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Abstract. A recovery monitoring system, based on hybrid computational intelligent techniques, is presented for post anterior
cruciate ligament (ACL) injured/reconstructed subjects. The case based reasoning methodology has been combined with fuzzy
and neuro-fuzzy techniques in order to develop a knowledge base and a learning model for classification of recovery stages and
monitoring the progress of ACL-reconstructed subjects during the convalescence regimen. The system records kinematics and
neuromuscular parameters from lower limbs of healthy and ACL-reconstructed subjects using body-mounted wireless sensors
and a combined feature set is generated by performing data transformation and feature reduction techniques. In order to classify
the recovery stage of subjects, fuzzy k-nearest neighbor technique and adaptive neuro-fuzzy inference system have been applied
and results have been compared. The system was successfully tested on a group of healthy and post-operated athletes for analyzing their performance during ambulation and single leg balance testing activities. A semi-automatic process has been employed
for case adaptation and retention, requiring input from the physiotherapists and physiatrists. The system can be utilized by physiatrists, physiotherapists, sports trainers and clinicians for multiple purposes including maintaining athletes profile, monitoring
progress of recovery, classifying recovery status, adapting recovery protocols and predicting athletes sports performance
Keywords: Case based reasoning (CBR), fuzzy/neuro-fuzzy system, anterior cruciate ligament (ACL), wireless sensors, knee
injury, recovery monitoring
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1. Introduction
216 S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques
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S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques 217
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search Center at the Ministry of Sports, Brunei Darussalam. The healthy subjects were having an age (mean
std) of 31.0 8.29 years, height (mean std)
164.5 13.03 cm, and weight (mean std) 65.25
20.17 kg. For ACL reconstructed subjects the age
(mean std), height (mean std) and weight (mean
std) were 30.8 3.73 years, 166.9 7.18 cm and 68.2
14.46 kg, respectively. The ACL-reconstructed subjects were at different stages of recovery ranging from
3 months to more than a year after surgery. All subjects
read and signed an informed consent form and ethical procedures were carried out according to the guidelines approved by the Graduate Research Office and
Ethics Committee at Universiti Brunei Darussalam.
2.2. Activities monitored
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ral network to develop more robust classification systems [49]. A fuzzy CBR has been used to design a decision support system, with accuracy around 88%, for
stress diagnosis in different subjects [9]. The imprecision and uncertainty in sensors measurements was
dealt by using a fuzzy similarity metric for case retrieval. Alahakone [2] proposed a hybrid system combining Self Organizing Maps (SOM) and CBR for
evaluating postural control based on trunk sway obtained during a tandem Romberg stability test. The prediction accuracy of the system was claimed to be more
than 90%.
This paper presents a novel approach for monitoring and classification of recovery status and evaluating athletes sports performance after ACL reconstruction by combining machine learning techniques with
CBR system. The kinematics and neuromuscular data
are collected from ACL reconstructed and healthy subjects using body-mounted wireless sensors. The extraction of important features from electromyography
data has been performed by using wavelet decomposition technique and a feature reduction method has
been applied to reduce the large number of features. A
knowledge base has been designed to store subjects
profiles, recovery sessions data and problem/solution
pairs. In order to retrieve the most similar cases, two
techniques namely fuzzy k-nearest neighbor algorithm
and adaptive neuro-fuzzy inference system, have been
compared and case selection is done by using case density function. Once relevant cases are selected, adaptation is performed by adjusting the recovery protocols
for individuals and the performance evaluation can be
done. This system will facilitate the clinicians, physiotherapists, physiatrists and sports trainers to identify the subjects at various stages of recovery process
and those lacking behind the desired level. In addition, it will also assist them to do the needful intervention or accelerating the ongoing activity level of subjects. Moreover, objectively assessed recovery status
provides subjects self-satisfaction for the current stage
and ensures their positive feedback in future.
2. Experimental setup
2.1. Subjects
The system hardware is composed of two subsystems operating simultaneously: 1) wireless microelectro-mechanical systems (MEMS) motion sensors
units with command module and a radio for wireless
data transmission (KinetiSense from ClevMed Inc.)
and 2) wireless electromyography sensors unit (Bio-
Formulate
Problem
EMG Sensors
Motion Sensors
Data Acquisition
No
Generate Case
Found?
Yes
Initial Processing
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Retrieve Case
Retain Learned
Case
System
Hardware
218 S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques
Fig. 1. Hybrid intelligent framework for monitoring post ACL injury recovery and sports performance.
angular rates and linear acceleration from all four sensors were sent simultaneously in serial format to the
Command Module which transferred the digital data to
the computer through the USB Receiver connected to
the computers USB port. The raw data were viewed
and saved using KinetiSense software package for processing.
The surface EMG sensors record the action potential
of skeletal muscles which indicate the force of muscles. The amplitude of the EMG measurements (usually in millivolts) is related to the amount of force generated from the muscles contraction while performing
the motion. The EMG signals were recorded by placing foam snap electrodes on four different knee extensor and flexor muscles including vastus medialis (VM),
vastus lateralis (VL), semitendinosus (ST) and biceps
femoris (BF) on both legs of the subjects during walking. For balance testing activity, EMG data were also
collected from gastrocnemius medialis (GM) muscle
in addtition to above four muscles. SENIAM guidelines were followed for skin preparation, placing the
electrodes and EMG recording [26]. The sampling rate
to collect EMG signals was set to 960 Hz (maximum
available) at 12 bit Analog/Digital conversion and 2-D
linear acceleration was also recorded from BioRadio
unit to synchronize both KinetiSense and BioCapture
devices. The EMG data recorded using BioRadio were
transferred to the computer wirelessly through USB receiver connected to the computers USB port. These
signals were viewed and stored using BioCapture software package for processing. The data from both sys-
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In order to collect data and perform initial processing, following steps were performed.
3.2.1. Data acquisition
The sensing units were setup for recording signals
from the motion and EMG sensors. Two motion sensors were attached to each leg (one on thigh and one
on shank) of a subject using flexible bulk and Velcro
straps to note the knee joint movements. Each motion
sensor recorded the 3-D angular rates and 3-D linear
acceleration during the motion performed by the subjects. Motion sensor data were sampled at a frequency
of 128 Hz and digitized in the sensor unit. The recorded
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S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques 219
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Kinematics features The kinematics of the knee changes after ACL injury/reconstruction. In order to monitor these changes, the flexion/extension measurements
were computed for each gait cycle using angular rates
recorded through motion sensor units placed on the
thigh and shank segments of both legs. The sensors
were aligned to provide knee angle about the sagittal
plane. The orientations of lower extremities (RThigh ,
RShank , LThigh and LShank ) were estimated by applying trapezoidal integration method on respective angular rates (RThigh , RShank , LThigh and LShank ) of both
lower limbs. If (t) represents the angular rate of either
thigh or shank at time t and t is the sampling time,
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220 S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques
(a)
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(b)
(c)
Fig. 3. (a) Knee flexion/extension (degrees), (b) Angular rate for thigh (rad/sec) (c) Angular rate for shank (rad/sec) for multiple gait cycles of an
ACL intact leg.
(t) =
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(1)
ing contraction. In different applications, various timedomain, frequency-domain and time-frequency-domain features extracted from EMG signals have been
used [32,60,63]. Due to random and non-stationary nature of EMG signals, the wavelet transformation has
been found more appropriate for analyzing such biosignals as compared to only time/amplitude or frequency analysis. The wavelet analysis of EMG signals
can help in visualization of variations in energy levels
of muscles during different segments of the activities
being monitored and localizing the singularities in the
EMG data. The original EMG signal for vastus lateralis muscles of a healthy subject is shown in Fig. 4(a)
for multiple gait cycles. The filtered and rectified version of the same signal is shown in Fig. 4(b) and its
corresponding CWT coefficients representing the en-
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S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques 221
(a)
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(b)
(c)
Fig. 4. 3-D representation of coefficients energy for multiple gait cycles for an ACL intact subject (a) EMG signals for vastus lateralis muscle of
a healthy subject for multiple gait cycles, (b) filtered and rectified signal and (c) corresponding 3-D plot for CWT coefficients.
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wavelet coefficients from continuous wavelet transform (CWT) has been proved effective in classifying
subjects at different recovery stages after ACL reconstruction for slow walking speeds. In this study, an
EMG feature set has been generated based on multilevel discrete wavelet decomposition analysis. By employing discrete wavelet transform (DWT), EMG signal can be iteratively transformed into multi-resolution
subsets of coefficients using suitable wavelet basis
function. The time-domain EMG signal is passed
through various high pass and low pass filters to obtain the approximation coefficient subsets (e.g. cA1
. . . cA3 as shown in Fig. 6) and the detail coefficient subsets (e.g. cD1 . . . cD3 as shown in Fig. 6)
where the level of decomposition can be pre-defined
(e.g. 3 in Fig. 6). The choices of level and mother
wavelet depend on the domain and applications, but
for EMG analysis Daubechies 04/05 mother wavelet
with four/five levels of decomposition has shown bet-
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222 S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques
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Fig. 5. Muscle activation during a gait cycle for ALC intact leg (above) and corresponding wavelet energy levels (below) bright regions depict
high activation of muscles.
Fig. 6. EMG signal for vastus lateralis of a healthy (ACL intact) subject walking at 5 km/h analyzed by DWT with Daubechies 05 mother wavelet
at 3-levels of decomposition.
S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques 223
M AV =
N
1
|emgi |
N i=1
(2)
Kij = {knp }
Eij
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(4)
F =
{fij }
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(5)
(6)
vi = AT fi
(7)
where A is the N N orthogonal matrix whose ith column ai is the ith eigenvector of the sample covariance
matrix in Eq. (8).
224 S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques
n
1
fi fiT
n i=1
(8)
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Cov =
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C
N
2
um
ij ||vi cj ||
(9)
i=1 j=1
cj =
N
um
ij vi
i=1
N
i=1
uij =
C
k=1
(10)
um
ij
1
||vi cj ||
||vi ck ||
2
m1
(11)
S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques 225
k
i=1
Validity =
vV
vci v ci 2/KN
2
min(ci cj )
(12)
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In [50], a simple validity measure based upon the intra vs. inter cluster distance has been designed for Kmeans clustering. This measure has been adapted, as in
(9) by including fuzzy membership value assigned
to each of the clusters and minimum validity index has
been selected.
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Retrieve: Finding similar case(s) from the knowledge base whose problem description best matches with the given problem.
Reuse: Reusing the solution of most similar case
to solve the new problem.
Revise: Adapting/Modifying the chosen solution
according to the differences in new problem.
Retain: Storing the new problem-solution pair as
a case once it has been solved.
The details about these processes and other components of the CBR system designed for this study are
discussed in next subsections.
Activity and sets During each session, data for different activities (walking, running, one leg jumping
and balance testing etc.) can be recorded. In the postoperated data collection, the selection of activity depends on the current stage of recovery for an individual. For each activity, multiple datasets are stored to
identify outliers and avoid any measurements error.
Kinematics and EMG data The data recorded during
each set are stored in these tables after data processing
step. The link to the corresponding raw data file is also
stored along with each record.
Cluster and case The clustering is performed in order to group the subjects according to their similarities. This table contains the cluster indices and cases
under each cluster. In the initial stage of populating the
case library, the variation in number of clusters indices
is possible which is reduced as more cases are added
to the repository. The Case table contains all informa-
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226 S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques
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tion related to each solved case stored in the repository including problem description, transformed attribute/value pairs, recovery stage, class, recommendations and protocols followed during rehabilitation etc.,
as described in the next section.
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Case_Density(e, C) =
e C{e}
|C| 1
(13)
S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques 227
y=
n
n
w i fi =
i=1
wi fi
i=1
n
i=1
j=1
ij (xj )
(15)
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wi =
n
(14)
wi
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The subtractive-clustering method was used to partition the data due to large number of inputs, no requirement of setting the number of clusters in advance and noise robustness. It is one-pass algorithm
for estimating number of clusters by finding the high
density data point regions in feature space. The cluster center is the point with the highest number of
neighbors. The learning parameters of membership
functions (premise parameters) and outputs (consequent parameters) were tuned using hybrid learning
algorithm. This algorithm combines the least square
method and gradient descent method which makes the
convergence faster in the large search space. The forward pass (least square method) and backward passes
(gradient descent method) are used to optimize the
consequent and premise parameters, respectively. After determining the consequent parameters, the output of ANFIS is calculated and the premise parameters are adjusted based on output error by using backpropagation algorithm [28].
The classifiers (f-knn and ANFIS) were trained separately for each activity (three walking speeds and balance testing). The results of the retrieval step are: 1)
the recovery classification of the given problem i.e. the
recovery classification of an athlete for each activity
based on the values of currently measured parameters
and 2) retrieval of cases for adaptation process.
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Fig. 9. Percentage of variance explained by first 50 principal components for walking at 4 km/h.
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Fig. 10. Percentage of variance explained by first 50 principal components for walking at 5 km/h.
Fig. 11. Percentage of variance explained by first 50 principal components for walking at 6 km/h.
Fig. 12. Percentage of variance explained by first 50 principal components for single leg eyes open flat surface balance testing.
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S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques 229
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Fig. 14. Clusters centers identified by FCM for walking at 5 km/h cluster 1 () cluster 2 (o) cluster 3 (+). (Colours are visible in the online
version of the article; http://dx.doi.org/10.3233/HIS-130178)
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Fig. 15. Clusters centers identified by FCM for walking at 6 km/h cluster 1 () cluster 2 (o) cluster 3 (+). (Colours are visible in the online
version of the article; http://dx.doi.org/10.3233/HIS-130178)
230 S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques
Technique Activity
f-knn
ANFIS
Classification
Classification
accuracy
accuracy
mean SD (%) maximum (%)
Walking at 4 km/h 47.00 11.67
64.00
Walking at 5 km/h 52.39 8.58
80.00
Walking at 6 km/h 44.57 16.56
74.28
Balance testing
43.33 26.17
83.33
Walking at 4 km/h
Walking at 5 km/h
Walking at 6 km/h
Balance testing
85.93 4.47
90.48 4.39
99.34 0.54
98.89 0.62
91.29
99.89
99.94
99.66
Activity
Walking 4 km/h
Walking 5 km/h
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100.00
92.00
100.00
94.29
100.00
100.00
71.43
100.00
100.00
Walking 6 km/h
1
2
3
100.00
98.04
100.00
98.82
100.00
100.00
96.15
100.00
100.00
1
2
3
100.00
96.15
100.00
98.08
100.00
100.00
93.75
100.00
100.00
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forming the clusters, the case generation step was performed by storing problem-solution pairs, corresponding treatments given/followed by the subjects and the
recommendations from the physiatrists.
In order to classify a new subject as part of the case
retrieval, the input parameters were first transformed
using the coefficient matrix and then f-knn and ANFIS were used to classify the subject based on trained
clustered data. The cross validations of both methods
were done by partitioning the data into two groups:
training data (90% of the total data) and test data (10%
of the total data). The partitions were made by using
cvpartition function from MATLAB which randomly
partitions observations into a training set and a test set
with stratification such that both training and test sets
have roughly the same class proportions as in the clusters groups (original groups). The tenfold cross validation was performed for all activities using f-knn and
ANFIS techniques. The ANFIS networks were trained
for 100 epochs and the step size was set to an initial value of 0.01. The experiments showed that only
first few PCs were enough to achieve high classification accuracy and inclusion of further PCS deteriorated
the classification performance. The effect of number
of PCs on classification accuracy of f-knn and ANFIS
are presented in Figs 16 to 23. In general, it was found
that first 2 to 5 PCs produced that maximum classification accuracy for both techniques for all activities. The
maximum and average accuracy of each technique are
shown in Table 1.
The ANFIS technique proved to be more accurate in
classifying the recovery status of the subjects as compared to f-knn for all activities. Table 2 presents the
classification performance of ANFIS networks for all
activities. After classifying the recovery stage, the relevant cases are selected using case density function
Eq. (13). The performance of each subject is compared
with the most similar retrieved cases by using their recommendations and next stage results.
Table 2
ANFIS classification performance for all activities
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Table 1
Overall mean and maximum classification accuracy
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S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques 231
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Fig. 16. Classification accuracy for walking at 4 km/h using fuzzy k-nearest neighbor technique.
Fig. 17. Classification accuracy for walking at 5 km/h using fuzzy k-nearest neighbor technique.
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Fig. 18. Classification accuracy for walking at 6 km/h using fuzzy k-nearest neighbor technique.
Fig. 19. Classification accuracy for single leg eyes open balance testing using fuzzy k-nearest neighbor technique.
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232 S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques
Fig. 20. Classification accuracy for walking at 4 km/h using adaptive neuro-fuzzy inference system technique.
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Fig. 21. Classification accuracy for walking at 5 km/h using adaptive neuro-fuzzy inference system technique.
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Fig. 22. Classification accuracy for walking at 6 km/h using adaptive neuro-fuzzy inference system technique.
Fig. 23. Classification accuracy for single leg eyes open balance testing using adaptive neuro-fuzzy inference system technique.
S.M.N.A. Senanayke et al. / Anterior cruciate ligament recovery monitoring system using hybrid computational intelligent techniques 233
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The authors would like to acknowledge the support provided by Sport Medicine and Research Center
(SMRC) and Performance Optimization Center (POC),
Brunei Darussalam for providing test subjects for this
study.
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