (-14.1-4.0) -42.7-32.5 37.6 8 0.80 (0.54-0.92) -18.9 27.2
*Statistically significant at P<0.05 with Wilcoxon signed rank test
BBT, Box and Block Test; b/min, number of blocks per min; NHP, Nine-Hole Peg Test; s, seconds; R, Right; L, Left; CR, coefficient of repeatability;
CV, coefficient of variation; ICC, intraclass correlation coefficient, CI, confidence interval. The 95% limits of agreement is the mean difference (test
II test I) 2SD. Mean diff norm = The average of all individual subjects differences between the mean result of test I and II and data from age- and
sex-matched normative (BBT and NHP)

The following table lists grip and pinch strength.

Table 4.65 Grip and Pinch Strength


Measurement N Reliability Analysis Mean diff
Mean (test I Mean diff (test II 95% limits of CR CV (%) ICC (95% CI) norm SD
+ II) SD test I) (95% CI) agreement
Max grip [N] R 20 191.1 120.7 3.9 (-3.0-10.8) -24.7-32.5 28.6 6.5 0.39 (0.98-1.00) 188.2 141.2
Sus grip [N] R 20 169.4 111.1 0.9 (-5.5-7.3) -25.8-27.6 26.7 6.6 0.99 (0.98-1.00) 149.8 126.7
Max grip [N] L 20 185.9 114.1 5.6 (-1.7-12.8) -25.5-36.7 31.1 6.8 0.99 (0.98-1.00) 163 124.3
Sus grip [N] L 20 162.8 103.5 3.5 (-3.8-10.8) -27.6-34.6 31.1 7 0.99 (0.97-1.00) 131.1 111.4
Max pinch [N] R 18 27.5 16.3 2.7* (0.5-4.9) -5.8-11.3 8.5 9.4 0.97 (0.91-0.99) ND
Sus Pinch [N] R 18 22.9 14.9 2.2* (0.1-4.4) -6.0-10.5 8.2 11.7 0.96 (0.91-0.99) ND
Max pinch [N] L 18 25.4 14.9 1.1 (-0.9-3.2) -7.3-9.6 8.5 8.9 0.96 (0.90-0.99) ND
Sus Pinch [N] L 18 21 13.7 0.9 (-0.9-2.8) -6.6-8.5 7.5 9.4 0.96 (0.90-0.99) ND
*Statistically significant at P<0.05 with Wilcoxon signed rank test
Max, Maximal value in 10s; Sus, Sustained value (mean of 10 s); R, Right; L, Left; CR, coefficient of repeatability; CV, coefficient of variation; ICC,
intraclass correlation coefficient, CI, confidence interval. The 95% limits of agreement is the mean difference (test II test I) 2SD. Mean diff norm
= The average of all individual subjects differences between the mean result of test I and II and data from age- and sex-matched normative.

Gait and Posture. Despite variations in the genes that cause CMT disease, the phenotype tends
to have a similar pattern characterized by a slow decline in distal muscle strength and sensation
due to degeneration of the longer peripheral nerves. Thus gait and posture are often the most
affected functions.
Distal muscle wasting causes the classic inverted champagne bottle appearance of the lower
portion of the leg. A pes cavus foot deformity is also frequently observed due to an imbalance in
strength between the tibial muscle groups.
During normal walking the ankle plantarflexor muscles generate nearly all of the positive work in
late stance. In conditions where the distal leg muscles are weakened it has been suggested that
the hip flexors compensate for the reduced contribution from the plantarflexors and take over the
role of swing initiation. This causes a modified gait pattern. Paper [159] is a study of such a altered
pattern. Subjects were 18 people with CMT and 14 able-bodied people matched for age, gender,
eight, and height. Isometric strength of the lower limb muscles was measured with respect to
standardized position (see table below). The muscle groups tested were the hip flexors and

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extensors, knee extensors, plantarflexors, and dorsiflexors. The peak maximal voluntary
contraction (MVC) from three attempts was recorded. Tests were repeated after prolonged walking
session to point out sensitivity to fatigue.

Table 4.66 Isometric strength of the lower limb muscles


CMT Control
MVC [Nm/Kg]
Hip flexors (seated with 50 hip flexion) 1.13 0.42 1.32 0.38
Hip extensors (seated with 50 hip flexion) 0.65 0.33 1.09 0.68
Knee extensors (seated with 90 knee flexion) 1.53 0.68 2.06 0.64
Plantarflexors (seated with ankle in plantigrade) 0.63 0.57 1.21 0.58
Dorsiflexors (supine 10 ankle plantarflexion) 0.10 0.08 0.39 0.17

CMT subjects demonstrated differences in distal muscle strength (table above), sensation, and
range of motion compared with healthy subjects. They also demonstrated greater levels of fatigue
and lower scores for general health perception (see paper for more details).
CMT patients walked significantly slower (CMT: 1.13 0.1 m/s; controls: 1.59 0.2 m/s) and with a
reduced cadence (CMT: 108 7.3 steps/minute; controls: 120 10.7 steps/minute).

Table 4.67 Gait parameters according to [159]


CMT, mean (SD) Control, mean (SD)
Walking speed (m/s) 1.13 (0.1) 1,59 (0.2)
Cadence (steps/min) 108 (7.3) 120 (10.7)

Paper [160] is another study, which analyses gait pattern. The study involved 16 people affected
by CMT aged 8-52, and 40 control persons. A motion capture system was used to record gait in
three dimensions. Kinetic variables, such as the moment and powers developed at the joints of the
lower limb, were derived using the process of inverse dynamics from marker position data and
ground reaction force and centre of pressure data measured by two piezo-electric force plates.
Gait events (i.e. initiation of stance and swing phases) were identified by the onset and cessation
of the ground reaction force. A complete medical history, including family history, current and past
symptoms, physical abilities and limitations was obtained from each participant. Each participant
underwent a systematic neurological and orthopaedic clinical examination focusing on both lower
limbs.
Average gait velocities were of :
1.12 m/s S.D. 0.17 in the CMT group and of
1.31 m/s S.D. 0.13 in the control group.
The following apparent deviations were observed in a majority of the CMT group. Foot-drop in
swing was identified in 14 subjects. Failure of plantar flexion at push- off was seen in 11 cases.
Increased foot supination was observed in 11. Excessive internal rotation of the shank relative to
the thigh was found in 10 and knee hyperextension in terminal stance in 12. Thirteen subjects
displayed a pattern of excessive external rotation at the hips, and 13 had decreased hip adduction
in stance and early swing. The ensemble averaged gait kinematics of the CMT group are shown in
Paper Fig. 1.
Significant differences between the CMT group and the control group were observed for all the
corresponding static and dynamic variables that were tested (see table below). The paper reports
also joint torque estimation (see paper Fig.2).

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Table 4.68 Static and kinematic measurements of Charcot-Marie-Tooth disease (CMT) and control
groups according to [160]
CMT Mean (SD) Control Mean (SD) Difference
P-value
[deg] [deg] [deg]
Ankle dorsiflexion passive range (dorsiflexion: +, equines: -) +1.6 (7.6) +10.0 (5.4) 8.4 <0.001
Ankle angle at ground contact (dorsiflexion: +, plantar flexion: -) -10.4 (8.3) -1.2 (4.7) 9.2 <0.001
Peak ankle dorsiflexion (dorsiflexion: +, plantar flexion: -) -1.8 (4.8) 3.8 (3.5) 5.6 <0.001
Ankle angle at push off (dorsiflexion: +, plantar flexion: -) -4.5 (9.4) -13.9 (7.3) 9.4 <0.001
Mean ankle pro/supination (supination:+, pronation: -) +9.8 (8.8) -0.4 (8.6) 10.2 <0.001
Mean knee/tibia rotation (internal: +, external: -) -15.5 (10.9) -22.3 (8.3) 5.8 0.001
Minimal knee angle in stance (flexion: +, extension: -) +0.8 (6.0) +7.4 (4.8) 6.6 <0.001
Mean hip rotation (internal: +, external: -) -3.6 (8.2) 1.9 (6.0) 5.5 <0.001
Mean hip add/abduction (adduction: +, abduction: -) -0.5 (2.6) +1.7 (2.7) 2.2 <0.001

4.1.14. Stroke

Stroke is a cerebrovascular accident (also called CVA) causing insufficient oxygen supply to a
region of the brain. It can either be due to an ischemia (blockage of blood flow) or a hemorrhage.
Either way, a region of the brain is damaged and ceases its functions. When the affected region is
related to motor functions motor disabilities are produced. Usually only one side of the body is
involved.
Depending on the brain area that is affected, stroke (as for what concerns motor deficit) can
produce the following gross consequences:
Hemiplegia (paralysis of one side of the body);
Alteration of voluntary movements (apraxia);
Alteration of movement coordination;
Reduction of muscle responsiveness;
Inability to turn head to one side;
Walking problems;
Balance problems;
Vertigo.
Reduction of tactile sensitivity;
Face and eyes muscles weakness;
Nystagmus (unvoluntary eye movements);

As a consequence, the ability to manipulate objects (reach, point, grasp, manipulate, etc.) and to
move around (walk, stand, sit etc.) can be severely affected.
Post stroke rehabilitation allows partial recover of the lost functions by training other regions of the
brain. Nonetheless, survivors still hold various degrees of disabilities, which depend largely on the
extension and localization of the damaged area.

Metrics.
A number of clinical scales are used to both monitor post stroke rehabilitation and to assess the
degree of disability. Among the others we mention here:
Functional Independence Measure (FIM) [161],
Fugl-Meyer Assessment[162],
Wolf Motor Function Test [163],
Chedoke-McMaster Stroke Assessment [164].

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However, these are clinical scales, partly subjective (although largely used) that are not well suited
to derive parameters for modeling virtual users.

For the purpose of making virtual user models, indicators that are related to objectively measurable
motion quantities should be preferred. These metrics are thus related to motor performance in the
execution of tasks.

Point to point motion tasks. These task can reveal slowness, apraxia i.e. inability to use proper
patterns for muscle activation and spatio-temporal control problems.
An example of point-to-point motion task is the Fittss test, from which Fittss law parameters that
measure pointing time as a function of pointing difficulty (combined accuracy and distance) can be
derived. The Fittss law is described in annex B.
Following [165], a number of alternative indicators can be used for the assessment of the
performance in the task of target acquisition. These are (see annex B for definition):
Reaction Time (RT)
Movement Time (MT)
Path deviation
Movement speed
Number of speed maxima (alternatively some Jerk relate metrics)
Dwelling percentage time in target
Percentage of success
Other metrics related to trajectory error and target errors.

As for what concerns the latter group of indicators, paper [165] reports data for 8 able-bodied
people and 9 people with different degrees of stroke-induced disability ranging from grade 22 to 66
of the Fugl-Meyer scale, which were divide into two groups: severely impaired (Fugl-Meyer scale
22-57) and mildly impaired (Fugl-Meyer scale 63-66). The test task was the acquisition of targets
on a computer screen using a force feedback joystick (not direct movement of hand onto real world
objects). The Figure 4.17 summarizes the metrics a-g above for the control group (able bodied
people, the mildly impaired people (High) and the severely impaired people (Low)).
As can be seen, significant performance differences happen only for the severely impaired group:
- Reaction Time increases approximately 1.9 times;
- Movement Time increases approximately 2.9 times;
- Path deviation moves from 1-2% to 8-9% of the workspace;
- Movement speed decreases 1.5 times;
- Number of speed maxima increase to a typical value of 2 to 7, revealing a much jerkier
motion;
- Dwelling percentage time in target dropped from nearly 100% (perfect target keeping) to
about 70% (30% of the time the target was lost in a static test);
- Percentage of success dropped form nearly 100% to 50%.

Of course these data are task related and in particular are related to the use of joystick. Thus the
above figures must be considered as purely indicative.

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Figure 4.17 - Target acquisition test. DPTT: dwelling percentage time in target, MS: movement speed,
MT: movement time, PSN: peak speed number, RT: reaction time, SP: success percentage

Continuous tracking tasks. The following metrics are proposed following [165] (see annex B for
definition).
Percentage time on the target;
Root mean square value of tracking error;
Deviation of trajectory
Mean speed
Standard deviation of speed

Again these indicators are task related. The cited paper refers a task in which the subject has to
follow (by means of a Joystick) a target moving counterclockwise on a circumference. In one case
tracking was assisted by a spring-like force, in another case tracking was disturbed by a random
force. Again large deficit is observed for the severely impaired group (minor deficit for the mildly
impaired group). These can be summarized as follows:
Percentage time on the target dropped from 41% (able-bodied) to 32% (mildly impaired
group) to (14% (severely impaired group).
Root mean square value of tracking error increase 4 times from able-bodied to severely
impaired groups (1.2 times for the mildly impaired group);
Deviation of trajectory increases nearly 10 times for the severely impaired group (no
increase for mildly affected)
Mean speed increases 1.2 times to 1.7 (mild to severe)
Standard deviation of speed increases 1.4 to 2 times (mild to severe).

Hold position under random disturbance. To assess the ability to control muscle forces, a hold
under random noise force test is proposed. Metrics for this test are:

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Mean error of hold position;


Standard deviation of position.
These data are clearly related to the statistical properties of the force noise (intensity and
frequency, or power spectral density). The Figure 4.18 shows the results for a test in which force
disturbance could switch between three different levels with bandwidth up to 16 Hz.
Again, meaningful differences can be observed for the severely impaired group.
Under perturbations in the x direction:
- Mean error increase from 2% to 9% (of workspace size) in the x direction and from 0% to
2% in y (orthogonal to the disturbance) direction.
- Standard deviation of error increases from 4% to 15% for x direction and from 0% to 4% in
the orthogonal y direction.
Under perturbations in the y direction able-bodied people show very small error (0-1% of
workspace size) whereas only severely impaired people show mean error in the range 4-5% and
standard deviations in the range 5-10%.

Figure 4.18 - EM_X: Error_Mean at x direction, EM_Y: Error_Mean at y direction, ES_X: Error_StdDev
at y direction, ES_Y: Error_StdDev at y direction.

Gait parameters
Paper [166] investigates the benefits of music and rhythm in gait and motor activities. Some
spatiotemporal and kinematic parameters of the gait (only mean values were available) are given
Table 4.69.

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Table 4.69 Spatiotemporal and kinematic parameters during gait of stroke patients
Parameter Unit Mean
Stride length (paretic side) [% of height] 44.2
Stride length (non-paretic side) [% of height] 41.0
Hip joint range of motion (paretic) [deg] 29.0
Hip joint range of motion (non-paretic) [deg] 36.0
Knee joint range of motion (paretic) [deg] 47.0
Knee joint range of motion (non-paretic) [deg] 56.0
Trunk angle [deg] 96.0
Center of mass horizontal velocity [m/s] 0.6
Center of mass vertical displacement [cm] 3.3
Center of mass lateral displacement [cm] 11.0
Pelvic tilt [deg] 181.0

Paper [167] aims to evaluate lower extremity range of motion (ROM) during gait of Stroke patients.
The Table 4.70 summarizes the outcomes from the tests explained in the article.

Table 4.70 ROM of lower limb joints during normal gait


Joint Type Mean [deg] Standard Deviation [deg]
Hip Normal value 38 5
More involved 28 11
Less Involved 38 9
Knee Normal value 62 5
More involved 27 15
Less Involved 50 14
Ankle Normal value 28 3
More involved 13 6
Less Involved 22 8

Kinematic parameters
Paper [168] reports the ROM at ankle joint in stroke patients compared with control group (able-
bodied people). The data are summarized in Table 4.71.

Table 4.71 ROM of ankle joint in Stroke patients, depending knee position
Parameter Knee positions Stroke Patients Control Group
30 knee flexion -34.1 4.8 -37.7 4.8
Plantarflexion [deg]
Fully extended -31.2 7.9 -35.3 6.5
30 knee flexion -3.1 4.1 13.5 6.9
Dorsiflexion [deg]
Fully extended -6.4 5.1 6.5 5.3
Rest position [deg] Fully extended -18.2 6.6 -13.6 3.9
Values are expressed as mean Standard Deviation

Paper [169] reports the ROMs of shoulder, wrist and fingers of stroke affected patients (only mean
values were available). Table 4.72 reports the outcomes.

Table 4.72 Active ROMs of upper limbs in stroke patients


Joints Unit Mean
Shoulder (flexion) [deg] 88.6
Shoulder (abduction) [deg] 86.36
Wrist (flexion) [deg] 35.51
Wrist (extension) [deg] 35.52
Fingers (extension) [deg] 61.32

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4.1.15. Elder people

Aging, besides the chance of being affected by one of many diseases, involves the decline of
several cognitive and physical functions. Reaction time and muscular strength are two examples.

Paper [170] is a study based on 365 people, which gives statistical data about cognitive and
physical decline and their relationship.

The Baltimore Longitudinal Study of Aging (BLSA) is the US longest-running scientific study of
human aging, supported by the US he National Institute on Aging (NIA) [171]. The study begun in
1958 to trace the effects of aging in humans and to distinguish between the true effects of aging
and those processes, including disease, socioeconomic disadvantage, and lack of educational
opportunity, that may appear or become more pronounced with time but are biologically irrelevant
to the underlying mechanisms of human aging [172]. More than 1,400 men and women are study
volunteers. They range in age from their 20s to their 90s. Among the others, this study measured
37 anthropometric parameters, bone-mineral composition, subcutaneous fat, body mass
components and base metabolism. In addition also neuro-motor functions were measured: tapping
test for speed and accuracy in visually controlled motor tasks, reaction time (to touch, auditory and
reflex), nerve conduction velocity, muscular strength, and oxygen uptake (the study also addresses
cognitive functions which are relevant for other VERITAS WPs). Some data from the BLSA will be
reported in the following.

Chronological age does not correlate perfectly with functional age, i.e., two people may be of the
same age, but differ in their mental and physical capacities.
For example paper [173] identifies different phenotypes of ageing population, which are related
to cognitive function, physical strength and psychological state. Cognitive functions are assessed
in the study by the by Mini Mental State Examination (MMSE) test [174]; physical strength by
handgrip strength measured by a hand held dynamometer; psychological state by the short form
(15 items) of the Geriatric Depression Scale (GDS) [175].
In the age range 65-85 years the phenotypes frail, intermediate and non-frail Are found, and
correlated to the above indicators (the larger the better). In the age range >90 years two
phenotypes, described as very frail and frail are found. A correlation is found between these
phenotypes and disabilities in Activity of Daily Life. Non-frail group have 94.4% chance of having
no ADL disability, which drops to 12.5% for the very frail group (see paper table 3). Co-morbidity
and mortality chance is also correlated with these phenotypes (table 4-5). Non-frail phenotypes
have fewer diseases and 92.3% of surviving at least 18 months.

Fine motor skills. A review of studies concerning the effect of aging on fine motor skills was made
by Krampe [176]. The main finding was that fine movements can be dissociated into timing,
sequencing and executive components, and that these show differential patterns of age-related
declines that cannot be reduced to proportional reductions in general processing speed. Timing is
related to the existence an internal clock [177] which forms the baseline for motion planning and
which does not apparently decline in healthy adults (it may however be affected by the early signs
of diseases like dementia). Sequencing and executive components, on the other hand, refers to
the arrangement of a sequence of motion tasks and to their execution. These happen as variability
of motor movements. Wing and Kristofferson [177] developed a method to obtain separate
estimates for the variability of central timing and motor implementation component processes
based on isochronous tapping tasks.

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Sequencing and executive components decline with age. However, old people can learn to counter
these effects by deliberate practice. For example older adults handwriting speed is reduced relative
to young adults only when they have to write unfamiliar text [178].

As for what concerns age-related changes in maximum speed and accuracy of fine motor
movements, the overall pattern of results from many studies [179] indicates that older adults take
longer to plan (i.e., initiate after a starting signal) or restructure arm movements than young adults
do [180] and that their movements tend to be less smooth, that is, more segmented [181].

Fitts Law. Paper [182] provides data according to the Fitts law for elder people using mouse.
Elder people were 15 subjects in the age range 56-74 (mean 63.4) who had just completed a 36
hours computer literacy course. Young people were 13 students of bachelor and master degree
courses in the age range 17-30 (mean 23.9). The following modified Fitts law was considered
[183]:

(4.4)

In addition the index of difficulty ID was corrected for the effective distance and target size and
called IDe. Effective distance was determined as real distance between the coordinates of the two
mouse clicks on the screen. Effective target size was calculated based on standard deviation of
end-clicks, as recommended in [183], but the standard deviation was determined for each
participant instead of for each condition.
Missing targets by more than 10% of their size was classified as error. The error rate was
recorded too and found to be consistent with literature data (~6%). See paper for more details
about the error levels.
The fitting equations for elder and younger people were respectively:

(4.5)

Dependency on the subject age and experience level was also estimated in the form of:
(4.6)

where T is the age and LE represents low experience (but the paper does not define it). For
sufficient trained people LE should be apparently set to 0.

Loss of muscle strength. The gradual loss of skeletal muscle mass, strength, and quality that
takes place with advancing age is often called sarcopenia [184]. Reduced muscle strength is
predictive of functional limitation and physical disability in older people [185], [186]. Independent of
physical illness, there is evidence that cognitive impairment [170] and depression are associated
with functional limitation and physical disability.

Paper [187] is a study, which involved 1705 people aged 70 and above, focused on the
relationship between the decline of muscle force and the resulting functional limitations and
physical disabilities.
Muscle strength was assessed independently for upper body and lower body. For upper body the
grip strength was assumed as an overall indicator of upper body muscle strength. For lower body
an independent measurement was taken for quadriceps muscles. Muscle mass was also
measured and an indicator of muscle quality (force per unit mass) was also used.

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The following table summarizes the decline in muscle strength according to the two selected upper
and lower body indicators.

Table 4.73 Muscle Strength, Skeletal Lean Mass, and Muscle Quality as function of Age.
70-74 75-79 80-84 85-89 90 Overall
Factor
(n=659) (n=286) (n=286) (n=118) (n=38) (n=1612)
Muscle strength Grip strength 37.0 7.1 34.9 6.8 32.1 6.9 28.2 6.8 26.9 6.5 34.6 7.5
[Kg] Quadriceps strength 33.1 8.2 30.7 7.8 28.6 6.7 26.1 6.0 24.9 6.9 31.0 7.9
Muscle mass [Kg] Arm lean mass 5.9 0.9 5.7 0.8 5.5 0.9 4.9 0.8 4.8 0.8 5.7 0.9
Leg lean mass 16.8 2.3 16.4 2.4 15.9 2.2 14.9 2.1 14.3 2.2 16.3 2.4
Skeletal lean mass 22.8 3.0 22.1 3.0 21.4 2.9 19.9 2.8 19.1 2.8 22.0 3.1
Muscle quality, [Kg Upper extremity specific force 6.3 1.2 6.2 1.2 5.9 1.1 5.7 1.2 5.7 1.0 6.1 1.2
force/Kg mass]* Lower extremity specific force 1.9 0.5 1.8 0.4 1.8 0.4 1.7 0.4 1.6 0.4 1.9 0.4
* Upper extremity specific force (Kg force/Kg mass) was defined as ratio of grip strength (measured in Kg of force) to arm lean mass and lower
extremity specific force (Kg force/Kg mass) as ratio of quadriceps strength (measured in Kg force) to leg lean mass
NOTE: Values are expressed as mean Standard Deviation

From the above table a quite similar drop of muscle strength can be noticed for upper (-27%) and
lower (-25%) body. Thus this percentage drop could be used (in absence of other specific data) to
extrapolate the decline of muscle force with respect to able-bodied adults. Notice that no gender
specific data is reported.
Data on grip strength are also reported on paper [173] but unfortunately the paper does not declare
the units! (Presumably units are Kgf).

Grip strength for the whole life range is also reported in paper [397], see table 3.16 and 3.17 for
women and men. See also paper [397] figures 1 and 2. As explained in [397] these data may
depend on the measurement tool used and on other factors and show some variation. In fact data
in Tables 3.16, 3.17, 3.12, 3.14, 4.72 do not match exactly. However these data could be used to
obtain percentage losses as a function of age, which are more reliable than the absolute values.

Functional limitations and physical disabilities were assessed by means of:


1) Self-report (answers to questions concerning needing help from another person to perform
activities of daily living);
2) Performance-based functional limitation were measured according to the tasks of rising from a
chair repeatedly five times, and of walking 6m (walking speed for 6m at usual pace);
3) Physical disability was measured using the Katz activity of daily living (ADL) [188] and Rosow-
Breslau instrumental activity of daily living (IADL) [189] questionnaires. The ADL questions were:
Do you need help with personal care needs such as walking across a small room, bathing,
personal grooming, dressing, eating, getting from a bed to a chair, and using the toilet? The IADL
questions were: Do you need help in handling routine needs such getting to places out of walking
distance, grocery shopping, preparing own meal, and doing housework? Participants were
classified as physically disabled if they answered yes to any of these questions.
Comorbidity, physical activity and depression were independently assessed (physical activity was
measured by means of the Physical Activity Scale for the Elderly (PASE) [190] score, and
clustered in 5 quintiles). See paper table 1 for more details on the characteristics of participants.
Relations between sarcopenia and functional limitations and physical disabilities are als reported in
the paper.

Effect of sarcopenia on lower extremities performance (walk and sit functions). Paper [191]
is a study involving 3075 people in the age range 70-79, for both white and black ethnicity and for

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both male and female genders (see paper table 1 for more details abut the participants). The
scope was to correlate the loss of muscle mass and quality to reduced performance in the lower
limbs. A battery of two tests was used to assess lower extremities performance:
1) 6 meter walk. This test measured the time needed to complete a 6-meter walk at usual pace
(the fastest time of two trials).
2) Chair stand. This test measured the time needed to stand up and sit down five times from a
chair as quickly as possible with arms folded across their chest.
The following table summarizes the findings. Performance was associated to a score, whose
meaning is: 0 (unable to complete the task), 1-4 percentile.

Table 4.74 Lower Extremity Performance of Participants in Study [191] (3075 people aged 70-79):
Distribution of Walking, and Repeated Chair Stands, times.
Significantly different from whites within gender, P < .05.
Men Women
Test
White Black White Black
Six-meter walking score, %
0 (unable) 0 0 0 0
1 (>5.8 sec) 10.4 28.6 20.2 48.8
2 (5.2-5.8 sec) 19.5 26.8 23.9 27.7
3 (4.6-5.1 sec) 27.8 25.0 32.9 13.9
4 (<4.6 sec) 42.3 19.6 23.0 9.6
Repeated (5x) chair-stand score, %
0 (unable) 1.4 3.2 2.6 4.7
1 (>16.1 sec) 14.2 28.2 23.6 36.0
2 (13.8-16.1 sec) 22.8 28.7 23.4 23.2
3 (11.6-13.7 sec) 26.5 20.6 27.9 19.8
4 (<11.6 sec) 35.1 19.3 22.5 16.3

Walking score, mean SD 3.0 1.0 2.4 1.1 2.6 1.1 1.8 1.0
Chair stands score score,
2.8 1.1 2.2 1.2 2.4 1.2 2.1 1.2
mean SD

Another paper dealing with functional limitations induced by sarcopenia on female gender is [192].
The paper analyzed 1458 French women, aged 70 or older (mean 80.3, SD 3.8). A questionnaire
concerning self-reported difficulties in the activities of daily life was used to assess the IADL score
[193], [194]. The IADL scale consists of eight items. Only those IADL variables that involved
locomotion (food preparation, housekeeping, grocery shopping, doing laundry, and using public
transportation) were used. Participants were also asked whether they had difficulties
(no/some/serious difficulty) performing various physical movements, such as walking, climbing
stairs, rising from a chair or bed, picking up an object from the floor, lifting heavy objects, or
reaching an object.
The paper defines the association between sarcopenia and markers of disability, physical function,
and risk of fall (paper table 3). Below we report an excerpt of table 3 listing the incidence of
reported difficulties.

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Table 4.75 Incidence of disabilities in a population of French women aged 70+ according to [].
IADL 8 items: food preparation, housekeeping, shopping for groceries, doing laundry, handling
money, using the telephone, taking medications, using public transport.
IADL 5 items: food preparation, housekeeping, shopping for groceries, doing laundry, using public
transport.
Moving difficulties: walking, climbing stairs, rising from a chair or bed, picking an object from the
floor, lifting heavy objects, reaching an object.

Disability %
Activity of daily living disabilities
Walking difficulties 6.8
Bathing/dressing or walking difficulties 7.2
IADL disabilities
IADL 8 items ( 3 incapacities) 3.4
IADL 5 items ( 3 incapacities) 2.7
Physical function difficulties
Ascendings stairs 7.8
Descending stairs 6.2
Rising from a chair 2.8
Picking an object from the floor 4.7
Lifting heavy objects 11.8
Moving difficulties (( 3 difficulties) 6.0
Risk of fall
Fear of falling 58.0
Fall during the 6 previous months 23.5
History of bone fracture 41.7

A last study (here reported) concerning the effect of reduced muscle strength on physical function
is [195]. The study compared 30 younger men (mean age 38.7, SD 1.4), 31 older men (mean age
68.4, SD 1.4) and 39 older men with mobility limitations (mean age 73.3, SD 0,8). For the latter
cohort, mobility limitation was defined as self-reported difficulty in walking two blocks on a level
surface or in climbing a flight of stairs and mild to moderate limitations in physical mobility, defined
as a score of 4 to 9 on the Short Physical Performance Battery (SPPB) [196].
The study measured:
- Muscle strength. Maximal voluntary strength for the leg press and chest press, measured with
Keiser A420 pneumatic resistance machines and integrated software (Keiser Sport, Fresno, CA).
- The time to walk 50 m as fast as possible (running was prohibited) and allowed to use assistive
devices (e.g., canes and walkers) as needed.
- The time to walk 50 m as fast as possible while carrying two canvas bags equally weighted with
weight equivalent to 25% (young men and older men) or 20% (older men with mobility limitations)
of their body weight.
- The time to ascend a single flight of stairs consisting of 12 steps (step height 16 cm) as fast
as possible while touching every step and allowed to use the handrail only if needed.
- The time to ascend 12 steps as fast as possible while carrying two canvas as described and used
for the loaded 50-m walk. Subjects who were unable to perform this task (primarily due to safety
concerns or need to use a handrail) were excluded from the analyses.
- Lift a weighted basket (equivalent to 15% of body weight) from a shelf positioned at standard
desk height (78.5 cm) and place it on a shelf positioned at their respective shoulder height and
then to a shelf positioned at their respective head height and then to lower it back down in the
reverse sequence. Subjects repeated this sequence as many times as possible in 1 minute, and
the number of shelves completed was recorded.
Results are listed in the following table (adapted form data in the paper).

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Table 4.76 Effect of reduced muscle strength on physical function according to [196].
Younger men Older men Older with Mobility
age 38.7, SD 1.4 age 68.4, SD 1.4 Limitations
age 73.3, SD 0,8
Muscle Strength Leg Press (N) 2795 2236 1760
50 m walk (s) 22 26.5 37
Stair climb (s) 3.8 4.9 7.5
Lift and load shelves (items) 42 33 22

Gait and balance. Gait speed in older adults is a good measure of overall walking performance. It
reflects energetic efficiency, muscle strength, balance control and endurance. Changes in gait
patterns with ageing have been described in many studies and a decline in gait speed appears as
one of the most consistent age-associated changes [197]. Slower walking of older adults was
related to fear of fall, muscle weakness and impairment of motor control.

Paper [198] describes age-related changes in gait pattern form the Baltimore longitudinal study of
ageing (BLSA). The study concerned 183 people, aged 60-96. Participants who did not have a hip
or knee joint prosthesis, severe joint osteoarthritis, pain or history of stroke or Parkinsons disease
and who could follow instructions and safely complete a 4 m walk unaided were included in the
study. Participants who had a body mass index (BMI, kg/m2) over 40 were not included.
Participants were instrumented with 20 reflective markers positioned according to anatomical
landmarks. A motion-capture system allowed to capture three dimensional kinematic and kinetic
gait parameters, and to compute the mechanical work expenditure according to gait periods.
Three different walking tasks were examined. The usual-speed walking task was based on a gait
test at the self-preferred customary gait speed. The fast-speed walking task was based on a gait
test where subjects were asked to walk as fast as possible without running. Post activity walking
task was carried out after approximately 30 min of additional task, in which participants were asked
to perform a final walking task at their customary, self- selected gait speed.
Spatiotemporal gait parameters and their associations with age in the three walking tasks are
summarized in the following table. Coefficient is the estimated linear regression coefficient
related to age (changes per year). Consistent with previous studies, slower gait speed and shorter
stride length with older age were confirmed in this study in a usual-speed walking task as well as in
fast-speed walking and post-activity walking [197], [199]. Wider stride width with older age, already
reported from previous studies [200], [201], was also confirmed in the present study in the usual-
speed walking and post-activity walking tasks.
With increasing age, gait speed and stride length were significantly lower, whereas cadence was
significantly higher for all walking tasks. Stride width and stance percent of the gait cycle (PGC)
were higher with older age in the usual-speed walking and post-activity walking, but not in the fast-
speed walking. PGC for hip flexion and ankle plantar flexion were higher with older age for the
usual-speed walking.

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Table 4.77 Spatiotemporal gait measures during the usual-speed, fast-speed and post-activity
walking tasks and their relationship with age according to [198]. PGC Percentage of Gait Cycle.
Spatiotemporal Interactions of fast-speed and
Regression analysis with advanced agea
parameters post-activity conditionb
Fatigue
Fast speed vs
Usual speed (n=183) Fast speed (n=162) Post activity (n=147) condition vs
Usual speed
usual speed
P-
c c c c c
Mean P-value Mean P-value Mean P-value P-value valu
e
Speed and distances
Gait speed [m/s] 1.11 -0.014 <0.001 1.66 -0.024 <0.001 1.27 -0.015 <0.001 -0.01 <0.001d -0.001 0.353
Stride length [m] 1.19 -0.014 <0.001 1.42 -0.016 <0 001 1.30 -0.014 <0.001 -0.003 0.003d -0.000 0.456
Cadence [steps/min] 111.78 0.641 <0.001 140.20 0.741 <0.001 116.77 0.615 <0.001 0.101 0.287 -0.026 0.660
Stride width [cm] 11.08 O.078 0.007 10.35 0.012 0.668 10.06 0.050 0.049 -O.066 <0 .001 -0.028 0.061
PGC
Stance 63.83 0.063 <0.001 62.33 0.016 0.188 63.02 0.044 <0.001 -0.048 <0.001 -0.019 0.048
Hip extension 51.02 0.027 0.277 48.45 0.033 0.256 49.99 0.051 0.043 0.06 0.769 0.024 0.131
Hip flexion 10.87 0.050 <0.001 12.18 0.023 0.232 10.95 0.016 0.258 -0.027 0.083 -0.035 <0.001
Knee extension 27.39 0.037 0.357 25.42 -0.025 0.378 26.79 0.007 0.825 -0.062 0.029 -0.030 0.167
Knee flexion 23.19 0.030 0.441 22.57 0.009 0.762 22.74 0.015 0.640 -0.021 0.486 -0.015 0.545
Ankle dorsiflexion 38.90 0.031 0.296 29.69 0.093 0.076 36.15 0.038 0.239 0.062 0.146 0.008 0.753
Ankle plantar flexion 18.93 0.083 0.003 27.28 -0.054 0.322 20.56 0.020 0.516 -0.137 0.002 -0.063 0.023
Bold indicates significance with P<0.05
a
Gait parameter differences in walking tasks as fast-speed and post-activity condition compared with usual-speed walking
b
Estimated coefficient for linear regression
c
Adjusted for gait speed, height, weight and sex (gait speed: adjusted for height, weight and sex).
d
Exacerbated decline compared with the usual-speed walking (only for the case both compared walking tasks showed negative associations with older age).

Range of rotation of joints and mechanical Work Expenditure (MWE) for the three walking tasks
from the hip, knee and ankle in the anteriorposterior (AP) plane and mediallateral (ML) plane are
summarized in the following table.
The range of rotations for the hip, knee and ankle in the AP plane were lower with older age in all
walking tasks. With older age, MWE during hip extension in the AP plane was higher in the usual-
speed walking, while MWE during hip flexion in the AP plane was higher in the usual-speed and
post-activity walking tasks. AP ankle-generated MWE during ankle plantar flexion in late stance
was lower with older age only in the fast-speed walking. AP hip absorption MWE during hip
extension was lower with older age in the usual-speed walking and post- activity walking.
The range of rotation for the hip and ankle in the ML plane and ML hip-generated MWE during hip
extension and flexion were lower with older age for all three walking task. ML knee-generated
MWE during knee flexion was lower with older age in the fast-speed walking. ML ankle-generated
MWE during ankle plantar flexion for the usual-speed walking was higher with older age. ML hip
absorption MWE during hip flexion for the usual-speed walking and post-activity walking was
higher with older age. ML ankle absorption MWE during ankle plantar flexion was lower with older
age for all three walking tasks.

Table 4.78 Age-associated changes in gait parameters for the rotations of lower extremities in the
usual-speed, fast-speed and post-activity condition according to [198].
Spatiotemporal Interactions of fast-speed and
Regression analysis with advanced age
parameters post-activity conditiona
Fatigue
Fast speed vs
Usual speed (n=183) Fast speed (n=162) Post activity (n=147) condition vs
Usual speed
usual speed
P-
b b b b b
Mean P-value Mean P-value Meanc P-value P-value valu
e
AP side
Range of motion [deg]
Hip 39.67 -0.176 <0.001 45.39 -0.141 0.004 42.33 -0.173 <0.001 0.035 0.246 0.003 0.829

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Spatiotemporal Interactions of fast-speed and


Regression analysis with advanced age
parameters post-activity conditiona
Fatigue
Fast speed vs
Usual speed (n=183) Fast speed (n=162) Post activity (n=147) condition vs
Usual speed
usual speed
P-
b b b b b
Mean P-value Mean P-value Meanc P-value P-value valu
e
Knee 53.68 -0.254 <0.001 56.77 -0.205 <0.001 55.39 -0.248 <0.001 0.050 0.050 0.006 0.716
Ankle 23.49 -0.138 <0.001 24.19 -0.160 <0.001 24.56 -0.144 <0.001 -0.022 0.373 -0.005 0.766
Generated MWE, 1000 J/Kg for mean in
Hip extension 103.49 1.077 0.036 156.32 0.189 0.799 107.27 0.960 0.091 -0.889 0.159 -0.117 0.805
Hip flexion 90.67 1.063 <0.001 177.51 0.431 0.236 106.24 0.827 0.002 -0.632 0.048 -0.236 0.174
Knee extension 71.17 -0.119 0.769 110.17 -0.080 0.911 89.74 -0.139 0.770 0.039 0.948 -0.020 0.956
Knee flexion 7.81 -0.019 0.869 7.78 -0.133 0.347 7.45 0.004 0.974 -0.113 0.288 0.024 0.800
Ankle dorsiflexion 7.69 -0.015 0.833 10.05 0.013 0.908 10.82 0.141 0.161 0.028 0.812 0.156 0.126
Ankle plantar flexion 156.72 -0.144 0.750 219.89 -1.377 0.043 173.80 -0.856 0.115 -1.233 0.015 -0.712 0.074
Absorption MWE, 1000 J/Kg for mean in<0.001
Hip extension 235.58 -2.629 <0.001 309.39 -2.000 0.083 276.36 -2.109 0.022 0.628 0.534 0.519 0.486
Hip flexion 1.75 0.058 0.127 2.91 -0.041 0.158 1.65 -0.031 0.095 -0.099 0.094 -0.090 0.078
Knee extension 11.44 -0.172 0.117 15.61 -0.118 0.426 13.16 -0.038 0.731 0.054 0.666 0.134 0.160
Knee flexion 178.39 -0.299 0.629 243.39 0.096 0.908 199.78 -0.271 0.735 0.395 0.574 0.028 0.962
Ankle dorsiflexion 131.91 0.019 0.987 105.23 -0.135 0.820 117.57 -0.046 0.922 -0.154 0.773 -0.064 0.886
Ankle plantar flexion 5.52 0.043 0.372 5.64 -0.037 0.246 5.18 -0.010 0.757 -0.080 0.120 -0.054 0.265
ML side
Range of motion [deg]
Hip 9.80 -0.064 <0.001 12.06 -0.094 <0.001 10.88 -0.082 <0.001 -0.030 0.054 -0.018 0.122
Knee 10.53 -0.072 0.031 10.62 -0.033 0.362 10.72 -0.064 0.068 0.040 0.089 0.008 0.591
Ankle 8.42 -0.095 <0.001 8.70 -0.093 <0.001 9.04 -0.097 <0.001 0.001 0.939 -0.002 0.896
Generated MWE, 1000 J/Kg for mean in
Hip extension 62.30 -1.079 <0.001 70.58 -1.434 <0.001 68.89 -1.370 <0.001 -0.356 0.032d -0.291 0.027d
Hip flexion 14.64 -0.361 <0.001 9.54 -0.353 <0.001 15.65 -0.537 <0.001 0.008 0.879 -0.177 0.003d
Knee extension 6.57 -0.001 0.989 9.66 0.007 0.945 8.01 -0.026 0.693 0.008 0.901 -0.026 0.407
Knee flexion 3.33 -0.033 0.229 4.00 -0.116 <0.001 3.61 -0.069 0.017 -0.083 <0.001 -0.037 0.024
Ankle dorsiflexion 5.24 -0.029 0.364 5.86 -0.080 0.197 6.20 -0.006 0.896 -0.051 0.425 0.023 0.599
Ankle plantar flexion 4.45 0.061 0.009 3.95 -0.005 0.848 3.42 0.007 0.787 -0.066 0.020 -0.054 0.030
Absorption MWE, 1000 J/Kg for mean in
Hip extension 44.75 0.305 0.125 64.88 0.068 0.820 49.52 0.211 0.355 -0.238 0.266 -0.094 0.463
Hip flexion 2.47 0.122 <0.001 7.70 0.043 0.307 3.26 0.127 <0.001 -0.080 0.015 0.005 0.760
Knee extension 7.98 0.023 0.630 8.35 -0.061 0.311 7.79 -0.011 0.822 -0.085 0.024 -0.035 0.181
Knee flexion 7.81 -0.031 0.669 6.67 0.019 0.795 7.31 -0.030 0.686 0.050 0.425 0.001 0.980
Ankle dorsiflexion 8.81 0.120 0.340 8.46 0.021 0.742 8.20 -0.106 0.045 -0.099 0.446 -0.226 0.082
Ankle plantar flexion 7.13 -0.145 <0.001 10.91 -0.292 <0.001 8.63 -0.183 <0.001 -0.147 0.004d -0.037 0.362
Bold indicates significance with P<0.05
a
Gait parameter differences in walking tasks as fast-speed and post-activity condition compared with usual-speed walking
b
Estimated coefficient for linear regression
c
Adjusted for gait speed, height, weight and sex (gait speed: adjusted for height, weight and sex).
d
Exacerbated decline compared with the usual-speed walking (only for the case both compared walking tasks showed negative associations with older age).

Further data concerning the combined effect of obesity and age can be found in another study from
the Baltimore Longitudinal Study of Aging (BLSA) [202]. See tables 2-3 of the cited paper.

4.2. Literature review about visual impairments


4.2.1. Senile or age related macular degeneration

Age related macular degeneration (AMD) is a medical condition, which usually affects older adults
which results in a loss of vision in the center of the visual field (the macula) because of damage to
the retina. The macula is a small, about 5 mm in diameter, area of the retina. It is the part of the
retina that is the most densely packed with rods and cones and it is essential for central vision.

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The main early symptoms of AMD are a blurring of central vision and visual distortion, i.e. straight
lines appear wavy or crooked, as well as reduction of contrast sensitivity. In progressed disease a
'blind spot' develops in the middle of the visual field, which increases with time (Figure 4.19).

Figure 4.19 - Views of a person with normal vision (left) and of a person with AMD (right)

Because the peripheral vision is not affected, people with macular degeneration can learn to use
their remaining vision to continue most activities.

In a survey with 104 participants, of which 18% had no ocular pathology, 5% had posterior vitreous
detachment in 1 eye and 77% participants had some degree of AMD in 1 eye, it was found that
23% participants had vision 20/30 and 77% participants had some degree of visual impairment
(<20/30).

4.2.2. Diabetic retinopathy

Diabetic retinopathy is a complication of diabetes that results from damage to the blood vessels of
the light-sensitive tissue at the back of the eye (retina). Initially, diabetic retinopathy may cause no
or only mild symptoms, but it can finally result in blindness. Symptoms may include: blurred or
fluctuating vision, blind spots, impaired color vision. Diabetic retinopathy usually affects both eyes.

In a population-based study of diabetic retinopathy in southern Wisconsin persons diagnosed prior


to 30 years of age (n = 996) and those diagnosed at 30 years of age or older (n = 1370) were
examined. The results are shown in Table 4.79 [203].

Table 4.79 - Visual acuity of diabetic patients in a southern Wisconsin study


Best corrected visual acuity in better Younger onset group Older onset group
eye
20/80 - 20/160 1.4% 3%
<= 20/200 3.6% (86% of which due to diabetic 1.6% (33% of which due to
retinopathy) diabetic retinopathy)

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[204] performed a study with 891 younger-onset persons with diabetes, 485 persons with older-
onset diabetes who were taking insulin, and 502 persons with older-onset diabetes who were not
taking insulin and who participated in baseline, 4-year, and 10-year examinations. The results are
shown in Table 4.80.

Table 4.80 - Visual acuity of diabetic patients at 10 years


Best corrected visual acuity in better Younger onset group Older onset taking Older onset not taking
eye insulin group insulin group
Visual impairment (acuity <= 20/40) 9.4% 37.2% 23.9%
Blindness (acuity <= 20/200) 1.8% 4% 4.8%

[205] reports the outcomes of a national screening program for diabetic eye disease, which
included 70-90% of type 1 and 1/5 of type 2 diabetic patients in the country. The results are shown
in Table 4.81.

Table 4.81 - Visual acuity of diabetic patients in a national study


Visual acuity in better eye Type 1 diabetic patients Type 2 diabetic patients
>= 6/12 96% 91%
6/18-6/36 3% 7%
<= 6/60 1% 1.6%

[206] performed an analysis of 1047 diabetic patients. Of them:


1.5% had visual acuity of 20/200 or worse (legally blind) in the better eye;
8.2% had visual acuity of 20/200 or worse in the worse eye.

4.2.3. Glaucoma

Glaucoma is a disease in which damage to the optic nerve results in vision loss. The most
common forms are open-angle glaucoma, which is a chronic condition, and angle-closure
glaucoma, which is acute.

Open-angle glaucoma develops slowly and sometimes without symptoms for many years. The
optic nerve is damaged due to clogging in the eyes drainage canals. When symptoms become
noticeable, the disease is usually quite advanced. Vision loss from glaucoma is not reversible with
treatment, even with surgery.

Symptoms of Angle-Closure Glaucoma include hazy or blurred vision and the appearance of
rainbow-colored circles around bright lights. The main visual ability to be affected by glaucoma is
the visual field and glaucoma is diagnosed and monitored based also on visual field examinations.

Any clinically or statistically significant deviation from the normal shape of the hill of vision can be
considered a visual field defect. In glaucoma, these defects are either diffuse depressions of the
visual field or localized defects that conform to nerve fiber bundle patterns.

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Figure 4.20 - Diffuse depression of the hill of vision

The National Eye Institute conducted the Advanced Glaucoma Intervention Study [207] which used
the algorithm for scoring visual field defects depicted in Table 4.82.

Table 4.82 - AGIS scoring system for visual field defects


STEP AND CRITERION SCORE

1. Score the nasal area (step or defect): Max = 2


1 depressed location in nasal area and only in 1 hemifield
or
3 clustered depressed locations of 6 possible nasal sites 1
4 to 6 clustered locations depressed 12 dB 1
2. Score each hemifield (defect): Max = 9
1 cluster of 2 locations with 1 depressed by 12 dB 1
1 cluster of 3 to 5 depressed locations 1
1 cluster of 6 to 12depressed locations 2
1 cluster of 13 to 20 depressed locations 3
1 cluster of >20 depressed locations 4
If 50% of depressed hemifield locations are depressed by
12 dB +1
16 dB +2
20 dB +3
24 dB +4
28 dB +5
3. Sum the scores for each hemifield and for the nasal area Max = 20

Using the above AGIS score, [208] performed a study on the progression of visual field loss of
untreated glaucoma patients. The results are shown in Table 4.83.

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Table 4.83 - Mean and standard deviations of mean defects (AGIS score) in visual field for untreated
glaucoma patients
ALL EYES EYES PROGRESSED BY AGIS CRITERIA
STANDARD STANDARD
EYE N MEAN N MEAN
DEVIATION DEVIATION
Mean defect
1987 R 121 -5.8 4.9 63 -6.2 4.8
L 118 -6.8 7.5 58 -7.2 9.1
1997 R 121 -10.3 8.7 63 -14.5 8.7
L 118 -10.9 8.5 58 -16.3 7.0
Change R 121 -4.4 - 63 -8.3 -
L 118 -4.3 - 58 -9.0 -
Corrected pattern standard deviation
1987 R 121 5.1 2.8 63 5.4 3.0
L 118 5.9 5.6 58 6.3 7.4
1997 R 121 7.0 3.5 63 8.5 3.1
L 118 7.8 8.2 58 8.7 3.0
Change R 121 1.9 - 63 3.0 -
L 118 1.9 - 58 2.4 -

4.2.4. Color vision deficiencies

Color vision deficiency is the inability to perceive differences between some of the colors that
others can distinguish.

The human retina contains two kinds of light cells: the rod cells (active in low light) and the cone
cells (active in normal daylight). Normally, there are three kinds of cones, each containing a
different pigment, which are activated when the pigments absorb light. The absorption spectra of
the cones differ; one is maximally sensitive to short wavelengths, one to medium wavelengths, and
the third to long wavelengths, with their peak sensitivities in the blue, yellowish-green, and yellow
regions of the spectrum, respectively. Red light, for example, stimulates the long wavelength cones
much more than either of the others, and reducing the wavelength causes the other two cone
systems to be increasingly stimulated, causing a gradual change in hue.

There are three types of colour vision deficiencies: monochromacy, dichromacy, and anomalous
trichromacy.

Monochromacy, is the complete lack of ability to distinguish colors; caused by cone defect
or absence.
Dichromacy is a defect in which one of the three basic color mechanisms is absent or not
functioning.
Protanopia is caused by the complete absence of red retinal photoreceptors. It is a form of
dichromatism in which red appears dark.
Deuteranopia is a color vision deficiency in which the green retinal photoreceptors are
absent, moderately affecting red-green hue discrimination.
Tritanopia is a very rare color vision disturbance in which there are only two cone pigments
present and a total absence of blue retinal receptors.
Anomalous trichromacy occurs when one of the three cone pigments is altered in its
spectral sensitivity. This results in an impairment, rather than loss, of trichromacy (normal
three-dimensional color vision).

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In Protanomaly an altered spectral sensitivity of red retinal receptors (closer to green


receptor response) results in poor red-green hue discrimination.
Deuteranomaly, caused by a similar shift in the green retinal receptors, is the most common
type of color vision deficiency, mildly affecting red-green hue discrimination.
Tritanomaly is rare and affects blue-yellow hue discrimination.

Based on clinical appearance, partial color blindness can be distinguished in two major types:
people who have difficulty distinguishing between red and green, and people who have difficulty
distinguishing between blue and yellow.

Figure 4.21 - The rainbow colours as viewed by a person with protanopia, deuteranopia and
tritanopia

Figure 4.22 - Colours as seen by dichromat patients. Left: a protanopic may not be able to see the
number 37; centre: a deuteranopic may not be able to see the number 49; right: a tritanopic may not
be able to see the number 56.

4.3. The experts opinion


In the context of literature review about data on motor impairments, the opinion of Dr. Guandalini
Giovanni has been taken into account.
Dr. Guandalini Giovanni works in Villa Rosa Hospital, located in Trento (Italy), and its main activity
concerns the Physical Medicine and Rehabilitation.
During an informal meeting with UNITN, Dr. Guandalini provided some useful information,
suggestions and opinions.
The first concerned the literature review on numeric data about the characterization of the
diseases. His views on this aspect was that it will be very difficult to find an extensive literature
data in order to cover all the pathologies considered. This consideration is due to the fact the
doctors, in general, dont use this kind of information because it is uninteresting for their diagnosis.
In motor impairments, they usually attempt to advance a diagnosis by a direct and qualitative
inspection of the symptoms the disease causes.

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The second opinion concerns the meaning of the data we are able to find in literature. In fact these
data could be incomplete or not so specific in order to satisfy the level of detail required. So the
numeric values need to be parsed and used appropriately.
For example, now we consider a pathology that affects one of the shoulder movement and a
numeric value of its range of motion is available from literature. However this value is not sufficient
to characterize the movement. In fact the restriction of the range of motion could not be symmetric,
as depicted in Figure 4.23.

Figure 4.23 - Symmetric (left) and symmetric (right) restriction of shoulder ROM

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5. The abstract user model


5.1. The abstract user model for motor impairments
The Table 5.1 represents the abstract user model for motor impairments.

Table 5.1 The abstract user model for motor impairments


Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

Motor G20 G20 G22 Parkinsons H Yes b760 Control of 1. Gait 1.1 Gait 1.05 (0.05)
Impairmen G26 Parkinsons disease is an voluntary parameter speed [m/s] Table 4.30
ts Extrapy disease age-related, movement s Reference: [74]
progressive,
ramidal functions
degenaritive
and Note- Table 0.94 (0.20)
brain disorder,
movem related to b7651 Tremor 4.30 Table 4.31
ent insufficient reports Reference: [75]
disorde generation of b770 Gait data for 1.2 Stride 1.11 (0.05)
rs dopamine in pattern patients length [m] Table 4.30
the midbrain. It functions with and Reference: [74]
affects several without L-
functions. dopa. 0.96 (0.19)
Table 4.31
Reference: [75]
1.3 118.3 (15.3)
Cadence Table 4.31
[steps/min] Reference: [75]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

1.4 Gait 24.7 (4.8)


cycle in Table 4.31
double limb Reference: [75]
support [%]
1.5 Stride 2.09 (0.16)
time Table 4.30
variability Reference: [74]
[%]
1.6 Gait 5.17 (1.64)
asymmetry Table 4.30
Reference: [74]
1.7 Hoehn 2.3 (0.1)
& Yahr Table 4.30
stage Reference: [74]
1.8 UPDRS 35.8 (2.6)
score Table 4.30
Reference: [74]
2. 2.1 Speed 0.968 (0.399)
Control/de [contacts/s] Table 4.29
xterity Reference: [66]
parameter 2.2 0.728 (0.257)
s Precision Table 4.29
[fraction of Reference: [66]
hits in A
zone]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

2.3 0.823 (0.204)


Imprecision Table 4.29
[fraction of Reference: [66]
hits in B, C,
D zones]
2.4 2.288 (0.807)
Sureness Table 4.29
[contacts/e Reference: [66]
vent]
2.5 Tremor 0.578 (0.616)
[extra- Table 4.29
contacts/ev Reference: [66]
ent]
2.6 Transit 0.939 (0.462)
time [s] Table 4.29
Reference: [66]
2.7 Contact 0.280 (0.220)
time [s] Table 4.29
Reference: [66]
2.8 Fitts 0.168 (0.071)
constant Table 4.29
[ms] Reference: [66]
2.9 0.181 (0.135)
Irregularity Table 4.29
[s] Reference: [66]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

3. 3.1 To see reference [68], Fig.


Kinematic Arm/should 4, pp. 635
parameter er angles
of upper during
body grasp [deg]
3.2 Wrist To see reference [69]
Movement delay 127 ms
Time to max grip aperture
631 ms
4. Fingers 4.1 Flexion 44.08
amplitude Reference: [70]
[mm]
4.2 42.52
Extension Reference: [70]
amplitude
[mm]
4.3 Flexion 190.13
duration Reference: [70]
[ms]
4.4 206.44
Extension Reference: [70]
duration
[ms]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

5. Clinical 5.1 Unified Score [52-56]


scales and Parkinson
tests s Disease
Rating
Scale
UPDRS
5.2 Spiral Score [58-60]
Analysis First order crossing, Second
order smoothness, mean
speed, degree of severity
[61,63]
WSTS SDDV scores [63]
G24 Dystonia is a H No b7650 1. Knee 1.1 Knee 1.22 [Min:0.97-Max:1.31]
Dystonia neurological Involuntary torque position at Table 4.32
disorder contractions of parameter fully Reference: [81]
characterized
muscles s extension
by involuntary,
[rad]
abnormal
muscle 1.2 0.60 [Min:0.00-Max:2.11]
contractions Maximal Table 4.32
that result in isometric Reference: [81]
sustained torque in
abnormal flexion
postures. [N/m ]
3

1.3 55 [Min:20-Max:100]
Cocontracti Table 4.32
on ratios Reference: [81]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

during
voluntary
flexion [%]
1.5 3.9
Maximal Table 4.32
isometric Reference: [81]
torque in
extension
3
[N/m ]
1.4 52.50 [Min:20-Max:80]
Cocontracti Table 4.32
on ratios Reference: [81]
during
voluntary
extension
[%]
1.5 Position 1.00 [Min:0.75-Max:1.08]
when Table 4.33
torque Reference: [81]
change
from to +
in
extension
[rad]
1.6 Torque -1.40 [Min:-2.30-Max:-0.99]
when Table 4.33

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

torque Reference: [81]


change
from to +
in
extension
3
[N/m ]
1.7 Position 0.47 [Min:0.27-Max:0.70]
when Table 4.33
torque Reference: [81]
change
from + to
in
extension
[rad]
1.8 Torque -1.07 [Min:-2.23-Max:-0.82]
when Table 4.33
torque Reference: [81]
change
from + to
in
extension
3
[N/m ]
1.9 Position 1.42 [Min:0.92-Max:1.75]
when Table 4.33
torque Reference: [81]
change

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

from to +
in flexion
[rad]
1.10 1.17 [Min:0.22-Max:2.19]
Torque Table 4.33
when Reference: [81]
torque
change
from to +
in flexion
3
[N/m ]
1.11 1.65 [Min:0.92-Max:2.00]
Position Table 4.33
when Reference: [81]
torque
change
from + to
in flexion
[rad]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

1.12 1.02 [Min:0.04-Max:2.46]


Torque Table 4.33
when Reference: [81]
torque
change
from + to
in flexion
3
[N/m ]

2. Gait 2.1 Knee 35 [Min:5-Max:55]


parameter angular Table 4.34
s position at Reference: [81]
the
beginning
of stance
phase [deg]
2.2 25 [Min:0-Max:35]
Minimum Table 4.34
knee angle Reference: [81]
during
stance
phase [deg]
2.3 46.5 [Min:5-Max:75]
Maximum Table 4.34
knee angle Reference: [81]
during the

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

swing
phase [deg]
2.4 knee 9 [Min:0-Max:20]
ROM Table 4.34
during Reference: [81]
stance
phase [deg]
2.5 Knee 8.50 [Min:0-Max:23]
ROM Table 4.34
during Reference: [81]
swing
phase [deg]
2.6 Velocity 0.37 [Min:0.13-Max:0.50]
[m/s] Table 4.34
Reference: [81]
3. 3.1 Rest in 4.45 (18.49)
Kinematic sagittal Table 4.35
s plane [deg] Reference: [83]
parameter 3.2 Flexion 37.47 (15.08)
of neck [deg] Table 4.35
and head Reference: [83]
3.3 49.87 (40.01)
Extension Table 4.35
[deg] Reference: [83]
3.4 Rest in 1.21 (26.42)

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

axial plane Table 4.35


[deg] Reference: [83]
3.5 Right 38.21 (28.65)
rotation Table 4.35
[deg] Reference: [83]
3.6 Left 41.73 (30.65)
rotation Table 4.35
[deg] Reference: [83]
3.7 Rest in 4.13 (19.80)
coronal Table 4.35
plane [deg] Reference: [83]
3.8 Right 33.72 (21.54)
lateral Table 4.35
tilting [deg] Reference: [83]
3.9 Left 30.24 (23.60)
lateral Table 4.35
tilting [deg] Reference: [83]
3.10 Axial: 2.06 (18.35)
Coupled Coronal: 1.08 (12.88)
movements Table 4.36
during Reference: [83]
flexion
[deg]
3.11 Axial: -2.48 (22.41)
Coupled Coronal:1.90 (34.22)

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

movements Table 4.36


during Reference: [83]
extension
[deg]
3.12 Sagittal: 11.56 (17.79)
Coupled Coronal: -4.26 (20.35)
movements Table 4.36
during right Reference: [83]
rotation
[deg]
3.13 Sagittal: 10.52 (14.50)
Coupled Coronal: 3.03 (20.19)
movements Table 4.36
during left Reference: [83]
rotation
[deg]
3.14 Sagittal: 5.12 (19.49)
Coupled Axial: 7.69 (23.14)
movements Table 4.36
during right Reference: [83]
lateral
tilting [deg]
3.15 Sagittal: 22.54 (19.21)
Coupled Axial: 4.70 (20.44)
movements Table 4.36
during left Reference: [83]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

lateral
tilting [deg]
4. Other 4.1 Posture Musician: 78.91 (11.54)
physical [% normal] Writer: 64.63 (20.14)
parameter Table 4.37
s Reference: [84]
4.2 UE Musician: 81.31 (9.86)
ROM [% Writer: 66.78 (18.27)
normal] Table 4.37
Reference: [84]
4.3 CAF Musician: 89.96 (8.63)
40 [% Writer: 79.08 (13.04)
normal] Table 4.37
Reference: [84]
4.4 Ordinal Musician: 67.14 (30.93)
work [% Writer: 68.75 (37.30)
normal] Table 4.37
Reference: [84]
4.5 Musician: 2.00 (1.09)
Lumbrical Writer: 6.80 (4.20)
strength Ft- Table 4.37
lbs] Reference: [84]
4.6 FDP Musician: 9.93 (4.80)
strength Ft- Writer: 14.29 (8.22)
lbs] Table 4.37

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

Reference: [84]
4.7 Musician: 0.22 (0.08)
Strength Writer: 0.48 (0.21)
ratio [-] Table 4.37
Reference: [84]
5. Other 5.1 Musician: 33.85 (13.72)
sensory Graphesthe Writer: 53.23 (26.45)
parameter sia [% Table 4.38
s wrong] Reference: [84]
5.2 Musician: 15.67 (6.69)
Localization Writer: 20.82 (12.13)
[cm off Table 4.38
target] Reference: [84]
5.3 Musician: 3.87 (2.10)
Kinesthesia Writer: 14.00 (17.51)
[mm off Table 4.38
target per Reference: [84]
digit]
5.4 Musician: 55.15 (27.81)
Stereognos Writer: 32.79 (18.04)
is accuracy Table 4.38
[% wrong] Reference: [84]
5.5 Musician: 118.10 (66.85)
Stereognos Writer: 117.72 (68.16)
is time [s] Table 4.38

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

Reference: [84]
G35 G35 Multiple H No b147 1. Gait 1.1 T25FW 18.9 (19.1)
G37 Multiple Sclerosis is a Phychomotor parameter [s] Table 4.39
Demyeli Sclerosis disease that functions, s Reference: [89]
includes
nating 1.2 6MWT 647.7 (423.6)
symptoms like
disease b760 Control of [m] Table 4.39
difficulty
s of the walking or
voluntary Reference: [89]
central performing movement 1.3 TUG [s] 24.5 (19.4)
nervous tasks, loss of functions, Table 4.39
system sensation, Reference: [89]
weakness, b780 1.4 MCGT 97.5 (66.9)
tremors and Sensations time to Table 4.39
spasticity. related to complete Reference: [89]
muscles and [s]
movement
1.5 Knee To see Table 4.40
functions,
ROM [deg] Reference: [90]
1.6 Stride To see Table 4.40
b7603
time [s] Reference: [90]
Supportive
functions of 1.7 Stance To see Table 4.40
arm and leg time [s] Reference: [90]
1.8 Stance To see Table 4.40
[%] Reference: [90]

71.2 (3.5)
Reference: [91]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

1.9 Swing To see Table 4.40


time [s] Reference: [90]
1.10 Swing To see Table 4.40
[%] Reference: [90]
1.11 Step To see Table 4.40
length [m] Reference: [90]
1.12 Foot To see Table 4.40
angle [deg] Reference: [90]
1.13 Toe To see Table 4.40
clearance Reference: [90]
[m]
1.14 Pre-intervetion: 0.23 (0.07)
Double Post-intervention:0.21 (0.06)
support Table 4.41
time [s] Reference: [90]
1.15 Pre-intervetion: 18.3 (2.8)
Double Post-intervention: 16.8 (2.8)
support [%] Table 4.41
Reference: [90]
1.16 Stride Pre-intervetion: 1.06 (0.16)
length [m] Post-intervention: 1.14
(0.12)
Table 4.41
Reference: [90]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

1.06 (0.21)
Table 4.42
Reference: [91]
1.17 Pre-intervetion:0.91 (0.23)
Velocity Post-intervention: 0.98
[m/s] (0.22)
Table 4.41
Reference: [90]

0.98 (0.1)
Table 4.42
Reference: [91]
1.18 Step Pre-intervetion: 0.19 (0.04)
width [m] Post-intervention: 0.22
(0.09)
Table 4.41
Reference: [90]
1.19 102 (6)
Cadence Table 4.42
[steps/min] Reference: [91]
1.20 15.6 (2.7)
Double Table 4.42
stance [% Reference: [91]
gait cycle]
1.21 Min -6.86 (7.4)

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

hip flexion Table 4.43


[deg] Reference: [92]
1.22 Min 6.24 (6.8)
knee Table 4.43
flexion at Reference: [92]
toe off [deg]
1.23 Max 63.23 (12.8)
knee Table 4.43
flexion Reference: [92]
[deg]
1.24 Peak -12.22 (11.5)
ankle Table 4.43
plantarflexi Reference: [92]
on [deg]

2. Strength 2.1 MTU 42.7 (3.4)


parameter slack length Table 4.44
[cm] Reference: [95]
2.2 17.7 (2.6)
Maximal Table 4.44
strain of Reference: [95]
MTU [%]
2.3 Muscle 3.8 (0.3)
fascicle Table 4.44
slack length Reference: [95]
[cm]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

2.4 79.2 (12.5)


Maximal Table 4.44
strain of Reference: [95]
muscle
fascicles
2.5 Tendon 39.3 (3.4)
slack length Table 4.44
[cm] Reference: [95]
2.6 11.2 (2.0)
Maximal Table 4.44
strain of Reference: [95]
tendon [%]
2.7 Area 2.6 (0.5)
under Table 4.44
passive Reference: [95]
length-
tension
curves
[Nm]
2.8 Pre-intervention: 74.7 (20.6)
Isometric Post-intervention: 80.1
strength (20.7)
during knee Table 4.45
extension Reference: [90]
[Nm]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

2.9 Pre-intervention: 39.3 (10.9)


Isometric Post-intervention:45.6 (24.1)
strength Table 4.45
during knee Reference: [90]
flexion [Nm]
2.8 Pre-intervention: 60.2 (20.3)
Isometric Post-intervention: 93.4
strength (45.3)
during Table 4.45
plantarflexi Reference: [90]
on [Nm]
2.8 Pre-intervention:29.1 (9.9)
Isometric Post-intervention:29.1 (11.6)
strength Table 4.45
during Reference: [90]
dorsiflexion
[Nm]

3. 3.1 Radial To see Table 4.46


Control/de distances Reference: [97]
xterity from the

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

parameter target [mm]


s

3.2 Mean To see Table 4.47


directional Reference: [97]
error [mm]
4. Clinical 4.1 UPDRS Score [52-56]
Scales (tremor
subscale)
G60 Idiopathic H No b760 Control of 1. 1.1 BBT To see Table 4.64
Hereditary neuropathy is voluntary Dexterity [blocks/min] Reference: [154]
and a disorder that movement Test [155-157]
affects the
Idiopathic functions results 1.2 Nine To see Table 4.64
peripheral
Neuropathies Hole Peg Reference: [154]
nerves. The
common b730-b749 test [s]
symptoms are Muscle [158]
numbness, functions 2. Hand 2.1 Peak 227 (130)
tingling and (b730-b749) strength Force of Table 4.62
pain; more grip [N] Reference: [152]
rarely there b770 Gait 2.2 Fatigue 34 (18)
could be pattern
tremors. Index [%] Table 4.62
functions Reference: [152]
2.3 2-Point- 47.9 (24.5)
Pinch [N] Table 4.63
b265 Touch
Reference: [152]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

function 2.4 Lateral 68.9 (32.1)


Pinch Table 4.63
b280 Sensation Reference: [152]
of pain 2.5 Max To see Table 4.65
grip [N] Reference: [158]
b7651 Tremor 2.5 Sus To see Table 4.65
grip [N] Reference: [158]
2.6 Max To see Table 4.65
pinch [N] Reference: [158]
2.7 Sus To see Table 4.65
pinch [N] Reference: [158]
3. 3.1 Hip 1.13 (0.42)
Isometric flexors (50 Table 4.66
strength of hip flexion) Reference: [159]
lower limb [Nm/Kg]
and Gait 3.2 Hip 0.65 (0.33)
extensors Table 4.66
(50 hip Reference: [159]
flexion)
[Nm/Kg]
3.3 Knee 1.53 (0.68)
extensors Table 4.66
(90 knee Reference: [159]
flexion)
[Nm/Kg]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

3.4 0.63 (0.57)


Plantarflexo Table 4.66
rs (ankle in Reference: [159]
plantigrade)
[Nm/Kg]
3.5 0.10 (0.08)
Dorsiflexors Table 4.66
(10 ankle Reference: [159]
plantarflexi
on)
[Nm/Kg]
3.6 Ankle +1.6 (7.6)
dorsiflexion Table 4.68
passive Reference: [160]
range [deg]
3.7 Ankle -10.4 (8.3)
angle at Table 4.68
ground Reference: [160]
contact
[deg]
3.8 Peak -1.8 (4.8)
ankle Table 4.68
dorsiflexion Reference: [160]
[deg]
3.9 Ankle -4.5 (9.4)

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

angle at Table 4.68


push off Reference: [160]
[deg]
3.10 Mean +9.8 (8.8)
ankle Table 4.68
pro/supinati Reference: [160]
on [deg]
3.11 Mean -15.5 (10.9)
knee/tibia Table 4.68
rotation Reference: [160]
[deg]
3.12 +0.8 (6.0)
Minimal Table 4.68
knee angle Reference: [160]
in stance
[deg]
3.13 Mean -3.6 (8.2)
hip rotation Table 4.68
[deg] Reference: [160]
3.14 Mean -0.5 (2.6)
hip Table 4.68
add/abducti Reference: [160]
on [deg]
3.15 Gait 1.12 (0.17)
velocity Reference: [160]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

[m/s]
1.13 (0.1)
Table 4.67
Reference: [159]
3.16 108 (7.3)
Cadence Table 4.67
[steps/min] Reference: [159]
G80 G83 Cerebral Palsy H No 1. Gross 1.1 GMFM GMFM scores is a function
Cerebral is a broad set motor scores of age, and GMFCS level
palsy of motor function see Fig.4.15
disorders
measure Asymptotic value:
which are
98.6 (2.6) level 1
caused by
damages to 89.3 (5.5) level 2
the cerebellum 61.3 (2.9) level 3
and its 36.1 (2.9) level 4
connections to 12.9 (3) level 5
the motor Reference: [108]
cortex, which 2.2 Gross Gross Motor Skill
occur during
Motor Skill (probability of task success)
pregnancy,
can be predicted as function
birth or in the
very first years of GMFM score,
of life. CP may See Table 4.48
Reference: [108]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

be 2.3 Level of Table 4.49 provides


accompanied disability distribution of gross motion,
by from survey fine motion and other
disturbances
disabilities.
of sensation,
Reference [100]
perception,
cognition, 2.4 Sitting Papers [113-120]
speech, and posture
behaviour.

2. Posture 2.1 Root Sagittal plane: To see


of the mean Fig.4.16
head square of Frontal plane: To see
displaceme Fig.4.16
nt (RMS) Reference: [119]
[cm]
2.2 Mean Sagittal plane: To see
Velocity Fig.4.16
(MV) [cm/s] Frontal plane: To see
Fig.4.16
Reference: [119]
2.3 Root Sagittal plane: To see
mean Fig.4.16
square of Frontal plane: To see
velocity Fig.4.16
(RMSV) Reference: [119]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

[cm/s]
2.4 Sagittal plane: To see
Frequency Fig.4.16
which Frontal plane: To see
contains Fig.4.16
95% of Reference: [119]
signal
power [Hz]
3. Reach 3.1 Jerk To see equation 4.2
3
and Grasp [m/s ] Table 4.50
Reference: [121]

Small button: 150.6 (134.7)


Large button: 92.9 (65.7)
Reference: [121]
3.2 Table 4.50
Movement Small button: 0.91 (0.31)
time [s] Large button: 0.78 (0.23)
Reference: [121]
3.3 Number Table 4.50
of Small button: 3.00 (1.3)
movement Large button: 2.86 (1.10)
units Reference: [121]
[items]
3.4 To see equation 4.3

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

Intercept a Reference: [125]


of Fitts
Law [ms]
3.5 b is the same for control
Parameter group and CP subjects
b of Fitts Reference: [125]
Law
3.6 Table 4.51
Processing Mild CP: 2.21 (0.91)
rate in force Moderate CP: 2.08 (0.87)
[bits/s] Severe CP: 0.47 (0.64)
Reference: [128]
3.7 Table 4.51
Processing Mild: 3.81 (0.89)
rate in Moderate: 3.49 (0.86)
position Severe: 1.32 (0.54)
[bits/s] Reference: [128]
3.8 Hand MACS levels as function of
Function the specific form of CP see
table 4.52
Prediction of functional
limitations given the
MACS level see table
4.53
Reference: [133]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

3.9 Peg Table 4.54


dexterity Right: 36.5 (31.7)
(no splint) Left: 51.3 (24.3)
[s] Reference: [135]
3.10 Peg Table 4.54
dexterity Right: 29.2 (28.6)
(dynamic) Left: 41.7 (26.0)
[s] Reference: [135]
3.11 Peg Table 4.54
dexterity Right: 29.6 (27.2)
(static) [s] Left: 47.9 (21.4)
Reference: [135]
4. 4.1 Grip (no Tbale 4.54
Grasp/Pinc splint) [lb] Right: 7.9 (16.1)
h strength Left: 1.7 (2.1)
Reference: [135]
4.2 Grip Table 4.54
(dynamic) Right: 10.8 (11.8)
[lb] Left: 1.6 (1.2)
Reference: [135]
4.3 Grip Table 4.54
(static) [lb] Right: 5.4 (8.4)
Left: 0.6 (0.4)
Reference: [135]
4.4 Lateral Table 4.54

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

pinch (no Right: 6.1 (5.4)


splint) [lb] Left: 2.4 (2.7)
Reference: [135]
4.5 Lateral Table 4.54
pinch Right: 5.3 (5.6)
(dynamic) Left: 1.6 (1.5)
[lb] Reference: [135]
4.6 Lateral Table 4.54
pinch Right: 4.1 (4.7)
(static) [lb] Left: 1.1 (1.1)
Reference: [135]
5. Upper 5.1 Flexion Table 4.55
limb torque 7.83 (4.96)
strength, elbow [Nm] Reference: [138]
control/de 5.2 Table 4.55
xterity Extension 10.83 (6.78)
parameter torque Reference: [138]
s in elbow [Nm]
children/a 5.3 Table 4.55
dolescent Supination 0.69 (0.65)
torque Reference: [138]
forearm
[Nm]
5.4 Table 4.55
Pronation 1.17 (0.84)

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

torque Reference: [138]


forearm
[Nm]
5.6 Grip Table 4.55
force [N] 104.83 (66.50)
Reference: [138]
5.7 Table 4.55
Resistance 2.33 (1.16)
torque Reference: [138]
elbow
extension
[Nm]
5.8 Table 4.55
Resistance 0.35 (0.20)
torque Reference: [138]
forearm
supination
[Nm]
5.9 AROM Table 4.55
elbow -9.34 (13.43)
extension Reference: [138]
[deg]
5.10 AROM Table 4.55
forearm -55.21 (39.21)
supination Reference: [138]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

[deg]
5.11 Force Table 4.55
control 0-40 4.75 (4.36)
rms [%] Reference: [138]
5.12 Force Table 4.55
control 40-0 6.11 (5.09)
rms [%] Reference: [138]
5.13 Force Table 4.55
control 0-40 0.19 (0.19)
CV [%] Reference: [138]
5.14 Force Table 4.55
control 40-0 0.53 (0.99)
CV [%] Reference: [138]
5.15 Table 4.55
Melbourne 80.78 (15.23)
assessmen Reference: [138]
t [%]
5.16 AHA Table 4.55
[%] 62.91 (22.70)
Reference: [138]
6. Gait 6.1 ankle To see Table 4.56
parameter torque- Reference: [140]
s rotation
characterist
ic [Nm]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

6.2 Walking Table 4.57


speed [m/s] 1.05
Reference: [142]

Table 4.58
Age <4y: 0.32
Age >4y: 0.37
Reference: [143]

Table 4.60
0.81 (0.14)
Reference: [146]
6.3 Stance Table 4.57
phase [s] Less affected: 0.59
More affected: 0.62
Reference: [142]

Table 4.60
0.65 (0.09)
Reference: [146]
6.4 To see equation 4.4
Correlation Table 4.59
between Reference: [143]
GMFM
score and
gait

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

parameters
6.5 Table 4.58
Cadence Age <4y: 90
[steps/min] Age >4y: 140
Reference: [143]

113.4 (15.1)
Reference: [146]
6.6 Step Table 4.58
length [cm] Age <4y: 19
Age >4y: 37
Reference:[143]
6.7 Table 4.60
Velocity/hei 0.62 (0.11)
ght [m/s/m] Reference: [146]
6.8 Gait Table 4.60
cycle time 1.08 (0.14)
[s] Reference: [146]
6.9 Swing Table 4.60
phase [s] 0.43 (0.06)
Reference: [146]
6.10 Stride Table 4.60
length [m] 0.86 (0.15)
Reference: [146]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

Table 4.61
Plegic side: 0.43 (0.08)
Non-plegic side: 0.43 (0.08)
Reference: [146]
6.11 Stride Table 4.60
length/heig 66.1 (6.3)
ht [%] Reference: [146]

Table 4.61
Plegic side: 33 (3.2)
Non-plegic side: 33.2 (3.5)
Reference: [146]
7. Clinical 7.1 MACS Manual Ability Classification
scales System [105]

7.2Modifie A spasticity scale [106]


d
Ashworth
scale

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

7.3 GMFCS Gross Motion Function


Classification System [108]

7.4 GMFM Gross Motion Function


Measure [109-110]

7.5 House Hand function scale [111]


classificati
on

7.6 Life-H 62 questions concerning


questionn daily activities [112]
aire See Table 4.48

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

7.7 Classification of voluntary


Zancolli grasp and release patterns
classificati [107]
on

I60 I69 I64 Stroke is a H No b760 Control of 1. Point to 1.1 Increase of 1.9 times
Cerebro Stroke cerebrovascul voluntary point Reaction Reference: [165]
vascula ar accident. It movement motion time [s]
can either be
r functions task 1.2 Increase of 2.9 times
due to an
disease Movement Reference: [165]
ischemia
s (blockage of b770 Gait See Fig. time [s]
blood flow) or pattern 4.17 1.3 Path 8.9 % of workspace
a hemorrhage. functions deviation Reference: [165]
Either way, a [%]
region of the b780 1.4 Decrease 1.5 times
brain is Sensations Movement Reference: [165]
damaged and related to
ceases its speed [m/s]
muscles and
functions. 1.5 Number 2 to 7
movement
When the of speed Reference: [165]
affected region functions
peak [#]
is 1.6 70
related to b260
Dwelling Reference: [165]
motor Proprioceptive
functions
percentage
function
time in

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

motor target [%]


disabilities are
produced. 1.7 50
Percentage Reference: [165]
of success
[%]
2. 2.1 Mildly impaired: 32%
Continous Percentage Severely impaired: 14%
tracking time on the Reference: [165]
tasks target [%]
2.2 RMS Increases 4 times (severely
tracking impaired)
error [mm] Increases 1.2 times (mildly
impaired)
Reference: [165]
2.3 Increases 10 times (severely
Deviation of impairments)
trajectory No increase (mildly
[mm] impaired)
Reference: [165]
2.4 Mean Decreases 1.2 times (mildly
speed [m/s] impaired)
Decreases 1.7 times
(severely impaired)
Reference: [165]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

2.5 Increases 1.4 times (mildly


Standard impaired)
deviation of Increases 2 times (severely
speed [m/s] impaired)
Reference: [165]
3. Hold 3.1 Mean X perturbation: Increases
position error of from 2% to 9% in X and
under holding from 0% to 2% in Y
random position [%
disturbanc of Y perturbation: Increases
e workspace from 4% to 5%
size]
See Fig. Reference: [165]
4.18 3.2 X perturbation: Increases
Standard from 4% to 15% in X and
deviation of from 0% to 4% in Y
position [%
of Y perturbation: Increases
workspace from 5% to 10%
size]
Reference: [165]
4. Gait 4.1 Stride Paretic side: 44.2
parameter length [% of Non-paretic side: 41.0
s height] Reference: [166]
4.2 Hip joint Paretic side: 29.0

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

Table 4.69 ROM [deg] Non-paretic side: 36.0


Table 4.70 Reference: [166]
4.3 Knee Paretic side: 47.0
joint ROM Non-paretic side: 56.0
[deg] Reference: [166]
4.4 Trunk 96.0
angle [deg] Reference: [166]
4.5 Center 0.6
of mass Reference: [166]
horizontal
velocity
[m/s]
4.6 Center 3.3
of mass Reference: [166]
vertical
displaceme
nt [cm]
4.6 Center 11.0
of mass Reference: [166]
lateral
displaceme
nt [cm]
4.7 Pelvic 181.0
tilt [deg] Reference: [166]
4.8 Hip More involved: 28 (11)

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

ROM [deg] Less involved: 38 (9)


Reference: [167]
4.9 Knee More involved: 27 (15)
ROM [deg] Less involved: 50 (14)
Reference: [167]
4.8 Ankle More involved: 13 (6)
ROM [deg] Less involved: 22 (8)
Reference: [167]

5. 5.1 Table 4.71


Kinematic Plantarflexi 30 knee flexion: -34.1 (4.8)
parameter on [deg] Fully extended: -31.2 (7.9)
s Reference: [168]
5.2 Table 4.71
Dorsiflexion 30 knee flexion: -3.1 (4.1)
[deg] Fully extended: -6.4 (5.1)
Reference: [168]
5.3 Ankle Table 4.71
rest Fully extended: -18.2 (6.6)
position Reference: [168]
[deg]
5.4 Table 4.72
Shoulder 88.6
flexion Reference: [169]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

[deg]
5.5 Table 4.72
Shoulder 86.36
extension Reference: [169]
[deg]
5.6 Wrist Table 4.72
flexion 35.51
[deg] Reference: [169]
5.7 Wrist 35.52
extension Table 4.72
[deg] Reference: [169]
5.8 Fingers Table 4.72
extension 61.32
[deg] Reference: [169]
6. Clinical FIM Functional Independence
Scales Measure [161]
Fugl- [162]
Meyer
Assessme
nt
Wolf-Motor [163]
Function
test
Chedoke- [164]
McMaster

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

Stroke
Assessme
nt
M05 M05 M06 Rheumatoid H Yes b7100 Mobility 1. Range of 1.1 Women: 64 (16)
M14 Rheumatoid arthritis is a of a single joint motion of Extension Men: 69 (14)
Inflamm arthritis chronic cervical [deg] Reference: [24]
disease,
atory b7101 Mobility spine 1.2 Flexion Women: 46 (10)
mainly
Poliarth of several joints [deg] Men: 46 (6)
characterized
ropathi by Table 4.2 Reference: [24]
es inflammation 1.3 Women: 132 (22)
of the lining, or Rotation Men: 137 (20)
synovium, of [deg] Reference: [24]
the joints. It
1.4 Lateral Women: 66 (15)
can lead to
flexion Men: 70 (15)
long-term joint
damage, [deg] Reference: [24]
resulting in 2. Muscle 2.1 Women: 122 (43)
chronic pain, strength of Extension Men: 221 (73)
loss of function cervical [N] Reference: [24]
and disability. spine 2.2 Flexion Women: 60 (24)
[N] Men: 125 (37)
Table 4.3 Reference: [24]
2.3 Women: 4.4 (2.1)
Rotation Men: 10.7 (4.5)
[Nm] Reference: [24]
3. Hand 3.1 Hand No deformity: 4920 (111.0)

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

kinematics working Boutonnire: 3842 (292.2)


3
space [cm ] Ulnar deviation: 3861(324.5)
Table 4.5 Swan neck: 3270 (499.3)
Combined: 1154 (333.8)
Total: 3602 (154.7)
Reference: [25]
4. Hand 4.1 Grip MCP destruction: 5.9 (4.6)
dynamics strength Reference: [26]
[Kg]
Table 4.6 RA disease: 10.58 (7.08)
Table 4.7 Reference: [27]
4.2 Key MCP destruction: 5.5 (3.4)
(lateral) Reference: [26]
pinch [Kg]
4.3 2-point MCP destruction: 3.3 (2.8)
(tip) pinch Reference: [26]
[Kg]
RA disease: 3.34 (2.26)
Reference: [27]
4.4 Three MCP destruction: 3.8 (3.2)
jaw Reference: [26]
(palmar)
pinch [Kg]
4.5 Jebsen- MCP destruction: 44.8
Taylor [s] (13.8)
Reference: [26]

08/01/2014 148 UNITN


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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

5. Range of 5.1 Flexion Left leg: 126.8 (4.6)


motion of [deg] Right leg: 1.3 (2.9)
the knee Reference: [28]
joints 5.2 Left leg: 127.0 (4.4)
Extension Right leg: 1.1 (2.7)
Table 4.8 [deg] Reference: [28]
6. Knee 6.1 Peak Left leg: 39 (12)
isokinetic torque at Right leg: 42 (12)
parameters 60 deg/s Reference: [28]
(flexors) [Nm]
6.2 Peak Left leg: 30 (11)
Table 4.9 torque at Right leg: 30 (11)
180 deg/s Reference: [28]
[Nm]
6.3 Peak Left leg: 17 (11)
torque at Right leg: 18 (12)
300 deg/s Reference: [28]
[Nm]
6.4 Peak Left leg: 41 (17)
torque Right leg: 39 (14)
angle at 60 Reference: [28]
deg/s [deg]
6.5 Peak Left leg: 38 (17)
torque Right leg: 36 (15)
angle at Reference: [28]

08/01/2014 149 UNITN


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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

180 deg/s
[deg]
6.6 Peak Left leg: 45 (13)
torque Right leg: 47 (17)
angle at Reference: [28]
300 deg/s
[deg]
6.7 Peak Left leg: 0.10 (0.07)
torque acc. Right leg: 0.10 (0.06)
Time at 60 Reference: [28]
deg/s [s]
6.8 Peak Left leg: 0.09 (0.04)
torque acc. Right leg: 0.09 (0.05)
Time at 180 Reference: [28]
deg/s [s]
6.9 Peak Left leg: 0.16 (0.08)
torque acc. Right leg: 0.15 (0.08)
Time at 300 Reference: [28]
deg/s [s]
6.10 Power Left leg: 27 (9)
at 60 deg/s Right leg: 29 (9)
[W] Reference: [28]
6.11 Power Left leg: 48 (20)
at 180 Right leg: 52 (23)
deg/s [W] Reference: [28]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

6.12 Power Left leg: 27 (25)


at 300 Right leg: 34 (30)
deg/s [W] Reference: [28]
6.13 Total Left leg: 44 (15)
work at 60 Right leg: 49 (16)
deg/s [J] Reference: [28]
6.14 Total Left leg: 29 (12)
work at 180 Right leg: 32 (14)
deg/s [J] Reference: [28]
6.15 Total Left leg: 10 (9)
work at 300 Right leg: 13 (12)
deg/s [J] Reference: [28]
6.16 Set Left leg: 192 (70)
total work Right leg: 214 (75)
at 60 deg/s Reference: [28]
[J]
6.17 Set Left leg: 124 (55)
total work Right leg: 138 (67)
at 180 Reference: [28]
deg/s [J]
6.18 Set Left leg: 247 (211)
total work Right leg: 355 (234)
at 300 Reference: [28]
deg/s [J]
6.19 Left leg: 2.1 (1.1)

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

Explosion Right leg: 2.2 (1.2)


at 60 deg/s Reference: [28]
[J]
6.20 Left leg: 8.0 (3.1)
Explosion Right leg: 8.3 (3.2)
at 180 Reference: [28]
deg/s [J]
6.21 Left leg: 7.2 (5.1)
Explosion Right leg: 8.2 (5.5)
at 300 Reference: [28]
deg/s [J]
6.22 Left leg: 139 (95)
Endurance Right leg: 132 (76)
at 300 Reference: [28]
deg/s [%]
7. Knee 7.1 Peak Left leg: 80 (23)
isokinetic torque at Right leg: 81 (25)
parameters 60 deg/s Reference: [28]
(extensors) [Nm]
7.2 Peak Left leg: 50 (17)
Table 4.9 torque at Right leg: 49 (16)
180 deg/s Reference: [28]
[Nm]
7.3 Peak Left leg: 35 (14)
torque at Right leg: 33 (14)

08/01/2014 152 UNITN


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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

300 deg/s Reference: [28]


[Nm]
7.4 Peak Left leg: 58 (9)
torque Right leg: 59 (10)
angle at 60 Reference: [28]
deg/s [deg]
7.5 Peak Left leg: 54 (10)
torque Right leg: 56 (12)
angle at Reference: [28]
180 deg/s
[deg]
7.6 Peak Left leg: 52 (12)
torque Right leg: 53 (13)
angle at Reference: [28]
300 deg/s
[deg]
7.7 Peak Left leg: 0.06 (0.03)
torque acc. Right leg: 0.06 (0.04)
Time at 60 Reference: [28]
deg/s [s]
7.8 Peak Left leg: 0.08 (0.04)
torque acc. Right leg: 0.08 (0.04)
Time at 180 Reference: [28]
deg/s [s]
7.9 Peak Left leg: 0.11 (0.05)

08/01/2014 153 UNITN


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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

torque acc. Right leg: 0.11 (0.05)


Time at 300 Reference: [28]
deg/s [s]
7.10 Power Left leg: 50 (15)
at 60 deg/s Right leg: 48 (15)
[W] Reference: [28]
7.11 Power Left leg: 90 (36)
at 180 Right leg: 84 (30)
deg/s [W] Reference: [28]
7.12 Power Left leg: 76 (40)
at 300 Right leg: 69 (40)
deg/s [W] Reference: [28]
7.13 Total Left leg: 84 (24)
work at 60 Right leg: 84 (27)
deg/s [J] Reference: [28]
7.14 Total Left leg: 55 (19)
work at 180 Right leg: 53 (18)
deg/s [J] Reference: [28]
7.15 Total Left leg: 30 (14)
work at 300 Right leg: 28 (15)
deg/s [J] Reference: [28]
7.16 Set Left leg: 377 (116)
total work Right leg: 374 (127)
at 60 deg/s Reference: [28]
[J]

08/01/2014 154 UNITN


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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

7.17 Set Left leg: 241 (87)


total work Right leg: 231 (86)
at 180 Reference: [28]
deg/s [J]
7.18 Set Left leg: 692 (248)
total work Right leg: 637 (300)
at 300 Reference: [28]
deg/s [J]
7.19 Left leg: 3.7 (1.7)
Explosion Right leg: 3.4 (1.5)
at 60 deg/s Reference: [28]
[J]
7.20 Left leg: 12.7 (4.5)
Explosion Right leg: 12.1 (4.4)
at 180 Reference: [28]
deg/s [J]
7.21 Left leg: 16.5 (6.5)
Explosion Right leg: 15.3 (6.3)
at 300 Reference: [28]
deg/s [J]
7.22 Left leg: 88 (24)
Endurance Right leg: 89 (29)
at 300 Reference: [28]
deg/s [%]
8. Gait 8.1 Stride Feet RA: 0.96 (0.17)

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

parameters length [m] Reference: [30]

8.2 Feet RA: 104.8 (8.8)


Table 4.12
Cadence Reference: [30]
[step/min]
8.3 Stance Feet RA: 65.7 (2.5)
duration Reference: [30]
[mm]
8.4 Walking Feet RA: 0.89 (0.25)
speed [m/s] Reference: [30]
8.5 Knee Table 4.10
range of Reference: [29]
motion
and speed
during gait
M10 - Gout Acute gout is H Yes b710 Mobility 1. Gait 1.1 Step Left side: 0.57 (0.1)
a common of joint parameters length [m] Right side: 0.57 (0.1)
cause of functions Reference: [33]
arthritis. The Table 4.13 1.2 Stride Left side: 1.14 (0.2)
joints length [m] Right side: 1.13 (0.3)
involved are s750 Structure Reference: [33]
the of lower 1.3 Single Left side: 0.41 (0.1)
metatarsal extremity leg support Right side: 0.57 (0.8)
joint, the [s] Reference: [33]
base of the 1.4 Double Left side: 0.19 (0.1)
big toe, knee, leg support Right side: 0.20 (0.1)

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

wrist and the [s] Reference: [33]


joints of the
1.5 Stance Left side: 0.99 (0.8)
fingers.
phase [s] Right side: 1.1 (1.2)
Reference: [33]
1.6 Swing Left side: 0.48 (0.3)
phase [s] Right side: 0.41 (0.1)
Reference: [33]
1.7 Velocity Left side: 1.10 (0.3)
[m/s] Reference: [33]
1.9 Left side: 93.7 (16.9)
Cadence Reference: [33]
[steps/min]
M15 M16 Hand H Yes b710 Mobility 1. Clinical 1.1 AHFT Arthritis Hand Function Test
M19 Arthrosis of Osteoarthritis of joint Scales
Arthrosi first is functions
1.2 GAT Grip ability
s carpometacar degenerative
pal joint disorder b7101 Mobility
(Hand correlated to of several 1.3 Jebsen Test of completion of daily
Osteoarthritis age, but not joints Test of life activities.
) caused by Hand
aging (there Function
are people 1.4 DHI Duruoz Hand Index
that are not

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

affected). 1.5 AIMS2 Arthritis Impact


The cartilage Measurement Scale 2
covering the
1.6 Australian/Canadian
ends of the
AUSCAN Osteoarthritis Hand Index
bones
[400]
forming a
2. Joint 2.1 Flexion Table 4.24
joint
mobility deficit of Reference [401]
gradually
digits [mm]
deteriorates.
Contact 2.2 Table 4.24
between Extension Reference [401]
bones, deficit of
inflammation digits [mm]
and outgrow 2.3 Table 4.24
of spurs can Opposition Reference [401]
happen. deficit of
Overall joints the thumb
become [mm]
stiffer, cause 2.4 Thumb Table 4.24
pain, and radial Reference [401]
have abduction
reduced []
range of 3. Strength 3.1 Grip Table 4.24
motion, strength [N] Reference [401]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

causing 3.2 Table 4.24


disabilities Proportion Reference [401]
like reduced of normal
strength and grip
mobility. strength
Secondary [%]
OA may be 3.3 Pinch Table 4.24
caused by by strength [N] Reference [401]
diseases like
diabetes, by
injuries, joint
overload due
to obesity
and a
number of
other
syndromes.
M17 It is an H Yes b7100 Mobility 1. Range of 1.1 Knee Left leg:136.3 (11.4)
Gonarthrosis arthrosis of of a single joint motion of flexion Right leg: 136.3 (10.6)
(arthrosis of the knee the knee [deg] Reference: [46]
the knee) joint. After joint ()
sitting or

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

laying for a Table 4.26 1.2 Knee Left leg: 0.3 (5.3)
while, the extension Right leg: 0.2 (5.2)
affected [deg] Reference: [46]
person often
complains
about a
2. Gait 2.1 97.04 (8.1)
feeling of
parameters Cadence Reference: [45]
stiffness
[step/min]
within the
Table 4.25
knee joint

2.2 Step 903.1 (80.5)


length [mm] Reference: [45]

2.3 Walking 27.8 (5.2)


base [mm] Reference: [45]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

2.4 Double 18.2 (1.7)


support Reference: [45]
phase [% of
gait cycle]

2.5 Swing 31.4 (2.8)


phase [% of Reference: [45]
gait cycle]

M16 It is a H Yes b7100 Mobility 1. Range of 1.1 Hip Left leg: 115.4 (12.3)
Coxarthrosis disease, of a single joint motion of flexion Right leg: 115.3 (11.7)
(arthrosis of affecting the the hip joint [deg] Reference: [46]
the hip) hips. The () 1.2 Hip Left leg: 2.3 (7.3)
damage of extension Right leg: 2.2 (7.6)
the cartilage Table 4.27 [deg] Reference: [46]
and 1.3 Hip Left leg: 11.8 (4.7)
deformation adduction Right leg: 12.2 (4.6)
of joint [deg] Reference: [46]
surfaces 1.4 Hip Left leg: 18.3 (6.9)
leads to abduction Right leg: 17.2 (7.5)
shortening of [deg] Reference: [46]
the leg at the 1.5 Hip Left leg: 29.4 (9.5)
affected side. internal Right leg: 28.6 (10.2)
rotation Reference: [46]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

[deg]
1.6 Hip Left leg: 34.8 (9.6)
external Right leg: 34.5 (9.2)
rotation Reference: [46]
M40 M40 Kyphosis is H s750 Structure 1. Posture 1.1 Tx Table 4.14
M54 Kyphosis a common of lower of back () kyphosis 58.8 (3.2) [34]
Dorsop condition of extremity [deg]
athies a curvature 2. Gait 2.1 Upright: 0.77 (0.19)
b770 Gait parameters Average 257 trunk flexion: 0.76
of the
pattern walking (0.19)
upper spine
functions Table 4.15 speed 507 trunk flexion: 0.81
. It can be (slow (0.21)
either the walking Reference: [35]
result of speed)
degenerativ [m/s]
e diseases 2.2 Upright: 82.7 (10.7)
(such Average 257 trunk flexion: 86.0
as arthritis), cadence (10.8)
developmen (slow 507 trunk flexion: 93.3
walking (10.4)
tal
speed) Reference: [35]
problems, o
[steps/min]
steoporosis
2.3 Upright: 0.32 (0.04)
with compre Normalized 257 trunk flexion: 0.30
ssion step length (0.05)
fractures of (slow 507 trunk flexion: 0.30

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

the vertebra walking (0.05)


e, and/or speed) Reference: [35]
trauma. [step
length/heig
ht]
2.4 Single Upright: 35.72 (3.73)
support 257 trunk flexion: 36.15
(slow (1.60)
walking 507 trunk flexion: 36.00
speed) [% (1.96)
of gait Reference: [35]
cycle]
2.5 Double Upright: 15.11 (2.01)
support 257 trunk flexion: 14.08
(slow (1.58)
walking 507 trunk flexion: 14.81
speed) [% (4.07)
of gait Reference: [35]
cycle]
2.6 Upright: 1.20 (0.20)
Average 257 trunk flexion: 1.11
walking (0.17)
speed 507 trunk flexion: 1.19
(mediumwa (0.25)
lking Reference: [35]
speed)

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

[m/s]
2.7 Upright: 104.5 (10.6)
Average 257 trunk flexion: 104.2
cadence (10.1)
(medium 507 trunk flexion: 111.1
walking (10.9)
speed) Reference: [35]
[steps/min]
2.8 Upright: 0.40 (0.03)
Normalized 257 trunk flexion: 0.37
step length (0.04)
(medium 507 trunk flexion: 0.37
walking (0.05)
speed) Reference: [35]
[step
length/heig
ht]
2.9 Single Upright: 39.25 (1.72)
support 257 trunk flexion: 39.39
(medium (3.49)
walking 507 trunk flexion: 39.62
speed) [% (3.11)
of gait Reference: [35]
cycle]
2.10 Upright:11.86 (3.55)
Double 257 trunk flexion: 11.94

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

support (2.56)
(medium 507 trunk flexion: 11.03
walking (2.08)
speed) [% Reference: [35]
of gait
cycle]
2.10 Upright: 1.80 (0.29)
Average 257 trunk flexion: 1.78
walking (0.37)
speed (fast 507 trunk flexion: 1.79
walking (0.37)
speed) Reference: [35]
[m/s]
2.11 Upright: 125.2 (10.4)
Average 257 trunk flexion: 129.6
cadence (13.1)
(high 507 trunk flexion: 135.6
walking (11.9)
speed) Reference: [35]
[steps/min]
2.12 Upright: 0.49 (0.05)
Normalized 257 trunk flexion: 0.47
step length (0.06)
(high 507 trunk flexion: 0.45
walking (0.07)
speed) Reference: [35]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

[step
length/heig
ht]
2.13 Single Upright: 41.74 (1.80)
support 257 trunk flexion: 42.23
(high (2.07)
walking 507 trunk flexion: 42.29
speed) [% (2.18)
of gait Reference: [35]
cycle]
2.14 Upright: 8.26 (2.21)
Double 257 trunk flexion: 8.18
support (1.64)
(high 507 trunk flexion: 7.92
walking (2.12)
speed) [% Reference: [35]
of gait
cycle]
3. Lower 3.1 Ankle Upright: 11.3 (3.1)
body maximum 257 trunk flexion: 13.9 (2.8)
parameter dorsiflexion 507 trunk flexion: 16.9 (3.8)
during gait in slow Reference: [35]
() walking
speed[]
Table 4.16 3.2 Ankle Upright: -14.1 (4.0)
Table 4.17 maximum 257 trunk flexion: -9.7 (3.3)

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

plantarflexi 507 trunk


flexion: -7.7 (2.7)
on in slow Reference: [35]
walking
speed []
3.3 Ankle Upright: 25.5 (4.3)
ROM in 257 trunk flexion24.9 (3.2)
slow 507 trunk flexion: 26.5 (3.8)
walking Reference: [35]
speed []
3.4 Knee Upright: 55.1 (4.1)
maximum 257 trunk flexion: 56.3 (4.4)
flexion in 507 trunk flexion: 61.2 (8.4)
slow Reference: [35]
walking
speed []
3.5 Knee Upright: 60.7 (5.8)
ROM in 257 trunk flexion: 59.4 (5.9)
slow 507 trunk flexion: 59.9 (4.2)
walking Reference: [35]
speed []
3.6 Hip Upright: 28.4 (6.4)
maximum 257 trunk flexion: 34.1 (7.2)
flexion in 507 trunk flexion: 46.7 (9.4)
slow Reference: [35]
walking
speed []

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

3.7 Hip Upright: 34.6 (4.0)


ROM in 257 trunk flexion: 29.1 (6.7)
slow 507 trunk flexion: 21.9 (5.1)
walking Reference: [35]
speed []
3.8 Ankle Upright: 10.1 (3.6)
maximum 257 trunk flexion: 13.6 (3.0)
dorsiflexion 507 trunk flexion: 17.4 (4.2)
in normal Reference: [35]
walking
speed[] Right: 4.47 (6.06) or 6.69
(4.75)
Left: 4.53 (8.09) or 6.00
(3.76)
Reference: [36]
3.9 Ankle Upright: -16.6 (3.8)
maximum 257 trunk flexion: -11.2
plantarflexi (3.5)
on in 507 trunk flexion: -7.9 (3.2)
normal Reference: [35]
walking
speed []
3.10 Ankle Upright: 29.3 (3.6)
ROM in 257 trunk flexion: 26.7 (3.0)
normal 507 trunk flexion: 27.2 (3.2)
walking Reference: [35]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

speed []
3.11 Knee Upright: 54.7 (5.2)
maximum 257 trunk flexion: 58.5 (4.6)
flexion in 507 trunk flexion: 62.8 (8.9)
normal Reference: [35]
walking Right: 91.13 (1.36) or 98.54
speed [] (1.29)
Left: 92.27 (3.83) or 98.46
(2.70)
Reference: [36]
3.12 Knee Right: 3.00 (3.56) or 2.85
extention in (4.56)
normal Left: 3.27 (3.32) or 2.08
walking (2.87)
speed [] Reference: [36]
3.13 Knee Upright: 65.6 (3.8)
ROM in 257 trunk flexion: 65.1 (4.1)
normal 507 trunk flexion: 65.4 (4.1)
walking Reference: [35]
speed []
3.14 Hip Upright: 32.4 (8.1)
maximum 257 trunk flexion: 35.8 (7.2)
flexion in 507 trunk flexion: 48.8 (8.9)
normal Reference: [35]
walking
speed []

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

3.15 Hip Upright: 51.2 (6.3)


ROM in 257 trunk flexion: 35.6 (6.3)
normal 507 trunk flexion: 30.0 (7.9)
walking Reference: [35]
speed []
3.16 Hip Right: 12.60 (5.32) or 14.62
extention in (7.40)
normal Left: 12.20 (5.59) or 13.23
walking (7.47)
speed [] Reference: [36]
3.17 Ankle Upright: 10.1 (3.6)
maximum 257 trunk flexion: 12.8 (3.1)
dorsiflexion 507 trunk flexion: 17.4 (4.3)
in fast Reference: [35]
walking
speed[]
3.18 Ankle Upright: -16.6 (3.8)
maximum 257 trunk flexion: -12.0
plantarflexi (3.7)
on in fast 507 trunk flexion: -7.5 (3.6)
walking Reference: [35]
speed []
3.19 Ankle Upright: 29.3 (3.6)
ROM in fast 257 trunk flexion: 27.4 (3.2)
walking 507 trunk flexion: 28.0 (3.7)
speed [] Reference: [35]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

3.20 Knee Upright: 54.7 (5.2)


maximum 257 trunk flexion: 57.3 (4.6)
flexion in 507 trunk flexion: 61.0
fast walking (11.1)
speed [] Reference: [35]
3.21 Knee Upright: 65.6 (3.8)
ROM in fast 257 trunk flexion: 65.9
walking (3.8))
speed [] 507 trunk flexion: 67.7 (4.7)
Reference: [35]
3.22 Hip Upright: 32.4 (8.1)
maximum 257 trunk flexion: 36.8 (7.5)
flexion in 507 trunk flexion: 48.2 (9.9)
fast walking Reference: [35]
speed []
3.23 Hip Upright: 51.2 (6.3)
ROM in fast 257 trunk flexion: 47.3 (8.2)
walking 507 trunk flexion: 40.8
speed [] (11.3)
Reference: [35]
4. Dynamic 4.1 Spine 4.21 (0.89) or 4.31 (1.18)
trunk data extensors Reference: [36]
(N) [N]
4.2 3.80 (1.52) or 3.54 (1.45)
Table 4.18 Abdominals Reference: [36]
[N]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

M40 Lordosis is H No s760 Structure 1. Posture 1.1 Cobb Table 4.19


Lordosis a medical of trunk (L1-S1) 58.8 (3.2)
term used angle [] Reference: [37]
to describe
an inward
curvature of
a portion of
the vertebra
column
M45 Ankylosing H s760 Structure 1. Gait 1.1 Trunk 5.49 (1.64)
Ankylosing spondylitis of trunk parameter ROM Reference: [38]
spondylitis (AS) is s during gait
defined as []
the Table 4.20 1.2 Hip Right: 34.92 (6.99)
formation of ROM Left: 33.18 (6.41)
a stiff joint during gait Reference: [38]
by []
consolidation 1.3 Knee Right: 65.69 (7.77)
of the ROM Left: 66.39 (3.53)
articulating during gait Reference: [38]
surfaces and []
inflammation 1.4 Ankle Right: 29.37 (8.42)
of the ROM Left: 30.19 (11.22)
vertebral during gait Reference: [38]
column []

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

1.5 Stride 0.89 (0.19)


legth [m] Reference: [38]
2. Posture 2.1 PI 61.9 (13.7)
Angle [] Reference: [41]
Table 4.21
2.2 SS 23.9 (11.3)
Angle [] Reference: [41]
2.3 PT 38.5 (10.9)
Angle [] Reference: [41]
2.4 C7T 72.6 (14.7)
Angle [] Reference: [41]
2.5 SSA 96.4 (17.8)
Angle [] Reference: [41]
2.6 KTA 74.9 (12.7)
Angle [] Reference: [41]
3. Other 3.1 Chest 4.5 (1.3) or 4.2 (1.7)
kinematic expansion Reference: [39]
parameter [cm]
s 3.2 Posture 5.1 (2.5) or 5.2 (1.8)
cervical Reference: [39]
Table 4.22 spine [cm]
Table 4.23 3.3 Posture 37.3 (10.3) or 39.3 (8.3)
thoracic Reference: [39]
spine [cm]
3.4 Posture 21.2 (6.8) or 23.6 (6.4)
lumbar Reference: [39]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

spine [cm]
3.5 Sagittal 14.0 (8.3) or 13.3 (6.5)
thoracic Reference: [39]
spine
flexion []
3.6 Sagittal 4.7 (5.2) or 6.6 (6.0)
thoracic Reference: [39]
spine
extension
[]
3.7 Sagittal 18.7 (9.5) or 19.8 (6.2)
thoracic Reference: [39]
spine ROM
[]
3.8 Lumbar 36.9 (14.5) or 37.5 (6.7)
thoracic Reference: [39]
spine
flexion []
3.9 Lumbar 7.3 (5.7) or 7.9 (6.7)
thoracic Reference: [39]
spine
extension
[]
3.10 44.2 (17.7) or 45.4 (10.1)
Lumbar Reference: [39]
thoracic

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

spine ROM
[]
3.11 7.36 (3.74)
Cervical Reference: [40]
rotation left
[cm]
3.12 7.28 (3.57)
Cervical Reference: [40]
rotation
right [cm]
3.13 19.71 (15.73)
Fingertip- Reference: [40]
to-floor
distance
[cm]
3.14 Lateral 53.10 (6.59)
lumbar Reference: [40]
flexion left
[cm]
3.15 Lateral 52.21 (6.30)
lumbar Reference: [40]
flexion right
[cm]
3.16 4.02 (2.30)
Modified Reference: [40]
Schober

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

index (15
cm) [cm]
3.17 17.94 (7.11)
Tragus-to- Reference: [40]
wall
distance
[cm]
M60 M75.0 Frozen L No b7100 Mobility 1. Upper 1.1 Right: 132.88 (15.72) or
M79 Adhesive shoulder is a of a single joint body Abduction 123.91 (14.06)
Soft capsulitis of disorder in parameter [] Left: 123.75 (15.9) or 129.58
tissue shoulder which s (17.44)
disorde the joint of Table 4.28 Reference: [48]
rs the 1.2 Internal Right: 32 (13.79) or 22.7
shoulder, rotation [] (15.53)
becomes Left: 22.81 (14.37) or 28.33
inflamed and (13.64)
stiff, and Reference: [48]
grows 1.3 Right: 64.71 (13.41) or
together with External 51.25 (14.23)
abnormal rotation [] Left: 52.18 (12.1) or 54.58
bands of (13.74)
tissue, called Reference: [48]
adhesions,
greatly
restricting
motion and

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

causing
chronic pain.

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Table 5.2 reports the abstract user model for the motor capabilities of elder people.

Table 5.2 - The abstract user model for motor impairments of elder people
Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

Motor Not Not classified Aging, besides H Yes 1. Fitts 1.1 To see equations 4.5, 4.6,
Impairmen classifi the chance of Law for Modified 4.7
ts of Elder ed being affected elder Fitts Law Reference: [183]
by one or
people people
more
diseases, 2. Muscle 2.1 Muscle For grip strength and
involves the strength strength quadriceps strength, as
decline of (upper function of age, see Table
several limb) [Kg] 4.73
cognitive and Reference: [187]
physical For grip strength across the
functions. whole life see tables 3.16
Reaction time
and 3.17.
and muscular
Reference: [397]
strength are
two examples. See also [397] Fig.1 and
Fig.2
2.2 Muscle For arm lean mass and leg
mass [Kg] lean mass, as function of
age, see Table 4.73
Reference: [187]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

2.2 Muscle For upper extremity specific


quality [Kg- force and lower extremity
force/Kg- specific force, as function of
mass] age, see Table 4.73
Reference: [187]
2.3 Muscle Table 4.76
strength leg Older men: 2236
press [N] Older with mobility
limitations: 1760
Reference: [195]
3. Walk, sit 3.1 6MWT Table 4.74
and other [s] Reference: [191]
functions 3.2 Chair Table 4.74
Stand Test Reference: [191]
[s]
3.3 50m Table 4.76
Walking Older men: 26.5
Test [s] Older with mobility
limitations: 37
Reference: [195]
3.4 Stair Table 4.76
Climb Test Older men: 4.9
[s] Older with mobility
limitations: 7.5
Reference: [195]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

3.5 Lift and Table 4.75


load Older men: 33
shelves Older with mobility
[items] limitations: 22
Reference: [195]
4. Gait and 4.1 Gait See Table 4.77
balance speed [m/s] Reference: [198]
4.2 Stride See Table 4.77
length [m] Reference: [198]
4.3 See Table 4.77
Cadence Reference: [198]
[steps/min]
4.4 Stride See Table 4.77
width [cm] Reference: [198]
4.5 Stance See Table 4.77
[%] Reference: [198]
4.6 Hip See Table 4.77
extension Reference: [198]
[deg]
4.7 Hip See Table 4.77
flexion Reference: [198]
[deg]
4.8 Knee See Table 4.77
extension Reference: [198]
[deg]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

4.9 Knee See Table 4.77


flexion Reference: [198]
[deg]
4.10 Ankle See Table 4.77
dorsiflexion Reference: [198]
[deg]
4.11 Ankle See Table 4.77
plantarflexi Reference: [198]
on [deg]
4.12 Age See Table 4.78
associated Reference [198]
changes in
gait
parameter
s
5. Clinical 5.1 BLSA Baltimore Longitudinal Study
scales and of Aging [171]
studies
5.2 MMSE Mini Mental State
Examination [147]

5.3 GDS Geriatric Depression Scale


[175]

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Disability Block Code and Short Priority Age- Functional Quantitative disability metrics
category (ICD Pathology description L (low) related limitations
classifi (ICD or H (Yes/No) (ICF
cation) classification) (high) Classification) Type Parameter Value

5.4 Katz Activity of Daily living scale


ADL [188]

5.5 IADL Rosow-Breslau instrumental


activity of daily living [189]

5.6 PASE Physical activity scale [190]

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5.2. The abstract user model for visual impairments


The Table 5.3 represents the abstract user model for visual impairments.

Table 5.3 The abstract user model for visual impairments


Disabilit Block Code and Short description Priority Age- Functional Quantitative disability metrics
y (ICD Pathology 1 (low) to related limitations Type Parameter Value for moderate
categor classifi (ICD 10 (high) (Yes/No) (ICF impairment
y cation) classificati Classification)
on)

Visual H25- H25 A cataract is a clouding that L Yes b2100 Visual Visual acuity Visually significant cataract
Impair H28 Senile develops in the crystalline acuity functions is defined as having an
ments Disord cataract lens of the eye or in its b21023 Visual acuity of less than 20/40
envelope, varying in degree picture quality Visual Picture Glare Sensitivity.
ers of
from slight to complete quality Glare sensitivity increaseds
lens opacity and obstructing the for all types of cataract.
passage of light.
Implications are loss of Contrast sensitivity.
visual acuity and loss of For nuclear and cortical
contrast sensitivity. cataracts with a LogMAR
visual acuity of less than
0.5 (Snellen equivalent
The term cataract is
better than 6/18) no loss of
generally used for an contrast sensitivity at the
opacification or a lowest spatial frequency
discoloration of the lens (1c/deg). [430]
substance. It may be
localized in certain lens For cortical cataract Grade
parts or may interfuse the 1
At 2c/deg: 1.9 Log CS
whole lens. According to its
At 4c/deg: 1.8, Log CS;
localization the opacity Table 1, [430].
causes a more or less
pronounced disturbance of

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Disabilit Block Code and Short description Priority Age- Functional Quantitative disability metrics
y (ICD Pathology 1 (low) to related limitations Type Parameter Value for moderate
categor classifi (ICD 10 (high) (Yes/No) (ICF impairment
y cation) classificati Classification)
on)

light transmission A cataract


is a cloudy or opaque area in
the normally clear lens of
the eye Located behind the
pupil and the colored iris.
Cataracts do not cause
discomfort, redness, tearing,
or inflammation; however,
they interfere with work or
lifestyle. A cataract absorbs
and scatters light as it
passes through the lens.
This increased absorption
and scattering results in
reduced visual acuity and
reduced contrast sensitivity
over the entire visual field,
as well as diminished color
discrimination and increases
sensitivity to glare.

Media opacities, such as


cataracts, can cause
generalized depression of
the visual field.

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Disabilit Block Code and Short description Priority Age- Functional Quantitative disability metrics
y (ICD Pathology 1 (low) to related limitations Type Parameter Value for moderate
categor classifi (ICD 10 (high) (Yes/No) (ICF impairment
y cation) classificati Classification)
on)

Disability glare: is the loss of


retinal image contrast as a
result of intraocular light
scatter, or straylight. It has
been described as a
reduction of visual acuity
caused by light elsewhere in
the field of vision (Koch
1989).

Adaptation glare: After


leaving a dark cinema, a
patient might experience a
period of relatively poor
vision when entering into
bright daylight. In
pathological conditions of
the retina or pupillary reflex,
this form of visual
dysfunction may be
increased.

Some patients experience


an actual discomfort from a
light source in their visual
field, known as discomfort

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Disabilit Block Code and Short description Priority Age- Functional Quantitative disability metrics
y (ICD Pathology 1 (low) to related limitations Type Parameter Value for moderate
categor classifi (ICD 10 (high) (Yes/No) (ICF impairment
y cation) classificati Classification)
on)

glare (van den Berg 1991).


This may also be referred to
as photoaversion [429].

H40- H40 Glaucoma is a disease in H No b2100 Visual Visual field Spot-like, stroke-like, or
H42 Glaucoma which the optic nerve is acuity functions arcuate absolute defects
Glauco damaged, leading to b2101 Visual field (areas with reduced visual
progressive, irreversible loss functions acuity), having no
ma
of vision. b21023 Visual connection to the blind
Symptoms hazy or blurred picture quality spot (Stage II as per
vision and the appearance Aulhorn and Karmeyer)
of rainbow-coloured circles
around bright lights. Humphrey Field Analyser,
Visual field defects are program 30-2 standard
either diffuse depressions of SITA
the visual field or localized mean deviation -7.18
defects that conform to 0.94 dB
nerve fibre bundle patterns. PSD 3.7 1.17 dB
Glaucoma is the term for a CPSD 3.55 1.33 dB
diverse group of eye
diseases, all of which involve Visual field defects
progressive damage to the (The most reliable test:
optic nerve. Glaucoma is Frequency Doubling
usually, but not always,
Perimetry), pp. 142, [415].
accompanied by high
intraocular (internal) fluid
pressure. Optic nerve Diffuse depressions in the
damage produces certain hill of vision. (Visual field
characteristic visual field loss more common

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Disabilit Block Code and Short description Priority Age- Functional Quantitative disability metrics
y (ICD Pathology 1 (low) to related limitations Type Parameter Value for moderate
categor classifi (ICD 10 (high) (Yes/No) (ICF impairment
y cation) classificati Classification)
on)

defects in the individuals superiorly at early field


peripheral (side), as well as defects) [416].
central, vision. Symptoms: Detectable field loss within
Subtle loss of contrast,
the central 24-30.
difficulty driving at night,
loss of peripheral vision, loss
of central vision in terminal Users with Chronic Angle
cases. When glaucoma Closure Glaucoma
progresses, the resultant - Nasal area damaged: 52%
optic nerve damage causes in the superior hemifield
an irreversible loss of - 58%in the inferior
peripheral vision.
hemifield [417]
All types:
Open Angle Glaucoma Early defects.
(OAG) - Paracentral scotoma
-Primary open angle extending from the blind
glaucoma (POAG) spot
-Angle closure glaucoma - Paracentral scotomas with
-Congenital glaucoma
a nasal step (51%) [418]. -
-Secondary
Pseudoexfoliation glaucoma Paracentral scotomas
(PEXG) In the central 30of the
visual field. [419]
Classifying the severity of - Partial and Full arcuate
Glaucoma defect, pp. 135 [420].
- Early Glaucoma
- Depression of central
- Moderate Glaucoma
- Advanced Glaucoma isopter [421].

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Disabilit Block Code and Short description Priority Age- Functional Quantitative disability metrics
y (ICD Pathology 1 (low) to related limitations Type Parameter Value for moderate
categor classifi (ICD 10 (high) (Yes/No) (ICF impairment
y cation) classificati Classification)
on)

Advanced glaucoma
Visual field: large arcuate
scotomata
(largest extend to the
temporal lower quadrant)
[422].

Fixation.
Visual field Defects
threaten fixation [423].

Macula lutea. (yellow spot)


in fovea centralis [424]
The farther from this spot
the rays are contacted, the
more the sharpness of the
visual perception decreases
[425].

Visual picture Spatial contrast sensitivity


quality (users age ~50 years) [426]

At 22.8c/deg strong CS
losses occur with small
visual field losses [426].

50% of the eyes with high

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Disabilit Block Code and Short description Priority Age- Functional Quantitative disability metrics
y (ICD Pathology 1 (low) to related limitations Type Parameter Value for moderate
categor classifi (ICD 10 (high) (Yes/No) (ICF impairment
y cation) classificati Classification)
on)

risk ocular hypertension


(early galucoma) show
losses of peripheral
contrast sensitivity [427].

Contrast thresholds
elevations related to visual
field loss [428]
Abnormally high values in
29 of 33 glaucomatous
eyes (87%)[428]

H30- H35.3 Medical condition that H No b2100 Visual Visual acuity Brown et al (2002) study.
H36 Senile results in a loss of vision in acuity functions 246 patients with age-
Disord macular the centre of the visual field b2101 Visual field related macular
(the macula) because of functions degeneration, four groups
ers of degenerat
damage to the retina. b21023 Visual according to visual acuity,
choroi ion Main early symptoms are picture quality as follows:
d and blurring of central vision and Group 1: 20/20-20/25 (60
retina visual distortion. In patients, 23.9%)
progressed disease a 'blind Group 2: 20/30 to20/40
spot' develops in the middle (65 patients, 26.4%)
of the visual field. Group 3: 20/50 to 20/100
(57 patients, 23.3%)
The macula is the Group 4: less than or equal
responsible for central to 20/200 (65 patients,
vision [405] and the ability 26.4%).
to see detail. When the
macula is damaged, the eye Maximum reading rate
loses its ability to see detail, below 100 words per

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Disabilit Block Code and Short description Priority Age- Functional Quantitative disability metrics
y (ICD Pathology 1 (low) to related limitations Type Parameter Value for moderate
categor classifi (ICD 10 (high) (Yes/No) (ICF impairment
y cation) classificati Classification)
on)

such as small print, facial minute. [408].


features or small objects. Reading speed [412]: 85
The damaged parts of the words min -1 (SD=37)
macula often cause Controls reading speed:
scotomas, or localized areas 187 words min -1
of vision loss. Objects may (reading speed was
seem to fade or disappear. recording using text
Straight lines or edges may presented at threee times
appear wavy. threshold visual acuity size
on a computer monitor set
Representative symptoms of 50cm in front of the
Macular Degeneration are: patient)
- Central scotomas (shadows
or missing areas of vision) User with 20/40 and a
- Near vision affected encircling ring scotoma,
- Metamorhosia (distorted inability to read headlines
vision)[406]. [409].
Visual field Blind spot at the middle of
Age-Related Macular visual field.
Degeneration is the most
important cause of adult Generally patients with
blindness in developed macular degeneration
countries and the third fixate above or to left of
cause of global blindness. their central scotoma
[410].
There are two main types of Preference for fixation to
AMD [407]: the left with the scotoma
- Neovascular AMD (NV- to the right [408].
AMD) The degree of eccentricity
- Geographic atrophy from the fovea: From 2 to

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Disabilit Block Code and Short description Priority Age- Functional Quantitative disability metrics
y (ICD Pathology 1 (low) to related limitations Type Parameter Value for moderate
categor classifi (ICD 10 (high) (Yes/No) (ICF impairment
y cation) classificati Classification)
on)

11[413].
Fixation variability
increases with scotoma
size. Scotoma sizes greater
than 20 average diameter,
sharp increase in fixation
variability [411].
Impaired fixation stability
(over the first 12 months
after losing central vision)
account for 52% of the
variance in reading speed
[412].
Visual picture Straight lines appear
quality distorted

Visual Field Defects [414]

Glare sensitivity.
Loss of Contrast sensitivity.
H36.0 It is a complication of H No b2100 Visual Visual acuity 20/50 to 20/100
Diabetic diabetes that results from acuity functions Visual picture Picture appears spotty
retinopat damage to the blood vessels b21023 Visual quality
of the light-sensitive tissue picture quality
hy Abnormal contrast
at the back of the eye
(retina). It can be discerned sensitivity [432]
into four stages: preclinical,
nonproliferative,
proliferative, and late
proliferative. The first two

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Disabilit Block Code and Short description Priority Age- Functional Quantitative disability metrics
y (ICD Pathology 1 (low) to related limitations Type Parameter Value for moderate
categor classifi (ICD 10 (high) (Yes/No) (ICF impairment
y cation) classificati Classification)
on)

stages may have no


symptoms. The proliferative
stage is characterised by
spotty / cloudy vision. The
late proliferative stage is
characterised by sever
vision loss.

Symptoms of diabetic
retinopathy include:
-Seeing spots or floaters in
your field of vision
-Blurred vision
-Having a dark or empty
spot in the center of your
vision
-Difficulty seeing well at
night [431].

H53- H53.5 Inability to perceive H No b1561 Visual Colour vision Simulate colour perception
H54 Colour differences between some perception as in [Gustavo et al, 2009]
Visual vision of the colours. Based on b21021 Colour
vision
distur deficienci prevalence, VERITAS should
e2401 Light
bances es focus on deuteranomaly, i.e. quality
and altered spectral sensitivity
blindn of green retinal receptors
ess (closer to red receptor
response).

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Disabilit Block Code and Short description Priority Age- Functional Quantitative disability metrics
y (ICD Pathology 1 (low) to related limitations Type Parameter Value for moderate
categor classifi (ICD 10 (high) (Yes/No) (ICF impairment
y cation) classificati Classification)
on)

Normal color vision is based


on the absorption of
photons by three different
types of fundamental
photoreceptor cells, the
cone cells. Three classes of
cones have different
spectral sensitivities with
peak responses lying in the
long- (L), middle- (M), and
short (S) wavelenght
regions of the spectrum,
respectively.
Aging Elderly often experience B210 Seeing Visual acuity Visual acuity: it is estimated
difficulties reading small functions that for every 13 years of
letters printed at low life, twice the amount of
light is needed to function
contrast.
effectively pp.6, [431].
More than 50 % of all
Visual picture Contrast sensitivity
individuals with severe
quality
vision impairments are over
65. A study by Lighthouse
International showed that
one in six people age 45 or
older report some type of
visual impairment.
The eyelids may lose

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Disabilit Block Code and Short description Priority Age- Functional Quantitative disability metrics
y (ICD Pathology 1 (low) to related limitations Type Parameter Value for moderate
categor classifi (ICD 10 (high) (Yes/No) (ICF impairment
y cation) classificati Classification)
on)

elasticity and tone causing


(drooping eyelid). This may
cause a reduction in the
area of visual field.
Spatial perception depends
on contrast detection, so
any reduction in contrast
perception affects this
ability as well.
Color vision may fade or
change with age

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5.3. The abstract user model for speech impairments


The Table 5.4 represents the abstract user model for speech impairments.

Table 5.4 The abstract user model for speech impairments


Disability Block (ICD Code and Short description Priority Age- Functional limitations Quantitative disability metrics
category classification) Pathology L (low) or related (ICF Classification) Type Parameter Value
(ICD H (high) (Yes/No)
classification)
Speech F98.5 Stuttering The flow of speech H No b320 Articulation Normal PCC 85%
impairment Stuttering is disrupted by functions development
involuntary b330 Fluency and rhythm ACI <50%
repetitions and of speech functions
prolongations of b3300 Fluency of speech
sounds, syllables, b3301 Rhythm of speech Mild to moderate PCC 6585%
words or phrases, b3302 Speed of speech disorder
and involuntary b3303 Melody of speech
ACI 50%
silent pauses or b3308 Fluency and
blocks in which the rhythm of speech
stutterer is unable functions, other specified
to produce sounds. b3309 Fluency and Moderate to PCC 5065%
rhythm of speech severe disorder
Also known as functions, unspecified
stammering (alalia b398 Voice and speech
literalis or anarthria functions, other specified
ACI 50%-70%
literalis). b399 Voice and speech
functions, unspecified
Sympthoms:
Repetition: a unit
of speech, such as a

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Disability Block (ICD Code and Short description Priority Age- Functional limitations Quantitative disability metrics
category classification) Pathology L (low) or related (ICF Classification) Type Parameter Value
(ICD H (high) (Yes/No)
classification)
sound, syllable, Severe disorder PCC <50
word, or phrase is
repeated
Prolongations: ACI >70%
unnatural
lengthening of
continuant sounds
Blocks:
inappropriate
cessation of sound
and air.
F98.6 Cluttering A rapid rate of H No b320 Articulation Normal PCC 85%
Cluttering speech with functions development
breakdown in b330 Fluency and rhythm
fluency, but no of speech functions
repetitions or b3300 Fluency of speech
hesitations, of a b3301 Rhythm of speech
severity to give rise b3302 Speed of speech
ACI <50%
to diminished b3303 Melody of speech
Mild to moderate PCC 6585%
speech b3308 Fluency and
disorder ACI 50%
intelligibility. rhythm of speech
Moderate to PCC 5065%
Speech is erratic functions, other specified
severe disorder
and dysrhythmic, b3309 Fluency and
with rapid jerky rhythm of speech
ACI 50%-70%
spurts that usually functions, unspecified

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Disability Block (ICD Code and Short description Priority Age- Functional limitations Quantitative disability metrics
category classification) Pathology L (low) or related (ICF Classification) Type Parameter Value
(ICD H (high) (Yes/No)
classification)
involve faulty b398 Voice and speech Severe disorder PCC <50
phrasing patterns. functions, other specified
b399 Voice and speech
functions, unspecified

ACI >70%

R47.0 Dysarthria Motor speech H No b320 Articulation Normal PCC 85%


Dysarthria disorder resulting functions development
from neurological b330 Fluency and rhythm
ACI <50%
injury, of speech functions
characterized by b3300 Fluency of speech
poor articulation. b3301 Rhythm of speech
Any of the speech b3302 Speed of speech Mild to moderate PCC 6585%
subsystems b3303 Melody of speech disorder
(respiration, b3308 Fluency and ACI 50%
phonation, rhythm of speech
resonance, prosody, functions, other specified

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Disability Block (ICD Code and Short description Priority Age- Functional limitations Quantitative disability metrics
category classification) Pathology L (low) or related (ICF Classification) Type Parameter Value
(ICD H (high) (Yes/No)
classification)
articulation and b3309 Fluency and Moderate to PCC 5065%
movements of jaw rhythm of speech severe disorder ACI 50%-70%
and tongue) can be functions, unspecified
Severe disorder PCC <50
affected. b398 Voice and speech
functions, other specified
b399 Voice and speech
ACI >70%
Symptoms: functions, unspecified
Phonation:
Phonatory
dysfunction [403]
-Monopitch (in all
types of dysarthria)
-Harsh voice (in all
types of dysarthria)
-sound Acoustic parameters by the Multi-
prolongation, dimensional Voice Program (MDVP) [404]:
-syllable duration: -Average fundamental frequency
(a 1 syllable word, -Average pitch period
as a 2 syllable word: - Highest fundamendal frequency
daydial), words -Lowest fundamendal frequency
with long voiceless -Standard deviation of fo
stops -Phonatory fo range in semitones
-Fundamental -Amplitude tremor frequency
frequency range - Length of analyzed sample
modification. -Absolute jitter
-Inter-utterance - Jitter percent
variability of - Relative average perturbation
syllable duration. - Shimmer in dB

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Disability Block (ICD Code and Short description Priority Age- Functional limitations Quantitative disability metrics
category classification) Pathology L (low) or related (ICF Classification) Type Parameter Value
(ICD H (high) (Yes/No)
classification)
Prosody: -Shimmer percent
Articulation, -Number of voice breaks
abnormality in
articulation rate
Resonance:
Hypernasality
Respiration

H91.3 Deaf Muteness, no Muteness or H No b398 Voice and speech


mutism, not speech mutism is a kind of functions, other specified
elsewhere speech disorder b399 Voice and speech
classified that causes an functions, unspecified
inability to speak.
The term mute
originates from the
latin word mutus,
for silent.
R48.2 Apraxia Apraxia of A disorder caused H No b156 Perceptual functions Normal PCC 85%
speech by damage to b1560 Auditory development
specific areas of the perception
cerebrum, b1561 Visual perception ACI <50%
characterized by b1564 Tactile perception
loss of the ability to b160 Thought functions
execute or carry out b1600 Pace of thought
learned purposeful b1601 Form of thought
movements, b1602 Content of thought Mild to moderate PCC 6585%
despite having the b1603 Control of thought disorder

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Disability Block (ICD Code and Short description Priority Age- Functional limitations Quantitative disability metrics
category classification) Pathology L (low) or related (ICF Classification) Type Parameter Value
(ICD H (high) (Yes/No)
classification)
desire and the b1608 Thought functions, ACI 50%
physical ability to other specified
perform the b1609 Thought functions,
movements. It is a unspecified
disorder of motor b164 Higher level Moderate to PCC 5065%
planning which may cognitive functions severe disorder
be acquired or b1640 Abstraction
developmental, but b1641 Organization and ACI 50%-70%
may not be caused planning
by incoordination, b1642 Time management
sensory loss, or b1643 Cognitive flexibility
failure to b1644 Insight Severe disorder PCC <50
comprehend simple b1645 Judgement
commands (which b1646 Problem-solving
can be tested by b1648 Higher-level ACI >70%
asking the person to cognitive functions, other
recognize the specified
correct movement b1649 Higher-level
from a series). cognitive functions,
unspecified
b167 Mental functions of
language
b1670 Reception of
language
b16700 Reception of
spoken language
b16701 Reception of
written language

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Disability Block (ICD Code and Short description Priority Age- Functional limitations Quantitative disability metrics
category classification) Pathology L (low) or related (ICF Classification) Type Parameter Value
(ICD H (high) (Yes/No)
classification)
b16702 Reception of sign
language
b16708 Reception of
language, other specified
b16709 Reception of
language, unspecified
b1671 Expression of
language
b16710 Expression of
spoken language
b16711 Expression of
written language
b16712 Expression of sign
language
b16718 Expression of
language, other specified
b16719 Expression of
language, unspecified
b1672 Integrative
language functions
b1678 Mental functions
of language, other
specified
b1679 Mental functions
of language, unspecified

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5.4. The abstract user model for hearing impairments


The Table 5.5 represents the abstract user model for hearing impairments.

Table 5.5 The abstract user model for hearing impairments


Disability Block (ICD Code and Short description Priority Age- Functional Quantitative disability metrics
category classification) Pathology (ICD 1 (low) to related limitations Type Parameter Value
classification) 10 (high) (Yes/No) (ICF Classification)
Hearing H90.0-90.2 Conductive Conductive hearing Yes b156 Perceptual dBHL
impairment Hearing Loss , loss happens when functions Mild Hearing 25 -
bilateral, there is a problem b1560 Auditory Loss 40dBHL
conducting sound perception
unilateral with
waves through the b230 Hearing
unrestricted outer ear, tympanic functions
hearing on the dBHL
membrane b2300 Sound
Moderate 41 -
contralateral (eardrum) or middle detection
Hearing Loss 70dBHL
side or ear (ossicles). This b2301 Sound
unspecified type of hearing loss discrimination
may occur in b2302 Localisation
conjunction with of sound source
sensorineural b2303 dBHL
hearing loss or Lateralization of Severe 71 -
alone. sound Hearing Loss 95dBHL)
b2304 Speech
discrimination
b2308 Hearing
functions, other
specified
b2309 Hearing
dBHL
functions,
Profound 96+ dBHL
unspecified
Hearing Loss
H90.2-90.5 Sensorineural Sensorineural Yes b156 Perceptual dBHL
Hearing Loss , hearing loss is a type functions Mild Hearing 25 -
of hearing loss in b1560 Auditory Loss 40dBHL

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Disability Block (ICD Code and Short description Priority Age- Functional Quantitative disability metrics
category classification) Pathology (ICD 1 (low) to related limitations Type Parameter Value
classification) 10 (high) (Yes/No) (ICF Classification)
bilateral, which the root perception dBHL
unilateral with cause lies in the b230 Hearing Moderate 41 -
unrestricted vestibulocochlear functions Hearing Loss 70dBHL
nerve (Cranial nerve b2300 Sound dBHL
hearing on the
VIII), the inner ear, detection Severe 71 -
contralateral or central b2301 Sound
side or Hearing Loss 95dBHL)
processing centers discrimination
unspecified of the brain. b2302 Localisation
of sound source
b2303
dBHL
Lateralization of
Profound 96+ dBHL
sound
b2304 Speech Hearing Loss
discrimination
b2308 Hearing
functions, other
specified
b2309 Hearing
functions,
unspecified

H90.6-90.8 Mixed Hearing Mixed Hearing Loss Yes b156 Perceptual dBHL
loss conductive is simply a functions Mild Hearing 25 -
and combination of b1560 Auditory Loss 40dBHL
sensorineural sensorineural and perception dBHL
hearing loss, conductive Hearing b230 Hearing Moderate 41 -
bilateral, Loss. functions
Hearing Loss 70dBHL
unilateral with b2300 Sound
unrestricted detection dBHL
hearing on the b2301 Sound Severe 71 -
contralateral discrimination Hearing Loss 95dBHL)
side or b2302 Localisation dBHL
unspecified of sound source Profound 96+ dBHL
b2304 Speech

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Disability Block (ICD Code and Short description Priority Age- Functional Quantitative disability metrics
category classification) Pathology (ICD 1 (low) to related limitations Type Parameter Value
classification) 10 (high) (Yes/No) (ICF Classification)
discrimination Hearing Loss
b2308 Hearing
functions, other
specified
b2309 Hearing
functions,
unspecified
H 91.9 Hearing loss, Hearing loss or Yes b156 Perceptual dBHL
unspecified deafness involves a functions Mild Hearing 25 -
substantial b1560 Auditory Loss 40dBHL
uncorrectable perception dBHL
impairment of b230 Hearing Moderate 41 -
hearing in both ears. functions (All)
Hearing Loss 70dBHL
Some deaf
individuals' first dBHL
language is a sign Severe 71 -
language, and they Hearing Loss 95dBHL)
may or may not dBHL
read a written Profound 96+ dBHL
language fluently, or Hearing Loss
speak clearly.
H91 H9.1 Presbycusis, is the Yes b230 Hearing
Presbycusis cumulative effect of functions 1. Loss of high pitched sounds (such as
aging on hearing. It b2300 Sound /s/, /f/, /th/, /k/ (unvoiced consonants).
is defined as a 2. Hearing loss (H) as a function of age (N,
detection
progressive bilateral
b2301 Sound in years) and frequency [402]:
symmetrical age-
related discrimination
sensorineural Median value of hearing loss
2
hearing loss. The H = a(N-18)
hearing loss is most Standard deviation of hearing loss:
marked at higher SD = 0.4 H + b
frequencies. Upper quartile: H+0.75SD

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Disability Block (ICD Code and Short description Priority Age- Functional Quantitative disability metrics
category classification) Pathology (ICD 1 (low) to related limitations Type Parameter Value
classification) 10 (high) (Yes/No) (ICF Classification)
Lower quartile: H-0.6SD

Where a and b depend on frequency


and sex.

For males:
2
a = 0.003 dB/years at 125Hz
2
a = 0.003 dB/years at 250Hz
2
a = 0.0035 dB/years at 500Hz
2
a = 0.004 dB/years at 500Hz
2
a = 0.0055 dB/years at 1500 Hz
2
a = 0.007 dB/years at 2000 Hz
2
a = 0.0115 dB/years at 3000 Hz
2
a = 0.016 dB/years at 4000 Hz
2
a = 0.018 dB/years at 6000 Hz
2
a = 0.022 dB/years at 8000 Hz
2
a = 0.028 dB/years at 10000 Hz
2
a = 0.036 dB/years at 12000 Hz
b = 6.5 dB at 125 Hz
b = 6. dB at 250 Hz
b = 5.5 dB at 500 Hz
b = 5.5 dB at 1000 Hz
b = 6 dB at 1500 Hz
b = 6.5 dB at 2000 Hz
b = 7 dB at 3000 Hz
b = 7.5 dB at 4000 Hz
b = 8.5 dB at 6000 Hz
b = 9.5 dB at 8000 Hz
b = 10.5 dB at 10000 Hz

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Disability Block (ICD Code and Short description Priority Age- Functional Quantitative disability metrics
category classification) Pathology (ICD 1 (low) to related limitations Type Parameter Value
classification) 10 (high) (Yes/No) (ICF Classification)
b = 12 dB at 12000 Hz

For females:
2
a = 0.003 dB/years at 125Hz
2
a = 0.003 dB/years at 250Hz
2
a = 0.0035 dB/years at 500Hz
2
a = 0.004 dB/years at 500Hz
2
a = 0.005 dB/years at 1500 Hz
2
a = 0.006 dB/years at 2000 Hz
2
a = 0.0075 dB/years at 3000 Hz
2
a = 0.009 dB/years at 4000 Hz
2
a = 0.012 dB/years at 6000 Hz
2
a = 0.015 dB/years at 8000 Hz
2
a = 0.021 dB/years at 10000 Hz
2
a = 0.028 dB/years at 12000 Hz
b = 6. dB at 125 Hz
b = 5.5 dB at 250 Hz
b = 5.5 dB at 500 Hz
b = 5.5 dB at 1000 Hz
b = 6. dB at 1500 Hz
b = 6. dB at 2000 Hz
b = 6.5 dB at 3000 Hz
b = 7. dB at 4000 Hz
b = 8. dB at 6000 Hz
b = 9.5 dB at 8000 Hz
b = 10.5 dB at 10000 Hz
b = 12 dB at 12000 Hz

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6. Conclusions
This document provides the abstract physical model for 29 prioritized disabilities plus the generic
elderly condition.
The study is based on a survey of more than 300 references. To describe functional limitations we
looked for quantitative data and objective parameters.
We found a variegated situation. Most of the (very large) literature has a medical aim and provide
data for diagnosis and/or for monitoring of the disease progress. Even those papers that provide
objective data often have the ultimate goal to provide objective indicators as a substitution for
clinical scales (i.e., again to focus on diagnosis and monitoring).
In other words data that can be found in the literature were not collected with the purpose of being
useful for modelling virtual users. Thus data are sometime incomplete and sometime of difficult use
for the scope of VERITAS.
Metrics about kinematics, hearing, vision and speech are the most easy to exploit for VERITAS. As
an example we can find the range of motion of joints for able-bodied people an for people with
many disabilities (mostly in the ICD-10 M block).
Strength data and the drop of muscular strength in elder people is also quite easy to find.
The data most incomplete and difficult to use in VERITAS are those related to neuro-muscular
body control. In this case we find a plethora of objective indicators (e.g., dexterity tests, Fittss
law, balance control indicators, spatiotemporal gait parameters etc.), which actually are measures
of performance in specific tests. The use of these indicators is not straightforward. In facts, the use
is simple only if we have to predict the behaviour in tasks that resemble the original test (e.g.,
predicting pointing time by means of Fittss data). If the task to be simulated departs from the test
tasks, extrapolation becomes a critical.
Anyway, performance indicators in specific tests can be used, in principle, to tune virtual users to
behave as observed in the tests. Thereafter we can, in principle use the virtual users to simulate
other tasks, although the error would inevitably increase as far as the simulated task is different
form the one in which observations were made, but the question of accuracy arises and will have
to be addressed in the virtual users validation.

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Annex A
A.1. Prioritization of motor pathologies
A.1.1. Prioritization of diseases of block G

ICD Pathology Prevalence Notes Priority References


G00
Various infective diseases (*) L
G09
http://www.wolframalpha.com/input/?i=Huntington's+disease, source NAMCS and
G10 Huntington's disease 0.002564103 L
NHAMCS ( all in 2006-2007 USA) [209]
Hereditary ataxia (Friedreichs
G11 0.002 L
ataxia) http://www.news-medical.net/health/Friedreichs-Ataxia-Prevalence.aspx [210]
Spinal muscular atrophy and RARE
G12 L
related syndromes (SLA) (***)
Systemic atrophies primarily
G13 affecting central nervous system (*) L
in diseases classified elsewhere
G20
Parkinsons disease 0.333333333 H http://www.neurologychannel.com/parkinsonsdisease/incidence-prevalence.shtml [211]
G22
Other degenerative diseases of
G23 (*) L
basal ganglia
http://www.wolframalpha.com/input/?i=dystonia, source NAMCS and NHAMCS ( all in
G24 Dystonia 0.076 H
2006-2007 USA) [212]
Other extrapyramidal and
G25 (*) L
movement disorders
Extrapyramidal and movement
G26 disorders in diseases classified (*) L
elsewhere
G30 Other degenerative diseases of
(*) L
G32 the nervous system (Alzheimer)
G35 Multiple sclerosis 0.15 H Rosati G (April 2001). "The prevalence of multiple sclerosis in the world: an

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ICD Pathology Prevalence Notes Priority References


update". Neurol. Sci. 22 (2): 11739 [213]
Other acute disseminated
G36 (*) L
demyelination
Other demyelinating diseases of
G37 (*) L
central nervous system
G40
Episodic and paroxysmal disorders (****) L
G47
G50
Miscellaneous of nerve disorders (*) L
G59
Hereditary and idiopathic http://www.wolframalpha.com/input/?i=icd+356, source NAMCS and NHAMCS ( all in
G60 0.076923077 H
neuropathy 2006-2007 USA) [214]
Hubertus Kller et al., Chronic Inflammatory Demyelinating Polyneuropathy, N Engl J Med
G61 Inflammatory polyneuropathy 0.002 L
2005;352:1343-56 [215]
G62 Other polyneuropathies (*) L
Polyneuropathy in diseases
G63 (*) L
classified elsewhere
Other disorders of peripheral
G64 (*) L
nervous system
Myasthenia gravis and other
G70 0.02 L
myoneural disorders http://www.myasthenia.org/amg_whatismg.cfm [216]
Primary disorders of muscles (***)
G71 L
(muscular dystrophy) RARE
G72 Other Myophaties clasified
(*) L
G73 elsewhere
Hirtz D, Thurman DJ, Gwinn-Hardy K, Mohamed M, Chaudhuri AR, Zalutsky R (2007). "How
0.24 H
G80 common are the "common" neurologic disorders?". Neurology 68 (5): 32637 [217]
Cerebral palsy
G83 http://www.wolframalpha.com/input/?i=icd+9+343, source NAMCS and NHAMCS ( all in
0.035 H
2006-2007 USA) [218]
G90 Other disorders of the nervous
(*) L
G99 system

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ICD Pathology Prevalence Notes Priority References


(*) Too generic group of diseases
(**) Surgically treated
(***) Rare disease
(****) Disease causing episodic symptoms

A.1.2. Prioritization of diseases of block M

ICD Pathology Prevalence Notes Priority References


0.01 L Larry R Holder, Septic Arthritis, http://emedicine.medscape.com/article/395381-overview [219]
M00 Pyogenic arthritis http://www.wolframalpha.com/input/?i=pyogenic+arthritis, source NAMCS and NHAMCS ( male 2006-2007
0.00 L
USA) [220]
M01 Direct Infections of joint (*) L

M02 Kvien T, Glennas A, Melby K, et al: Reactive arthritis: Incidence, triggering agents and clinical presentation. J
Reactive Arthropathies 0.01 L
M03 Rheumatol 21:115, 1994. [221]

M05 Charles G. Helmick, David T. Felson et alEstimates of the Prevalence of Arthritis and Other Rheumatic
Rheumatoid Arthritis 1.00 about H
M06 Conditions in the United States, 2008. Vol. 58, No. 1, January 2008, pp 1525 [222]
Shbeeb M, Uramoto KM, Gibson LE, OFallon WM, Gabriel SE, The epidemiology of psoriatic arthritis in Olmsted
M07 Psoriatic and enteropathic arthropathies 0.10 L
County, Minnesota, USA, 19821991. J Rheumatol 2000;27:124750. [223]
M08 Charles G. Helmick, David T. Felson et alEstimates of the Prevalence of Arthritis and Other Rheumatic
Juvenile Arthritis 0.40 L
M09 Conditions in the United States, 2008. Vol. 58, No. 1, January 2008, pp 1525 [222]
Charles G. Helmick, David T. Felson et alEstimates of the Prevalence of Arthritis and Other Rheumatic
M10 Gout 0.98 H
Conditions in the United States, 2008. Vol. 58, No. 1, January 2008, pp 1525 [222]
M11 Other Crystal Arthropathies (*) L
M12 Other Specific Arthropathies (*) L
M13 Other arthritis (*) L
Arthropathies in other diseases classified
M14 (*) L
elsewhere
http://www.wolframalpha.com/input/?i=polyarthrosis, source NAMCS and NHAMCS ( all in 2006-2007 USA)
M15 Polyarthrosis 0.00 L
[224]
ALEXANDROS A. ANDRIANAKOS, LEONIDAS K. KONTELIS, DIMITRIOS G. KARAMITSOS, Prevalence of
0.90 L Symptomatic Knee, Hand, and Hip Osteoarthritis in Greece. The ESORDIG Study, The Journal of rheumatology
M16 Coxarthrosis (osteoarthritis of the hip) [225]
9.20 H Charles G. Helmick, David T. Felson et alEstimates of the Prevalence of Arthritis and Other Rheumatic

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ICD Pathology Prevalence Notes Priority References


Conditions in the United States, 2008. Vol. 58, No. 1, January 2008, pp 1525 [222]
ALEXANDROS A. ANDRIANAKOS, LEONIDAS K. KONTELIS, DIMITRIOS G. KARAMITSOS, Prevalence of
6.00 H Symptomatic Knee, Hand, and Hip Osteoarthritis in Greece. The ESORDIG Study, The Journal of rheumatology
M17 Gonarthrosis (osteoarthritis of the knee) [225]
Charles G. Helmick, David T. Felson et alEstimates of the Prevalence of Arthritis and Other Rheumatic
5.00 up to 12 H
Conditions in the United States, 2008. Vol. 58, No. 1, January 2008, pp 1525 [222]
ALEXANDROS A. ANDRIANAKOS, LEONIDAS K. KONTELIS, DIMITRIOS G. KARAMITSOS, Prevalence of
2.00 H Symptomatic Knee, Hand, and Hip Osteoarthritis in Greece. The ESORDIG Study, The Journal of rheumatology
Arthrosis of first carpometacarpal joint
M18 [225]
(osteoarthritis of the hand)
Charles G. Helmick, David T. Felson et alEstimates of the Prevalence of Arthritis and Other Rheumatic
6.80 H
Conditions in the United States, 2008. Vol. 58, No. 1, January 2008, pp 1525 [222]
M19 Other arthrosis (*) L

Acquired deformities of fingers and toes 0.03 L http://www.wolframalpha.com/input/?i=ICD+735, source NAMCS and NHAMCS ( all in 2006-2007 USA) [226]
M20
(Coffin-Siris syndrome) 0.05 L http://www.wrongdiagnosis.com/c/coffin_siris_syndrome/basics.htm [227]
M21 Other acquired deformities of limbs (*) L
M22 Disorders of patella (**) L
M23 Internal derangment of knee 0.14 L http://www.wolframalpha.com/input/?i=ICD+717, source NAMCS and NHAMCS ( all in 2006-2007 USA) [228]
M24 Other specific joint derangements (*) L
Other joint disorders, not elsewhere
M25 (*) L
classified
http://www.wolframalpha.com/input/?i=polyarteritis, source NAMCS and NHAMCS ( all in 2006-2007 USA)
M30 Polyarteritis 0.00 L
[229]
M31 Other necrotizing vasculopathies (*) L
Charles G. Helmick, David T. Felson et alEstimates of the Prevalence of Arthritis and Other Rheumatic
M32 Systemic lupus erythematosus (SLE) 0.40 L
Conditions in the United States, 2008. Vol. 58, No. 1, January 2008, pp 1525 [222]
http://www.wolframalpha.com/input/?i=dermatopolymyositis, source NAMCS and NHAMCS ( all in 2006-2007
M33 Dermatopolymyositis 0.21 L
USA) [230]
Charles G. Helmick, David T. Felson et alEstimates of the Prevalence of Arthritis and Other Rheumatic
M34 Systemic Sclerosis 0.03 L
Conditions in the United States, 2008. Vol. 58, No. 1, January 2008, pp 1525 [222]
Other systemic involvement of connective
M35 (*) L
tissue
M36 Systemic disorders of connective tissue (*) L
M40 Kyphosis and lordosis 6.00 H http://www.virtualmedicalcentre.com/diseases.asp?did=317 [231]
M41 Scoliosis 0.50 L http://www.cureresearch.com/s/scoliosis/prevalence.htm [232]
Spinal osteochondrosis (Scheuermanns
M42
Disease)
0.07 L http://www.wrongdiagnosis.com/s/scheuermanns_disease/prevalence.htm [233]

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ICD Pathology Prevalence Notes Priority References


Other deforming dorsopathies (Ankylosis
M43 (*) L
of spinal joint)
M45 Ankylosing spondylitis 1.00 H Maxime Dougados, Ankylosing Spondilitis, http://www.orpha.net [234]
M46 Other Inflammatory spondylopathies (*) L
http://www.wolframalpha.com/input/?i=spondylosis, source NAMCS and NHAMCS ( all in 2006-2007
M47 Spondylosis 0.28 L
USA)[235]
M48 Other spondylopathies (*) L
Spondylopathies in diseases classified
M49 (*) L
elsewhere
M50- Cervical disc disorders and other
M51 intervetrebal disc disorders
3.10 H http://www.wrongdiagnosis.com/d/disc_disorders/stats-country.htm [236]
M53 Other dorsopathies (Spinal instabilities) (*) L
M54 Dorsalgia 0.36 L http://www.wolframalpha.com/input/?i=dorsalgia [237]
(***)
M60 Myositis
RARE
L http://www.wrongdiagnosis.com/m/myositis/prevalence.htm [238]
http://www.wolframalpha.com/input/?i=icd+728.1, source NAMCS and NHAMCS ( all in 2006-2007 USA)
M61 Calcification and ossification of muscle 0.00 L
[239]
http://www.wolframalpha.com/input/?i=paraplegia, source NAMCS and NHAMCS ( all in 2006-2007 USA)
M62 Other disorders of muscle (paraplegia) 0.00 L
[240]
Disorders of muscle in diseases classified
M63 (*) L
elsewhere
http://www.wolframalpha.com/input/?i=icd+727.0, source NAMCS and NHAMCS ( all in 2006-2007 USA)
M65 Synovitis and tenosynovitis 0.23 L
[241]
Spontaneous rupture of synovium and
M66 (*) L
tendon
M67 Other disorders of synovium and tendon (*) L
Disorders of synovium and tendon in
M68 (*) L
diseases classified elsewhere
Soft tissue disorders related to use,
M70 (*) L
overuse and pressure
M71 Other bursopathies (*) L
Fibroblastic disorders (palmar (***)
M72 L
fibromatosis) RARE
Soft tissue disorders in diseases classified
M73 (*) L
elsewhere
M75 Shoulder lesions (*) L
Enthesopathies of lower limb, excluding
M76 (*) L
foot

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M77 Other enthesopathies (*) L
Other soft tissue disorders, not elsewhere
M79 (*) L
classified
M80
Osteopathies and chondropathies (*) L
M94

M95 Other acquired deformities of


(*) L
M99 musculoskeletal system
(*) Too generic group of diseases
(**) Surgically treated
(***) Rare disease

A.2. Prioritization of visual pathologies


ICD10 Disorder Description / Extent of visual Prevalence Treatability Priority
code impairment caused
H18.4 Corneal It is a corneal disease derived from the Exact prevalence is unknown. Yes LOW
degeneration appearance of calcium on the central [242] found a 7% prevalence of spheroidal
(Band cornea, specifically, the limbus of the degeneration of the cornea in a sample of
keratopathy) eye. 2,427 South African Negroes.
It is painful and results in decreased NOT RARE
visual acuity as the deposits become
white and dense.
SEVERE
H18.5 Hereditary It is degenerative disorder of the Differs in different parts of the world. Yes LOW
corneal corneal endothelium with accumulation In USA it affects approximately 4% of the (therapeutic
dystrophies of focal excrescences, leading to population over the age of 40 years [243]. lenses,
(Fuchs corneal edema and loss of vision. It is also common in other developed surgical)
dystrophy) SEVERE countries.
It is much more common and more severe in

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code impairment caused
women than in men (34:1).
It is uncommon in Saudi Arabia and in the
Chinese of Singapore [244], and extremely
rare in Japan [245].
NOT RARE
H18.6 Keratoconus It is a non-inflammatory thinning and Prevalence varies per study, ranging from 4 Yes (often LOW
bulging of the cornea. It can cause per 100,000 people to 600 per 100,000. lenses are
substantial distortion of vision, with [246] found a prevalence rate of 54.5 per enough)
multiple images, reduction in visual 100,000 in the population of Olmstead County
acuity, streaking and sensitivity to in Minnesota based on records from 1935 to
light. 1982.
MODERATE RARE
H25 Senile cataract A cataract is a clouding that develops [247] study with 2,675 people revealed a Yes (surgery LOW
H26 Other cataract in the crystalline lens of the eye or in prevalence from 4.6% for those between the after it is
its envelope, varying in degree from ages of 52 to 64 years to 46% for those 75 to fully
slight to complete opacity and 85 years of age. developed)
obstructing the passage of light. NOT RARE
Implications are loss of visual acuity
and loss of contrast sensitivity.
MODERATE
H33 Retinal A common type is Retinoschisis, which Degenerative retinoschisis is very common Yes LOW
detachments and is characterized by the abnormal with a prevalence of up to 7% in normal
breaks splitting of the retina's neurosensory persons.
layers, usually in the outer plexiform NOT RARE
layer, resulting in a loss of vision in the
corresponding visual field in some rarer
forms. More common forms are usually
asymptomatic.
LIGHT
H35.3 Senile macular It affects older adults and results in a [247] study with 2,675 people revealed an No HIGH

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code impairment caused
degeneration loss of vision in the center of the visualoverall prevalence of senile macular
field (the macula) due to damage to the degeneration of 9%, with a prevalence rate of
retina. It can advance to blindness. 2% in the youngest age group and 28% in the
SEVERE oldest age group.
NOT RARE
H35.4 Peripheral Several types have been noted, i.e. the Lattice degeneration affects approximately Yes LOW
retinal Lattice degeneration. 10% of the population [248]
degeneration This is a common, atrophic disease of NOT RARE
the peripheral retina characterized by
oval or linear patches of retinal
thinning.
Patients are typically asymptomatic.
LIGHT
H35.5 Hereditary This includes several types, the most Approximate estimates about prevalence are No LOW
retinal common being the Stargardt's Disease. between 1 in 8,000 and 1 in 10,000 [249].
dystrophy This is a genetic disease that affects the RARE
retina, causing vision to gradually
deteriorate from slightly blurry vision
to legally blind vision by the late 20s.
SEVERE
H35.7 Separation of A common type is the Central serous Unknown. No, but often LOW
retinal layers retinopathy, which is characterized by it goes
leakage of fluid in the central macula, untreated
which results in blurred or distorted within six
vision (metamorphopsia). A blind or months
gray spot in the central vision is
common, along with flashes of light
(photopsia).
MODERATE
H36.0 Diabetic Diabetic retinopathy is damage to the [247] study with 2,675 people revealed a No, only HIGH

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code impairment caused
retinopathy retina caused by complications of prevalence of 2% for people between 52 and management
diabetes mellitus, which can eventually 64 years of age or older to reduce
lead to blindness. It affects up to 80% of all patients who have vision loss
SEVERE had diabetes for 10 years or more [250]
NOT RARE
H40 Glaucoma Glaucoma is a disease in which the [247] study with 2,675 people revealed an No, only HIGH
optic nerve is damaged, leading to overall prevalence for the open-angle temporary
progressive, irreversible loss of vision. glaucoma of approximately 3%. The management
SEVERE prevalence increased with age from 1.4% (52
to 64 years old) to 7.2% (75 to 85 years old).
NOT RARE
H47.2 Optic atrophy Optic atrophy is the loss of some or Ranges from 1:50,000 to 1:10,000 No LOW
most of the fibers of the optic nerve RARE
and it may refer to serious or mild, but
always irreversible visual loss.
SEVERE
H47.3 Other disorders These main refer to a condition named They are found clinically in about 1% of the No LOW
of optic disc optic disc drusen (ODD), which are population but this increases to 3.4% in , only
globules of mucoproteins and individuals with a family history of ODD . prevention of
mucopolysaccharides that About two thirds to three quarters of clinical complication
progressively calcify in the optic disc, cases are bilateral [251]. s
and eventually 75% of patients will NOT RARE
develop some peripheral field defects.
LIGHT
H49 Paralytic Strabismus is a condition in which the The prevalence of strabismus is 2% to 5% in Yes, LOW
strabismus eyes are not properly aligned with each European-based and African-American Management
other, typically involving a lack of populations [252]. with
H50 Convergent coordination between the extraocular NOT RARE eyeglasses,
concomitant muscles that prevents bringing the gaze vision
strabismus of each eye to the same point in space therapy,

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code impairment caused
and preventing proper binocular vision, surgery
which may adversely affect depth
perception.
SEVERE
H52.0 Hypermetropia Hypermetropia is a defect of vision Its prevalence is 4-7% between ages 5-20, Yes LOW
caused by an imperfection in the eye remains constant through early middle age, (glasses,
(often when the eyeball is too short or then increases in populations aged 45 or more surgery)
the lens cannot become round enough), [253].
causing difficulty focusing on near NOT RARE
objects, and in extreme cases causing a
sufferer to be unable to focus on
objects at any distance.
Patients can experience blurred vision,
asthenopia, accommodative
dysfunction, binocular dysfunction,
amblyopia, and strabismus.
SEVERE
H52.1 Myopia It is a refractive defect of the eye in Its prevalence varies with age, race and sex, Yes (glasses, LOW
which collimated light produces image increasing at least through adolescence, and is lenses,
focus in front of the retina when present in about 15% at 15 years [253]. NOT surgery)
accommodation is relaxed. Patients can RARE
see near objects clearly but far away
objects appear blurred.
SEVERE
H52.2 Astigmatism It is an optical defect in which vision is Its prevalence may be as high as 70%, if all Yes (glasses, LOW
blurred due to the inability of the optics amounts are included, but is considered to lenses,
of the eye to focus a point object into a decrease to 3% if the extent is limited to 1.25 surgery)
sharp focused image on the retina. diopters or more [253].
MODERATE NOT RARE
H52.3 Anisometropia Anisometropia is the condition in [254] report a prevalence of anisometropia of Yes (lenses) LOW

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code impairment caused
and aniseikonia which the two eyes have unequal 1.6% in 1765 6 year old children.
refractive power; that is, are in different
states of myopia, hypemetropia or in
the extreme, antimetropia (wherein one
eye is myopic and the other is
hyperopic), the unequal refractive
states cause unequal rotations thus
leading to diplopia and asthenopia. Its prevalence (>1D difference) is 5-10%
Aniseikonia is a condition where there above the age of 20[255].
is a significant difference in the NOT RARE
perceived size of images.
MODERATE
H52.4 Presbyopia It is a condition where the eye exhibits 9.0% of population self-reported having Yes (lenses, LOW
a progressively diminished ability to presbyopia in Australia 2001 [256]. surgery)
focus on near objects with age. NOT RARE
SEVERE
H53.0 Amblyopia Amblyopia is a disorder of the visual It has been estimated to affect 15% of the Yes LOW
system that is characterized by poor or population [257]. (correcting
indistinct vision in an eye that is NOT RARE optical
otherwise physically normal, or out of deficit and
proportion to associated structural forcing use
abnormalities. of the
SEVERE amblyopic
eye)
H53.5 Colour vision These deficiencies denote the inability The prevalences are: No HIGH
deficiencies to perceive differences between some Total colour blindness: 1 in 30,000 people
of the colors. It can be acquired or [258].
congenital. It is distinguished as: Protanopia: 1% males, 0.01% females [Birch
Total color blindness 1993]
Partial color blindness Deuteranopia: 1% males, 0.01% females

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ICD10 Disorder Description / Extent of visual Prevalence Treatability Priority


code impairment caused
Red-green [Birch 1993]
Dichromacy (protanopia and Protanomaly: 1% males, 0.03% females [Birch
deuteranopia). 1993]
Anomalous trichromacy Deuteranomaly: 5% males, 0.35% females
(protanomaly and [Birch 1993]
deuteranomaly) Tritanopia: 0.001% males, 0.03% females
Blue-yellow [Birch 1993]
Dichromacy (tritanopia) Tritanomaly: 0.01% males, 0.01% females
Anomalous trichromacy [Birch 1993]
(tritanomaly)
Dichromats patients can match any NOT RARE
color they see with some mixture of
just two spectral lights.
Dichromats patients the color matches
they make differ from the normal.
MODERATE (depends on the context,
i.e. for specific tasks and applications
the deficiencies can be critical)
H53.6 Night blindness It is a condition making it difficult or Characterised as rare disease. Prevalence in Yes LOW
impossible to see in relatively low general population is unknown, as many times Treatment of
light. It is a symptom of several eye it is a symptom of other diseases. underlying
diseases. It is congenital or acquired. RARE cause
SEVERE
H54 Blindness and These are defined according to the 0.57% of the general population were blind in Depends LOW
Low Vision ICD-10 and WHO definitions for visual 2002, 2% of general population had low vision Treatment of
acuity and visual field normal values. in 2002 [259]. NOT RARE underlying
SEVERE cause

H55 Nystagmus and It is a form of involuntary eye Its prevalence in the general population was No LOW
other irregular movement, characterized by alternating estimated to be 24.0 per 10,000 population

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code impairment caused
eye movements smooth pursuit in one direction and [260].
saccadic movement in the other RARE
direction. It causes a degree of vision
impairment, with varying severity.
SEVERE

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Annex B
B.1. Description of the metrics of motor impairments
B.1.1. Gait parameters

The metrics for gait parameters are those reported in Table B. 1.

Table B. 1 - Description of the Gait parameters


Term Description
Weight shift [kg] Weight shift is the transmission of the weight load from one feet to
the other during normal gait or specific tasks. It is measured in [kg]
Step length [m] Step length is defined as the anterior displacement of the foot from
foot strike to contralateral foot strike. In both cases the same given
point on foot is measured, usually is the midpoint of the distance
between the most posterior part of the calcaneus and the 1st or 5th
caput metatarsal. Its unit is either (m) or (cm). People can control
gait speed by changing this parameter: greater step length, faster
speed. During normal walking speed (1.2 and 2.2 m/s) healthy
populations have a step length of about 0.7 and 0.8m, respectively.
Step width [m] Step width is the mediolateral distance between the feet. It is
measured as the distance, perpendicular to the direction of
progression, between a point on one foot (usually at its initial
contact) and the same point on the other foot at the subsequent
contact. The width will therefore depend on which point is chosen.
The centre of the heel is often used, although again this may not be
appropriate for some pathological gait patterns. Other studies have
used the centres of mass of the feet, ankle joint centres or outside
borders of the feet. Step width has a value of a few centimetres for
normal subjects, while for patients with balance problems, such as
cerebellar ataxia or athetoid form of cerebral palsy, it can increase
to as much as 15 or 20 cm. Step width variability may relate to fall
risk. There is a high correlation between step length and height of a
person (Murray et al. 1964) (Grieve &Gear 1966). Older individuals
who tend to walk more slowly and have a shorter stride/step length
displayed a higher falls risk score.
Stride length [m] Stride length is the distance between two successive placements of
the same foot, consisting of two step lengths. In other words it is the
distance travelled by one person during one cycle. With normal
subjects, the two step lengths will be approximately equal, but with
certain patients there will be an asymmetry between the left and
right sides. Similar to step length it is measured either in (m) or (cm).
Stride length is an important component of speed (speed = stride
length cadence). Stride length depends on strong leg muscles and
a good range of motion in joints, especially those of the hip and
knee. The natural mix of joint mobility, muscle strength, neural
control and energy leads to a customary walking speed, stride length
and step rate. Time and distance factors combined with swing and

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Term Description
stance times, constitute the persons stride characteristics. Stride
length for normal persons averages 1.41 meters.
Gait cycle [Hz] The period of time between any two identical events in the walking
or running cycle. There are two main phases in gait: a. Stance phase,
during which the foot is on the ground and b. swing phase where the
same foot is no longer in contact with the ground and the leg and
the leg is swinging theough in preparation for the next foot strike. It
is measured in [Hz] cycle per second.
Cadence (steps per minute) It is the total number of 'revolutions per minute' or number of steps
taken within a minute, and is used as a measure of athletic
performance. Step rate is commonly called cadence. Cadence is
calculated in steps per minute. It is the second gait parameter after
step length with which people can control gait speed: again greater
cadence, increased speed. Healthy populations demonstrate during
normal walking speeds (1.0-3.0 m/s) a cadence of 70 steps/min at
the lowest speed and 155 steps/min at the highest speed. In speed
range of running (1.5-8.0 m/s), they ran with a cadence of 33
steps/min at the lowest and 214 steps/min at the highest speed.
Velocity (centimetres per A physical quantity that values the rate of change in position. The
second) scalar absolute value (magnitude) of velocity is speed. Velocity is a
measure of a bodys motion in a given direction. Because velocity
has both magnitude and direction, it is a vector quantity that can be
positive, negative, or zero. Normal free gait velocity on a smooth
level surface averages 82 meters per minute (m/min) for adults.
Velocity=Stride length 0.5 Cadence.
Scissoring of legs Legs that are crossed because of a disorder of the adductor muscles
of the thigh or a deformity of the hip.

B.1.2. Upper body parameters

The metrics for upper body parameters are those reported in Table B. 2.

Table B. 2 - Description of the upper body parameters

Term Description

Neck Rotation [rad] (see The neck rotation is the motion that occurs when a head turns on its
Figure B. 1) axis. The head rotates on the neck, as in shaking the head 'no'.

Neck flexion/extension [rad] The neck flexion/extension is the motion that occurs when a head
(see Figure B. 1) moves backward/forward.

Neck Lateral Bend [rad] (see The neck flexion/extension is the motion that occurs when the head
Figure B. 1) moves laterally.

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Term Description

Abduction is the motion that pulls a structure or part away from the
midline of the body, while the adduction is the motion that pulls a
Shoulder Horizontal
structure or part towards the midline of the body, or towards the
adduction/abduction [rad]
midline of a limb. Raising the arms laterally, to the sides, is an
(see Figure B. 1)
example of abduction. Dropping the arms to the sides is an example
of adduction.

Internal rotation (or medial rotation) of the shoulder or hip would


Shoulder rotation