Mitigating the impact of motor impairment on self-administered digital tests: a longitudinal cohort study in stroke

Cognitive impairments are prevalent in many neurological disorders and remain underdiagnosed and poorly studied longitudinally. Unsupervised remote cognitive testing is an accessible, scalable, and cost-effective solution. However it often fails to separate cognitive deficits from commonly co-occurring motor impairments. To address this gap, we present a computational framework that isolates cognitive ability from motor impairment in self-administered digital tasks.

Stroke was chosen as a representative neurological disorder, as patients frequently experience both motor and cognitive impairments. Our validation analyses spanned 18 computerised tasks that were completed longitudinally by a cohort of stroke survivors (N = 171) collected as part of the IC3 study between 2022 and 2024, covering a broad spectrum of cognitive and motor domains across multiple timepoints within the first two years post-stroke. IC3 study was registered under NCT05885295 and IRAS:299333. The computational model was applied on trial-level data to disentangle the contribution of motor and cognitive processes. Bayesian Principal Component Analysis (PCA) was applied to the resultant data for dimensionality reduction purposes, while mixed effects regression models and multivariate canonical correlation analyses were used to assess the model's clinical utility.

In patients with motor hand impairment, standard accuracy performance metrics were confounded in 10 tasks (p < 0.05, FDR-corrected). In contrast, the Modelled Cognitive metrics obtained from the computational framework showed no significant effects of impaired hand (p > 0.05, FDR-corrected). Moreover, the Modelled Cognitive metrics correlated more strongly with clinical pen-and-paper scales (mean R² = 0.65 vs 0.43) and functional outcomes (mean R² = 0.16 vs 0.09). Brain-behaviour associations were stronger when using the Modelled Cognitive metrics, and revealed intuitive multivariate relationships with individual tasks.

We present converging evidence for the improved clinical utility and validity of the Modelled Cognitive metrics within neurological conditions characterised by co-occurring motor and cognitive deficits. Addressing the confounding effects of motor impairment improves the reliability and biological validity of self-administered digital assessments, potentially enhancing accessibility and supporting early detection and intervention across neurological disorders.

This research is funded by the UK Medical Research Council (MR/T001402/1). Infrastructure support was provided by the National Institute for Health Research (NIHR) Imperial Biomedical Research Centre and the NIHR Imperial Clinical Research Facility. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.