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  <front>
    <journal-meta>
      <journal-id journal-id-type="publisher-id">JMIR</journal-id>
      <journal-id journal-id-type="nlm-ta">J Med Internet Res</journal-id>
      <journal-title>Journal of Medical Internet Research</journal-title>
      <issn pub-type="epub">1438-8871</issn>
      <publisher>
        <publisher-name>JMIR Publications</publisher-name>
        <publisher-loc>Toronto, Canada</publisher-loc>
      </publisher>
    </journal-meta>
    <article-meta>
      <article-id pub-id-type="publisher-id">v24i8e39190</article-id>
      <article-id pub-id-type="pmid">36001374</article-id>
      <article-id pub-id-type="doi">10.2196/39190</article-id>
      <article-categories>
        <subj-group subj-group-type="heading">
          <subject>Research Letter</subject>
        </subj-group>
        <subj-group subj-group-type="article-type">
          <subject>Research Letter</subject>
        </subj-group>
      </article-categories>
      <title-group>
        <article-title>Recognition of Gait Patterns in Older Adults Using Wearable Smartwatch Devices: Observational Study</article-title>
      </title-group>
      <contrib-group>
        <contrib contrib-type="editor">
          <name>
            <surname>Kukafka</surname>
            <given-names>Rita</given-names>
          </name>
        </contrib>
      </contrib-group>
      <contrib-group>
        <contrib contrib-type="reviewer">
          <name>
            <surname>Kraus</surname>
            <given-names>Moritz</given-names>
          </name>
        </contrib>
        <contrib contrib-type="reviewer">
          <name>
            <surname>Alexander</surname>
            <given-names>Keppler</given-names>
          </name>
        </contrib>
      </contrib-group>
      <contrib-group>
        <contrib id="contrib1" contrib-type="author" equal-contrib="yes">
          <name name-style="western">
            <surname>Kim</surname>
            <given-names>Hyeon-Joo</given-names>
          </name>
          <degrees>BSc</degrees>
          <xref rid="aff1" ref-type="aff">1</xref>
          <ext-link ext-link-type="orcid">https://orcid.org/0000-0001-8066-6563</ext-link>
        </contrib>
        <contrib id="contrib2" contrib-type="author" equal-contrib="yes">
          <name name-style="western">
            <surname>Kim</surname>
            <given-names>Hyejoo</given-names>
          </name>
          <degrees>BSc</degrees>
          <xref rid="aff1" ref-type="aff">1</xref>
          <ext-link ext-link-type="orcid">https://orcid.org/0000-0003-0917-1781</ext-link>
        </contrib>
        <contrib id="contrib3" contrib-type="author">
          <name name-style="western">
            <surname>Park</surname>
            <given-names>Jinyoon</given-names>
          </name>
          <degrees>MSc</degrees>
          <xref rid="aff1" ref-type="aff">1</xref>
          <ext-link ext-link-type="orcid">https://orcid.org/0000-0001-6440-1493</ext-link>
        </contrib>
        <contrib id="contrib4" contrib-type="author">
          <name name-style="western">
            <surname>Oh</surname>
            <given-names>Bumjo</given-names>
          </name>
          <degrees>MD, MPH</degrees>
          <xref rid="aff2" ref-type="aff">2</xref>
          <ext-link ext-link-type="orcid">https://orcid.org/0000-0002-2468-0755</ext-link>
        </contrib>
        <contrib id="contrib5" contrib-type="author" corresp="yes">
          <name name-style="western">
            <surname>Kim</surname>
            <given-names>Seung-Chan</given-names>
          </name>
          <degrees>PhD</degrees>
          <xref rid="aff1" ref-type="aff">1</xref>
          <address>
            <institution>Machine Learning Systems Lab</institution>
            <institution>College of Sports Science</institution>
            <institution>Sungkyunkwan University</institution>
            <addr-line>2066 Seoburo, Jangan-gu</addr-line>
            <addr-line>Suseong Bldg #05111a</addr-line>
            <addr-line>Suwon, 16419</addr-line>
            <country>Republic of Korea</country>
            <phone>82 10 2533 1915</phone>
            <email>seungk@g.skku.edu</email>
          </address>
          <ext-link ext-link-type="orcid">https://orcid.org/0000-0001-7292-5166</ext-link>
        </contrib>
      </contrib-group>
      <aff id="aff1">
        <label>1</label>
        <institution>Machine Learning Systems Lab</institution>
        <institution>College of Sports Science</institution>
        <institution>Sungkyunkwan University</institution>
        <addr-line>Suwon</addr-line>
        <country>Republic of Korea</country>
      </aff>
      <aff id="aff2">
        <label>2</label>
        <institution>Department of Family Medicine</institution>
        <institution>Seoul Metropolitan Government - Seoul National University Boramae Medical Center</institution>
        <addr-line>Seoul</addr-line>
        <country>Republic of Korea</country>
      </aff>
      <author-notes>
        <corresp>Corresponding Author: Seung-Chan Kim <email>seungk@g.skku.edu</email></corresp>
      </author-notes>
      <pub-date pub-type="collection">
        <month>8</month>
        <year>2022</year>
      </pub-date>
      <pub-date pub-type="epub">
        <day>24</day>
        <month>8</month>
        <year>2022</year>
      </pub-date>
      <volume>24</volume>
      <issue>8</issue>
      <elocation-id>e39190</elocation-id>
      <history>
        <date date-type="received">
          <day>3</day>
          <month>5</month>
          <year>2022</year>
        </date>
        <date date-type="rev-request">
          <day>15</day>
          <month>7</month>
          <year>2022</year>
        </date>
        <date date-type="rev-recd">
          <day>23</day>
          <month>7</month>
          <year>2022</year>
        </date>
        <date date-type="accepted">
          <day>11</day>
          <month>8</month>
          <year>2022</year>
        </date>
      </history>
      <copyright-statement>©Hyeon-Joo Kim, Hyejoo Kim, Jinyoon Park, Bumjo Oh, Seung-Chan Kim. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 24.08.2022.</copyright-statement>
      <copyright-year>2022</copyright-year>
      <license license-type="open-access" xlink:href="https://creativecommons.org/licenses/by/4.0/">
        <p>This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.</p>
      </license>
      <self-uri xlink:href="https://www.jmir.org/2022/8/e39190" xlink:type="simple"/>
      <kwd-group>
        <kwd>activity recognition</kwd>
        <kwd>machine learning</kwd>
        <kwd>health monitoring</kwd>
        <kwd>gait analysis</kwd>
        <kwd>wearable</kwd>
        <kwd>sequence classification</kwd>
        <kwd>mobile health</kwd>
        <kwd>mHealth</kwd>
        <kwd>neural network</kwd>
      </kwd-group>
    </article-meta>
  </front>
  <body>
    <sec sec-type="introduction">
      <title>Introduction</title>
      <p>It is challenging to routinely assess gait unless dedicated measuring devices are available. Inspired by a recent study that reported high classification performance of activity recognition tasks using smartwatches [<xref ref-type="bibr" rid="ref1">1</xref>], we hypothesized that the recognition of gait-related activities in older adults can be formulated as a supervised learning problem. To quantify the complex gait motion, we focused on hand motion because disturbed hand motions are frequently reported as typical symptoms of neurodegenerative diseases [<xref ref-type="bibr" rid="ref2">2</xref>].</p>
    </sec>
    <sec sec-type="methods">
      <title>Methods</title>
      <sec>
        <title>Data Acquisition</title>
        <p>We recruited 39 older adult participants (age: 80.4, SD 6.5 years; n=38, 73.7% women) from a local community. The number of participants for each class was as follows: cane-assisted gait (C0) (n=7), walker-assisted gait (C1) (n=5), gait with disturbances (C2) (n=21), gait without disturbances (C3) (n=6), and gait without disturbances in young controls (C4) (n=12). During the experiment, participants were asked to wear a smartwatch (DW9F1; Fossil Group, Inc) on each wrist and walk at a normal speed similar to their usual walk. <xref rid="figure1" ref-type="fig">Figure 1</xref> shows example photographs taken during the experiment.</p>
        <fig id="figure1" position="float">
          <label>Figure 1</label>
          <caption>
            <p>Five different gait styles: cane-assisted gait (C0), walker-assisted gait (C1), gait with disturbances (C2), gait without disturbances (C3), and gait without disturbances in young controls (C4).</p>
          </caption>
          <graphic xlink:href="jmir_v24i8e39190_fig1.png" alt-version="no" mimetype="image" position="float" xlink:type="simple"/>
        </fig>
      </sec>
      <sec>
        <title>Classification</title>
        <p>The multivariate time-series (MTS) signals captured at a sampling rate of 50 Hz were segmented into <inline-graphic xlink:href="jmir_v24i8e39190_fig3.png" xlink:type="simple" mimetype="image"/>. Here, <inline-graphic xlink:href="jmir_v24i8e39190_fig4.png" xlink:type="simple" mimetype="image"/> represents the inertial motion at a specific moment, <italic>t</italic>.  In this study, <italic>D</italic> was 12 (=6×2), since each smartwatch measures the 6-DOF (6 degrees of freedom) motion separately, and <italic>T</italic> was 100 (approximately 2s) so that each <bold>x</bold> could contain at least a full gait cycle. The task in our study was to infer the type of gait activity, <inline-graphic xlink:href="jmir_v24i8e39190_fig5.png" xlink:type="simple" mimetype="image"/>, where <italic>C</italic> was 5. Our neural network systems, tailored to learn gait features from MTS data, were trained in an end-to-end fashion using state-of-the-art deep learning architectures, including Conv1D [<xref ref-type="bibr" rid="ref3">3</xref>], long short-term memory (LSTM) [<xref ref-type="bibr" rid="ref4">4</xref>], and an LSTM with an attention mechanism [<xref ref-type="bibr" rid="ref5">5</xref>].</p>
      </sec>
      <sec>
        <title>Ethics Approval</title>
        <p>All participants were enrolled after institutional review board (IRB) approval (Sungkyunkwan University IRB approval number: SKKU 2021-12-014).</p>
      </sec>
    </sec>
    <sec sec-type="results">
      <title>Results</title>
      <p>We employed the accuracy and macro average of the <italic>F</italic><sub>1</sub>-score, <italic>F<sub>m</sub></italic>, as a measure of performance. For the both-hands condition, the accuracy (<italic>F<sub>m</sub></italic>) was 0.9757 (0.9728), 0.9736 (0.9699), and 0.9771 (0.9738) when Conv1D, LSTM, and attention-based LSTM were employed, respectively. In the case of the left-hand and right-hand conditions, the accuracies (<italic>F<sub>m</sub></italic>) obtained in the left-hand condition were 0.9652 (0.9623), 0.9611 (0.9583), and 0.9630 (0.9592), respectively. In the right-hand condition, the accuracies (<italic>F<sub>m</sub></italic>) were 0.9724 (0.9706), 0.9673 (0.9643), and 0.9673 (0.9635) for the same employed models, respectively. We also examined the learned representations as shown in <xref rid="figure2" ref-type="fig">Figure 2</xref> using t-distributed stochastic neighbor embedding (t-SNE) [<xref ref-type="bibr" rid="ref6">6</xref>], which visualizes the high-dimensional vectors by projecting them into a 2D space in such a way that similar points cluster together.</p>
      <fig id="figure2" position="float">
        <label>Figure 2</label>
        <caption>
          <p>Feature visualization using t-distributed stochastic neighbor embedding. Each point is colored according to the predicted class. LSTM: long short-term memory.
</p>
        </caption>
        <graphic xlink:href="jmir_v24i8e39190_fig2.png" alt-version="no" mimetype="image" position="float" xlink:type="simple"/>
      </fig>
    </sec>
    <sec sec-type="discussion">
      <title>Discussion</title>
      <p>The experimental results demonstrated an acceptable classification performance (ie, both accuracy and the <italic>F<sub>m</sub></italic> score were higher than 0.95). However, there is systematic confusion, such as recognizing C3 as C2 (0.03-0.04 for the left hand, 0.05-0.07 for the right hand, and 0.05-0.06 for both hands, respectively) as shown in <xref rid="figure2" ref-type="fig">Figure 2</xref> (see the region highlighted in black). It is noteworthy that the classification performance of the single-hand condition was similar to that of the both-hands condition, suggesting that wearing a single smartwatch is sufficient for the proposed gait assessment task. From the t-SNE plot, it was found that points from the LSTM and attention-based LSTM exhibit a more clustered distribution than those from the Conv1D model. We expect that the proposed approach can be applied to various health care applications for older adults (eg, wearable detection of gait disturbances).</p>
    </sec>
  </body>
  <back>
    <app-group/>
    <glossary>
      <title>Abbreviations</title>
      <def-list>
        <def-item>
          <term id="abb1">6-DOF</term>
          <def>
            <p>6 degrees of freedom</p>
          </def>
        </def-item>
        <def-item>
          <term id="abb2">LSTM</term>
          <def>
            <p>long short-term memory</p>
          </def>
        </def-item>
        <def-item>
          <term id="abb3">MTS</term>
          <def>
            <p>multivariate time-series</p>
          </def>
        </def-item>
        <def-item>
          <term id="abb4">t-SNE</term>
          <def>
            <p>t-distributed stochastic neighbor embedding</p>
          </def>
        </def-item>
      </def-list>
    </glossary>
    <ack>
      <p>This work was supported by a grant from the National Research Foundation of Korea (#NRF-2020R1C1C1010666). This work was also supported by Sungkyunkwan University and the BK21 FOUR (Graduate School Innovation) funded by the Ministry of Education (Korea) and the National Research Foundation of Korea.</p>
    </ack>
    <fn-group>
      <fn fn-type="con">
        <p>SCK and BO were responsible for the study concept and design; SCK and HK were involved in development; SCK, HJK, and JP conducted the analysis and interpreted the data; HK provided the visualizations; and all authors helped write the manuscript.</p>
      </fn>
      <fn fn-type="conflict">
        <p>None declared.</p>
      </fn>
    </fn-group>
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