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Fifteen transradial duke amputees (13 men, 2 women, beggarly age: 47.13 ± 14.16 y; beggarly years aback amputation: 9.5 ± 8.5) and 29 able controls (26 men, 3 women, beggarly age: 47.31 ± 15.18) alternate in the study. Out of the amputees, 47% were application a myoelectric prosthesis (mean hours/day: 10.06 ± 5), 33% were application a antidotal prosthesis (mean hours/day: 7.2 ± 3.6), and 20% were application a body-powered one (mean hours/day: 13.3 ± 3.6). All amputees accomplished non-painful PLS with aerial interindividual airheadedness in agreement of onset, intensity, and frequency. About 73% of the amputees appear aching PLS. Shrunk sensations were empiric in 60% of them. About 86% of the amputees could advisedly move the phantom, while the added 13% of the amputees appear the action of accepting the apparition limb ashore in a assertive position, i.e., arctic phantom21. This was activated by allurement the participants to accomplish apparition feel borer and apparition anchor movements. OBS and OBT were empiric in 46% and 54% of amputees. The OBS and OBT groups did not statistically alter in age (p = 0.37) nor years aback amputation (p = 0.23) as activated by a two-samples t-test. Of all fifteen participants, eight dreamed about themselves as able-bodied, two as amputated, and a alloyed arrangement was empiric in one amputee. Two amputees were not able to bethink their dreams. One amputee could not anamnesis the dreams vividly. Anatomy representation in dreams is not accessible for one actor because of the language barrier during abstracts collection. Referred sensations were appear in 40% of the amputees. Table 1 displays an overview of the demographical and analytic ambit presented above. For the advice about to able controls, we allure the clairvoyant to see Table 1 in Cognolato et al.13.
Participants were provided with a accounting and articulate account of the action and gave the active abreast accord anatomy as a aboriginal step. One of the participants bidding his accord to broadcast identifiable images by bushing in a form.
The alpha protocol, configured as a multi-center study, complies with the attempt bidding in the Declaration of Helsinki (1964) and it was accustomed by the Ethics Commission of the Province of Padova in Italy (NRC AOP1010, CESC 4078/AO/17) and the Ethics Commission of the Canton of Valais in Switzerland (CCVEM 010/11).
The accretion bureaucracy advised for contest 2, 4 and 5 included accretion accouterments and software accurately developed for recording gaze, video in the participant’s first-person perspective, sEMG, accelerometer as able as behavioral abstracts from assorted devices. The accretion software included a backend, a media player, a text-to-speech engine, and a graphical user interface. The backend was developed in C , and its primary cold was to access the abstracts from the altered accessories and abundance them in the laptop with as low cessation and the number of packets absent as possible. Furthermore, the backend applies a high-precision timestamp to the recorded data. These timestamps acquiesce synchronizing the modalities during the post-processing step.
Vocal instructions actinic by the text-to-speech agent guided the actor through the trails of the exercise. This band-aid accustomed us to advance a aerial affection testing environment, as it does not acquaint any beheld distractions that may accept biased the users’ boring behavior. In addition, the instructions were able in Italian, English, French, and German, accoutrement the languages announced by all the participants. A graphical user interface was additionally included and accustomed the experimenter to calmly collaborate with the software and conduct the experiment.
Gaze and first-person angle videos were calm with the Tobii Pro Glasses 2 (Tobii AB, Sweden, http://www.tobiipro.com/). This accessory is a lightweight, portable, and humble eye tracker able with a Full HD camera, an Inertial Motion Assemblage (IMU), and a microphone. The Tobii Pro glasses (Tobii AB, Sweden) can be beat in the aforementioned address as accepted glasses and assorted adenoids pads can be called to agreement the best tracking and comfort. Furthermore, antidotal lenses can be activated in case of users with a beheld impairment. The accessory includes a recording assemblage to which the glasses are connected. The recording assemblage provides the adeptness accumulation through a rechargeable battery, food the abstracts assimilate a SD card, and can acquaint wirelessly with added accessories (e.g., a claimed computer). The Tobii Pro glasses (Tobii AB, Sweden) accustomed measuiring of the boring position with account to the first-person angle video recorded by the arena camera. The boring point was again overlapped assimilate the arena camera video analysis area participants were looking. The Tobii Pro glasses (Tobii AB, Sweden) additionally alternate an admiration of the boring position in three-dimensional coordinates, the position, and bore of the pupils, as able as the dispatch and the angular acceleration of the participant’s head.
Muscle electrical action and inertial abstracts were recorded with a Delsys Trigno Wireless sEMG arrangement (Delsys Inc., USA, http://www.delsys.com/). This accessory is able with 16 electrodes that acquaint wirelessly with a abject station. Four argent bar contacts acquiesce anniversary electrode to almanac the EMG arresting at the skin level. In addition, a triaxial accelerometer is anchored in anniversary electrode. The abject assemblage receives the abstracts streamed by the electrodes with a sampling amount of 1926 Hz for the EMG and 148 Hz for the accelerometer. We set the accelerometer ambit to ±1.5 g. For this range, a babble of 0.007 g (RMS), and an account absurdity of ±0.201 g for the X and Y axes and 0.201 g to −0.343 g for the z-axis are reported22. These abstracts can again be accessed via a claimed computer affiliated to the abject station. For a added abundant description of the accretion software and best of the accessories acclimated in the present study, see Cognolato et al.13.
Moreover, a footswitch was active to aggregate the time to achievement of a trial. The footswitch was affiliated to the accretion laptop via USB and acclimated as an added keyboard. Thus, participants were able to apart ascribe contest into the accretion software by acute the footswitch. This band-aid let the actor chargeless to focus on the beheading of the exercise and fostered a accustomed high limb movement. A footswitch was adopted over manually provided keypresses as it ensures the absence of any contagion of the MI and ME of the high limbs by a motor acknowledgment with the aforementioned effector, as they did, for example, in Gallo et al.23.
The accretion bureaucracy accurately for exercise 2 (MDS2) consists of bristles ambition squares, referred to as pointing targets, and a ellipsoidal target. The pointing targets consisted of red squares of assorted sizes printed on the centermost of cellophane sheets. They served as ambition for the (imagery) pointing movements to be performed with the tip of a pen. The abandon of the red squares were 1.25 mm, 2.5 mm, 5 mm, 10 mm, and 20 mm, in band with a antecedent study24. The delimiting target, advertence the starting point of the movement, was a atramentous rectangle printed on a cellophane artificial sheet. The centermost of the aboriginal pointing ambition was accumbent to the participant’s body-midline and was anchored at a ambit of 47 cm from the bound of the table. The starting point of the (imagery) movements, apparent with the delimiting target, was angular accumbent with the pointing ambition at a ambit of 32.6 cm (see Fig. 1).
Acquisition bureaucracy for exercise 2 and the movement performed to point the ambition with the tip of the pen. The red aboveboard in the average of the arena and the atramentous rectangle on the appropriate of the arena represent the pointing and delimiting targets, respectively.
The accretion bureaucracy specific for contest 4 and 5 (MDS4) consists of an obstacle and two delimiting targets. The obstacle was a board rectangle box of ambit (H × W × L) 26 × 16.5 × 31.7 cm. This account was accumbent with the actor body’s midline at a ambit from the bound of the board that was advised adequate by the participant. The two delimiting targets adumbrated area the movement had to activate and finish. These targets were placed at 13 cm from both the larboard and the appropriate ancillary of the obstacle (see Fig. 2).
Acquisition bureaucracy of contest 4–5 and the arrangement of movements performed to reposition the (phantom) hand. The alpha and end credibility were belted by atramentous squares. (a) Exercise 4: The participants are appropriate to move the hand/stump about and aloft the obstacle. (b) Exercise 5: The amputees are asked to move the butt in a way that the apparition would canyon through the obstacle.
Demographic and analytic advice such as sex, age, weight, height, anatomy accumulation index, laterality of amputated hand, the reason of amputation, years aback amputation, blazon of acclimated prosthesis allegorical the hours per day and the best acclimated prosthesis at the time to abstracts accretion are provided. All amputees underwent the analytic account and cerebral tests in Italian according to their own and the examiners’ mother tongue, except in one case declared in the acceptance notes.
The tests were administered by accomplished neuropsychologists and absorb appear and absolute structured tests and interviews. An continued table advertisement the array of anniversary account of the interviews and the instructions for adaptation the array can be begin in MeganePro Participants advice Dataset (MDSinfo)16.
The amputees’ duke alternative for accomplished activities above-mentioned to amputation was adjourned by agency of the FLANDERS questionnaire25, which lists 10 accomplished activities and provides a account which indicates left, right, or ambidextrous duke preference.
The “Phantom and Butt Phenomena Interview”26(PSPI) was administered. It starts with the assuming of aching PLS and checks the attendance of 18 affliction descriptors (e.g., the affliction is burning, grueling, or exhausting), that partly overlap with those presented in the McGill Affliction Questionnaire-227,28. For the blueprint of the affliction descriptors and all the distinct items, we allure the absorbed clairvoyant to audit the continued table in the MDSinfo16.
Detailed letters are presented on the acuteness and abundance of aching PLS (computed as the allowance intensity/frequency, according to Lyu et al.29). Duration of these PLS was protocolled as able and the blazon (and effectiveness) of treatment, if applicable. The strategies a accommodating may accept adopted to abate affliction and the admeasurement to which the accommodating could account from them were additionally inquired, as able as ecology and affecting factors that can access or abatement the pain. The aforementioned abundant questions were additionally asked with account to non-painful PLS and balance limb sensations. They comprise, amid others, length, girth, position in space, and changes over time, ad-lib vs. advised movement of the apparition duke and temperature sensations. For anniversary attribute, array of intensity, frequency, and consequence are accustomed in the dataset. Shrinkage and addendum of the apparition are additionally appear in agreement of onset, intensity, frequency, and changes over time.
The PSPI additionally includes a area on anatomy representation in dreams. The way an amputee represents him/herself in dreams accept been taken as an absolute basis of ache during the alive accompaniment and was begin to be associated with specific aspects of PLS22,30,31.
The PSPI was hardly continued to call attendance and acuteness of referred sensations, that are, sensations localized to the apparition duke afterwards a concrete dispatch of a alien area of the amputee’s anatomy (“trigger zone”). In accordance with the literature5, the best accepted activate area is the participant’s face. The analysis of referred sensations has accurate important. Indeed antecedent studies showed that the acknowledged apotheosis is associated with the barometer of awareness to the prosthesis32.
The “Structured Account on Apparition Sensations”33 was decidedly advantageous for the appraisal of Obstacle Tolerance against Obstacle Shunning. OBT and OBS are abstinent in the afterward way: the amputee is asked to boring access the butt to a bank and indicate, qualitatively and quantitatively, any changes about to the baseline afterglow of the apparition limb. Two added tests crave the actor to accord a agnate rating, but not aloft abutting a wall, but instead on abutting the examiner’s anatomy and, finally, the amputee’s own body. A acumen amid OBS and OBT in affiliation to the attributes of the concrete amount (non-biological vs. biological) seems desirable, as the altered forms could be predictive of altered aspects of a prosthesis (embodiment vs. use in amusing contexts).
Special absorption is paid to the anatomic appulse of the amputation on the amputee’s circadian activity activities as adjourned by the “Disabilities of the Arm, Shoulder and Duke questionnaire”34 acclimatized for duke amputation. Patients were asked to amount their adeptness to accomplish circadian activity activities on a 5-point Likert scale.
The check “Vividness of Movement Adumbration Questionnaire-2 – VMIQ2”35 was acclimated to analyze a participant’s MI capabilities in altered modalities, namely kinaesthetic and visual. The area on beheld MI considers two altered beheld perspectives: (i) an alien one, area participants are absolutely asked to watch themselves assuming the movements from an alien point of view, appropriately adopting a third-person perspective; (ii) an centralized beheld adumbration condition, area a first-person angle has to be taken. The VMIQ2 was administered to both amputees and able participants. Versions adapted to a participant’s built-in mother argot were used.
After signing the abreast accord anatomy and accepting provided demographical data, amputees and able controls underwent the analytic account and neurocognitive tests. During both the tests and analytic interview, amputees were not cutting their prostheses. For amputees, the adjustment of administering of the tests was the following:
(i) “Flanders questionnaire”, (ii) “Phantom and Butt phenomena Interview”, (iii) “Structured account on Apparition Sensations”, (iv) “Disabilities of the Arm, Shoulder and Duke Questionnaire”, (v) “Vividness of Movement Adumbration Questionnaire-2 – VMIQ2”.
The analytic account was conducted afore the alpha of the contest declared in this arrangement but afterwards the achievement of exercise 113. This accustomed participants to blow amid the contest in adjustment to anticipate able fatigue on the balance limb.
The contest were conducted with the actor calmly sitting in advanced of a desk. A Delsys Trigno electrode was positioned on anniversary forearm. When possible, the sensors were placed at the akin of the extensor digitorum superficialis, articular by palpation. This was not a austere claim as in this experiment, the inertial abstracts were advised of ascendant importance, while the sEMG would serve for ascendancy analyses. The actor wore the Tobii Pro glasses (Tobii AB, Sweden) and the examiner placed the footswitch below the board in a position that accustomed the actor to columnist it with the bottom comfortably. As the aftermost step, the examiner abiding the items on the desk, as declared in the Accretion Bureaucracy section.
During this experiment, participants were told to accomplish pointing movements with the tip of a pen from a starting area to the ambition (see Fig. 1). Participants underwent a training area they were told to point with the tip of a pen from the atramentous rectangle to the red squares with accumbent and accustomed movements. Afterward, they were asked to brainstorm pointing movements afterwards active them and to use a motor action (rather than a beheld one) to break the exercise, that is, evoking the kinaesthetic and motor information. Participants were additionally instructed to columnist the pedal at the alpha and at the end of the training affair trials. Speed and accurateness were appropriately stressed. Able controls underwent the training application their ascendant hand; amputees acclimated both their complete and apparition hands.
The alpha MI and ME blocks consisted of 8 cycles for anniversary of the 5 pointing ambition dimensions, consistent in 40 trials each. The adjustment of the presentation of the balloon was randomized. A articulate apprenticeship arrive the actor to alpha the trial. The alpha and end of a balloon were adumbrated by the participants themselves by acute the footswitch amid below the table. The behavioral outcome, namely the time to completion, was authentic as the breach amid two pedal presses. We abstinent the time to achievement of one distinct pointing movement. Amputees underwent three pseudorandomised blocks: i) MI of the apparition limb, ii) MI of the complete hand, and iii) ME of the complete hand. For the able participants, these blocks were 2: i) MI and ii) ME of the ascendant hand. The MI blocks consistently preceded the ME ones24.
In exercise 4, participants were asked to brainstorm or reposition a (phantom) duke from point A to B, casual about and aloft an obstacle (see Fig. 2, larboard panel). The best distal articulation of the amputees’ balance limb was accumbent angular with the ancillary of the obstacle, which was accumbent to the anatomy midline. One balloon consisted of three times, affective from point A to B and again aback to point A. For the amputees, the archetype included 4 pseudorandomized blocks, anniversary absolute 8 trials: i) MI of the apparition limb, ii) ME of the apparition limb, which appropriate to move the stump, iii) MI of the complete hand, iv) ME of the complete hand. For able participants, the exercise additionally comprised 4 blocks: MI and ME of anniversary of the two hands.
Exercise 5 was performed in alone 11 out of 15 amputees because it was conceptualized alone afterwards testing the aboriginal 4 amputees. Here, behavioral, gaze, and able patterns were abstinent while the apparition progressively invades the amplitude active by an obstacle. The alpha archetype and bureaucracy are the aforementioned as in exercise 4. However, amputees were asked to reposition the apparition from a point A to a point B casual through the obstacle (see Fig. 2, appropriate panel). Two blocks of 8 trials anniversary were implemented for adumbration and absolute beheading of the apparition movements.
Throughout the exercises, the accretion accessories declared ahead recorded raw abstracts to files stored on disk. We developed a processing accepted in MATLAB (MathWorks, Natick, MA, USA, http://www.mathworks.com/) to accomplish abstracts curation (for instance, by acceptance the absence of accretion errors), to accord the alone modalities and assuredly to abundance them in a distinct unified abstracts file. This area briefly outlines the processing procedure; for a added abundant description, the clairvoyant is referred to Cognolato et al.13.
After the accretion concluded and above-mentioned to any added processing, repetitions not accurately performed were manually invalidated. The best accepted aberration was a delayed columnist of the footswitch due to a array of reasons, which would accept been hardly identifiable in post-processing.
The aboriginal footfall of automatic processing again complex account the accretion files one by one and converting them in to allusive abstracts structures. For all modalities, we fabricated corrections to the recorded timestamps to accompany them in a aggregate advertence time. Aback sEMG and accelerometry were sampled in batches for computational reasons, their timestamps were amid to access an alone timestamp for anniversary sample. Furthermore, the sEMG abstracts were filtered from outliers and powerline arrest and again rectified via a affective root-mean-square with a window breadth of 300 samples (approximately 156 ms). Separate types of advice from the Tobii Pro glasses (Tobii AB, Sweden) were aggregate calm if it had been abstinent at the aforementioned time (i.e., they were assigned an identical timestamp).
We after synchronized all modalities by re-sampling anniversary of them to the sampling amount of the boring modality. The re-sampling was implemented via beeline departure for real-valued signals and nearest-neighbor departure for detached signals. If an accretion was disconnected and accordingly consisted of added segments, again these were concatenated at the exact point that would abstain bifold trials. As a final allotment of the processing pipeline, anecdotic advice was removed from all videos.
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