Robotic assessment of sensorimotor and cognitive deficits in patients with temporal lobe epilepsy

Objective: Individuals with temporal lobe epilepsy (TLE) frequently demonstrate impairments in executive function, working memory, and/or declarative memory. It is recommended that screening for cognitive impairment is undertaken in all people newly diagnosed with epilepsy. However, standard neuropsychological assessments are a limited resource and thus not available to all. Our study investigated the use of robotic technology (the Kinarm robot) for cognitive screening. Methods: 27 participants with TLE (17 left) underwent both a brief neuropsychological screening and a robotic (Kinarm) assessment. The degree of impairments and correlations between standardized scores from both approaches to assessments were analysed across different neurocognitive domains. Performance was compared between people with left and right TLE to look for laterality effects. Finally, the association between the duration of epilepsy and performance was assessed. Results: Across the 6 neurocognitive domains (attention, executive function, language, memory, motor and visuospatial) assessed by our neuropsychological screening, all showed scores that significantly correlated with Kinarm tasks assessing the same cognitive domains except language and memory that were not adequately assessed with Kinarm. Participants with right TLE performed worse on most tasks than those with left TLE, including both visuospatial (typically considered right hemisphere), and verbal memory and language tasks (typically considered left hemisphere). No correlations were found between the duration of epilepsy and either the neuropsychological screening or Kinarm assessment. Significance: Our findings suggest that Kinarm may be a useful tool in screening for neurocognitive impairment in people with TLE. Further development may facilitate an easier and more rapid screening of cognition in people with epilepsy and distinguishing patterns of cognitive impairment.


Introduction
Epilepsy is a common neurological disorder that affects approximately 1 % of people worldwide [1].Although epilepsy is defined as an enduring predisposition to epileptic seizures [2], individuals with epilepsy often have other comorbidities that impact their lives, including cognitive [3], and sensorimotor impairments.For example, a study in children with epilepsy found that 60 % of participants had impairments in fine motor skills such as manual dexterity [4].These impairments may be the result of the underlying focal lesion, disruption from interictal and ictal epileptic discharges, or side effects from the anti-seizure medications.
Cognitive impairments vary by the type of epilepsy.Specifically, impairments in working memory, declarative memory, and executive function are common in temporal lobe epilepsy (TLE) [5].Laterality can also impact impairment, with left TLE (LTLE) commonly associated with impaired verbal memory and right TLE (RTLE) more associated with impaired visuospatial memory [6,7].However, it is increasingly Abbreviations: GP, Grooved Pegboard; FT, Finger Tapping; TM, Trail Making; VGR, Visually Guided Reaching; RVGR, Reverse Visually Guided Reaching; APM, Arm Position Matching; OH, Object Hit; OHA, Object Hit & Avoid; BOB, Ball on Bar.
recognised that the localization model may not always be applicable and that changes in cognition relate to effects on a distributed network, with other factors such as anti-seizure medications and seizure related injuries being important [8].Impairments may be greater with a longer duration of epilepsy [9,10].Neuropsychological assessments are used to track and assess these impairments.These assessments are a performance-based method of assessing cognitive and sometimes motor functioning [11,12].Typically, they are administered in a battery approach, evaluating a variety of cognitive and motor domains.
For patients with epilepsy, the ILAE Neuropsychology Task Force recommends at a minimum routine screening for cognitive difficulties in all individuals with newly diagnosed epilepsy [13].These screenings provide an efficient method for identifying people who require a more detailed neuropsychological assessment.However, the issue is that screenings are not easily accessible as these are still commonly a responsibility of neuropsychologists.A typical neuropsychological assessment can be lengthy with a "short" assessment averaging 5.36 h, a "medium" assessment averaging 7.89 h and a "long" assessment averaging 11.77 h [14].Neuropsychologists typically average 2.6 assessments per week, removing part-time employees, the average is 4.24 [14].However, the number of new diagnoses of epilepsy vastly exceeds this number.As a result, evaluations are inaccessible and tend to be lengthy, thus expensive and potentially fatiguing [15,16].
Technology-based tools may provide a solution to these limitations.Previous research has demonstrated that technology-based neuropsychological assessments may result in a more comprehensive assessment, potentially providing a better-informed diagnosis and treatment plan [17].This has been shown in studies looking at the integration of a computerized system for measuring cognitive function that can enable earlier detection of dementia in elderly populations where neuropsychological evaluations may be impractical due to their length [18], and machine learning techniques that can distinguish patients with stroke from healthy controls using subtle impairments detected by Kinarm [19].Additionally, it may reduce costs due to the updatable nature of digital testing, which could remove the need for regular purchase of tests with updated reference scores [20].Tests may also be more interactive, with visual, motor and auditory feedback, resulting in a more motivating and engaging environment for patients [21].
Kinarm is an upper-limb robot used to make quantitative neurological assessments of sensorimotor, and some cognitive functions (Fig. 1) [22].Participants are seated in a chair and instructed to hold on to handles in front of them.Participants look down onto a semitransparent screen, onto which tasks were projected from above.Their hands are obscured from view so only a projection of their hands' movements on the screen is seen.Kinarm has been studied in a variety of neurological disorders including stroke, ALS, and concussion, and has found promising results in its ability to assess cognitive and motor domains [23][24][25][26].For example, a previous Kinarm study, quantifying cognitive and motor skills after a transient ischemic attack, found that Kinarm could detect impairments in executive function, working memory and set-switching, similar to pen-and-paper assessment techniques such as the Montreal Cognitive Assessment (MoCA) [27].
A prior feasibility study was conducted in a mixed cohort of people with epilepsy using Kinarm.In the study, 46 participants with a variety of epilepsy subtypes were recruited and assessed with a brief MoCA exam and Kinarm assessment.Their study found that Kinarm was a feasible tool in populations of people with epilepsy, with no adverse events reported.They also found promising evidence of Kinarm's ability as a tool to detect impairments in motor, cognitive and sensory tasks in people with epilepsy [28].This study builds upon these findings by investigating this technology with a well-characterized cohort of participants with TLE and in comparison to a longer pen-and-paper based neuropsychological screening.
The benefits of Kinarm include its ability to measure multiple parameters at once.These parameters include standard measurements such as time taken to complete a task and number of errors but also include a variety of unique parameters unique to Kinarm, which are not typically collected in a neuropsychological assessment.Examples of these unique parameters include dwell time on trail making (TM) (i.e., amount of time spent with the hand on one target before moving to the next) and hand bias on object hit (OH) (i.e., a value that quantifies which hand is used more often for hitting the balls).It also allows for precision when recording time, reducing the possibility of human error.Furthermore, Kinarm assessments are shorter than traditional assessments, with a complete assessment being 30-45 min in length.Focusing on cost and accessibility, once the initial cost of Kinarm has been covered, further assessments may be more affordable and would reduce wait times as it is more readily available as it can be administered by a technician.When compared to traditional neuropsychologist assessments, which requires a licensed neuropsychologist who has had longer formal training and are relatively few in number, Kinarm can utilize technicians who need only a portion of the training required by a neuropsychologist as they are simply operating the robot.This would increase the number of individuals able to administer screenings, which would increase the accessibility of these assessments.
Neuropsychological screenings and Kinarm assessments (Table 1) overlap in the neurocognitive domains in which they screen (Table 2).This allows for the possibility that these screenings may replace or complement each other.Both approaches have a variety of tasks that can assess a variety of known areas of impairment in TLE including executive function, attention and to a lesser extent memory.However, while language is often impaired in people with TLE, presently, there are no Kinarm tasks developed to assess this domain.
In this study, we investigated whether Kinarm can identify impairments in participants with TLE when compared to a neuropsychological screening by addressing the following hypotheses: 1. Robotic evaluation using Kinarm can be used as a tool to assess neurocognitive domains, similar to pen-and-paper cognitive screenings in individuals with TLE. 2. A longer duration of epilepsy is reflected in more severe impairments in both neuropsychological screening and Kinarm assessments.

Participants
Participants were recruited from the Epilepsy Clinics held at Kingston Health Sciences Centre in Kingston, Ontario, in-person or via phone call.Participants were considered for the study if they met the following inclusion criteria: TLE diagnosed by an epileptologist, normal vision, within the ages of 18-65 years old, and no limitations to the movement of their upper extremities.The diagnosis of TLE was made by a boardcertified epileptologist on the basis of clinical seizure semiology compatible with temporal lobe onset and supportive evidence including EEG and/or MRI abnormalities and any other available investigations.Laterality was determined by clearly lateralised EEG and/or MRI abnormalities.Further exclusion criteria for the study included TLE caused by stroke or neurodegenerative disease, significant intellectual disability (i.e., preventing them from independently completing activities of daily living), inability to speak and understand English, and/or brain surgery.The assessment took place at one of two locations: Kingston General Hospital or Hotel Dieu Hospital.Both the neuropsychological screening

Table 1
Description of Kinarm tasks performed in this study.

Visually Guided Reaching
Tests the participant's ability to accurately reach one of four peripheral targets as quickly as possible.Used to quantify goal-directed voluntary control [35].

Reverse Visually Guided Reaching
Tests the participant's ability to accurately reach one of four peripheral targets as quickly as possible while their visual feedback is reversed to that of the subject's movement.Used to assess the subject's ability to inhibit their automatic motor response while performing a goaldirected movement [35].

Arm Position Matching
The robot moves one of the participant's arms and tests the ability of the subject to mirror-match this position with their other arm, as quickly and as accurately as possible.Used to assess the participant's ability to perceive the position of their arm in the horizontal plane [35].

Trail Making
Completed in two parts: trail A, which requires the subject to connect numbers 1 to 25 as quickly as possible, and trail B. which requires the subject to alternate an alphanumeric sequence of targets with a total of 25 targets.Used to assess processing speed and set-switching [35].

Object Hit
Tests the participant's ability to knock away balls with paddles at their hands as they drop from above at increasing frequency and faster speeds.Used to assess rapid motor skills [35].

Object Hit & Avoid
Tests the participant's ability to knock away two specific goal shapes with paddles at their hands as a variety of shapes drop from above at increasing frequency and faster speeds.Used to assess attention and inhibitory control [35].

Ball on Bar
Tests the participant's ability to move a balanced ball to four targets as quickly as possible.Completed in three levels, in which it becomes increasingly difficult to balance the ball.Used to assess the subject's bimanual coordination abilities [35].

Neuropsychological screening
Before each screening, the participants were read a set of instructions and asked to confirm if they understood the tasks' instructions.The assessment began with Grooved Pegboard (GP), followed by TM A and B, Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and Finger Tapping (FT).

Grooved Pegboard (GP)
GP is a dexterity test primarily used to assess motor functioning but its results can also reflect cognitive factors, such as attention and executive functioning [29].During this task, participants are instructed to insert identical pegs, into holes oriented in different directions as quickly as they can using one hand.During testing, the time and the number of pegs dropped were recorded.

Trail Making (TM)
TM is used to measure the domains of executive function such as processing speeds, sequencing, mental flexibility, and visual-motor skills [30].The test is completed in two parts, trail A, which requires the individual to connect numbers in ascending order from 1 to 25, presented in a manner that requires visual scanning, used to assess the participant's processing speed, and trail B, which consists of numbers 1 to 13 and letters A to L and requires the individual to connect numbers to letters in alternating order (e.g., 1 to A, A to 2, 2 to B, etc.), presented in a manner that requires visual scanning, requiring the subject to set-switch which reflects as an assessment of the individual's executive function [31].Before beginning each test, the individual is allowed to practice on a small sample trail comprised of six targets.During the task, the time to complete each trail and the number of errors are recorded.

RBANS
RBANS is a brief screening tool to measure neuropsychological status.It focuses on measuring five cognitive domains through the use of 12 different tasks: immediate memory (list learning, story memory), visuospatial/constructional (figure copy, line orientation), language (picture naming, semantic fluency) attention (digit span, coding), and delayed memory (list recall, list recognition, figure recall) [32].

Finger Tapping (FT)
FT is a neuropsychological test used to examine motor functioning, specifically motor speed and lateralized coordination [33].During the task, the individual is instructed to lay their hand flat on the apparatus and to tap their index finger as quickly as they can for 10 s.This is repeated until they have either reached five trial scores that are within ± 5 of each other or until they have completed all 10 trials.The means of either the five trials or all 10 trials are then computed for each hand.

Kinarm assessment
Robot-based assessment was performed with the Kinarm End-Point Lab which includes two graspable robots that allow movement of the hands in the horizontal plane [34].The integrated virtual reality system displayed objects and visual feedback aligned in the horizontal workspace.Direct vision of the arms was occluded with a physical barrier and bib.The participants were instructed to sit in a chair facing the robot, then rest their forehead on the integrated robot and look down at the virtual reality display.Kinarm behavioural tasks are described in Table 1 [35].

Data analysis 2.4.1. Grooved Pegboard, trail making, and finger tapping
Scores from the task are standardized into T-scores using information about the individual's age, sex, education level, and ethnicity [36].Traditionally, the normative range for these scores is 50 ± 10, with impairment defined as one standard deviation below the mean [36].However, we defined impairment as 1.65 standard deviations below the mean or a score of < 33.5.This corresponds to ~ 5 % of the population to match the definition for Kinarm tasks as in previous work [37].

RBANS
RBANS provides standardized scores for all 12 tasks, the five subdomains (index score), as well as a total scaled score, all of which are standardized by the individual's age [32].Usually, RBANS defines the normative range as being 100 ± 15 (mean ± stdev) in healthy controls.With a normal distribution, 16 % of healthy participants have a score of < 85 [32].However, we used a more stringent threshold of 1.65 standard deviations below the mean or an RBANS score of ≤ 75.Only 5 % of healthy controls fall below this cut-off to match the definition for impairment on Kinarm as in prior studies [37].

Kinarm
Task Scores are computed to represent a summary of the multiple parameter scores Kinarm collects.The Task Score represents a normalized measure of performance that is based on a large cohort of healthy individuals [38].Task Scores are always positive, with a score of zero representing the best performance and higher values indicating poorer performance [35].This corresponds to a Task Score of 0 representing best performance, and Task Scores of 1 and 1.96 representing the 68th and 95th percentile respectively for healthy cohorts.These Task Scores are corrected for age, sex, and handedness.We defined impairment on Kinarm as a Task Score of > 1.96 (95th percentile), which represents 5 % of the healthy population [35].

Statistical analysis
All analyses and graphs were conducted in R Studio (3.6.3,Posit).To assess the relationship between the scores on neuropsychological and Kinarm tasks, we used Pearson correlations and p-values with a 95 % confidence level.All p-values were corrected for multiple comparisons using the FDR correction [39].Correlations were conducted using standardized T-scores.The number of participants impaired per domain for neuropsychological screening and Kinarm was compared using a chisquared test of homogeneity.In tasks conducted using both hands, only the scores from the dominant hand were used in the analysis.
T-tests and chi-squared tests for trend were used to compare the patient demographics of LTLE and RTLE.T-tests were also used to assess the differences between participants with right and left TLE, with pvalues less than 0.05 being considered significant.All p-values were corrected using the FDR correction.
The relationship between the duration of epilepsy and performance on both neuropsychological screening and Kinarm assessments was assessed with Pearson correlations.Given the effect of laterality on scores and a smaller group with RTLE, only the individuals from the LTLE group were studied.P-values less than 0.05 were considered significant and all were corrected using the FDR correction.

Patient cohort
27 participants were recruited (17 left; age range 19-65 years, median 33.5 years; 11 male).Table 3 gives further demographic and clinical information.Overall, the assessment was well tolerated with no issues reported by participants on either the neuropsychological screening or Kinarm assessment.

Influence of laterality on performance
One subject was a significant outlier.This participant was a 45-yearold female with RTLE who had excessively low scores on almost all tasks, for example, a score of 8 on GP (cut-off for impairment < 33.5), 46 on attention (cut-off ≤ 75), and 10.56 on RVGR (cut-off > 1.96).Whilst included in the impairment counts above, this subject was omitted from the following laterality comparisons and correlation analyses to avoid bias.
The median age of onset and duration of epilepsy did not differ between the two groups, with the median age of onset being 24 years old for LTLE and 24.5 years old for RTLE (t-test p = 0.741), and median duration being 7 years for LTLE and 7.5 years for RTLE (t-test p = 0.498).The highest achieved education differed slightly between the two groups, with 4/17 (23.5 %) of the LTLE patients having completed college and undergraduate studies, while only one of the RTLE patients completed studies above Grade 12-13.Chi-squared test for trend showed that this was on the threshold for significance (p = 0.0501).
Participants with RTLE tended to be more impaired than subjects with LTLE on tasks (Table 4).Despite verbal memory being a common impairment in LTLE, participants with RTLE were more impaired on the RBANS delayed memory (right mean = 79.33,left mean = 96.47,t = 2.783, p = 0.010) which is comprised of primarily verbal memory tasks (e.g.list recall, story recall).Participants with RTLE also performed significantly more poorly than those with LTLE on the RBANS visuospatial tasks (right mean = 77.00,left mean = 91.29,t = 2.481, p = 0.02) and RBANS attention (right mean = 104.35,left mean = 88.78,t = 2.605, p = 0.016).

Relationship between neuropsychological screening and Kinarm assessment
The correlations between neuropsychological screening and Kinarm assessments are illustrated in Fig. 3.Note when comparing neuropsychology screening and Kinarm assessment, correlations are negative as lower scores indicate impairment in the neuropsychological screening and higher scores indicate impairment on Kinarm.
All RBANS index scores were strongly correlated with RBANS total scaled score as this score represents the sum of all the index scores, and thus represents global cognitive performance.The RBANS total scaled score had the greatest number of significant correlations with Kinarm tasks, totaling 4. Of the Kinarm tasks, trail B correlated with most neuropsychological tasks, with a total of 6.
Considering executive function and attention, 12 participants were impaired on neuropsychological screening (GP, trail B and/or RBANS attention), while a similar total of 11 participants were impaired on Kinarm screening (RVGR, trail B and/or OHA).Adding tasks that assess attention alone, 13 participants were impaired on neuropsychological screening (GP, trail A, trail B and/or RBANS attention), whereas a total of 17 participants were impaired on Kinarm screening (RVGR, trail A, trail B, OH and/or OHA).The number of participants impaired was compared using chi-squared test of homogeneity.Neither comparison concluded that the number of participants impaired on the neuropsychological assessment and Kinarm differed significantly (executive function p = 1, attention p = 0.400).

Motor performance
There was a significant correlation between GP, a motor-based task, and Kinarm's RVGR (r = -0.43,p = 0.03) and trail B (r = -0.42,p = 0.03), which assesses motor skills.A similar number of participants were impaired on each task (11 for GP, 9 for RVGR).The number of participants impaired on the neuropsychological screening and Kinarm assessment was not significantly different (p = 0.776).

Language and memory
Whilst RBANS Language and RBANS Delayed Memory showed some correlations with Kinarm tasks (visually guided reaching (VGR), trail B, OH; and OHA and ball on bar (BOB) respectively), we did not have any Kinarm tasks designed to specifically assess these domains.

Relationship between impairment on tasks and duration of epilepsy
There were no significant relationships between any of the tasks, either neuropsychological or Kinarm, and the duration of epilepsy for either the LTLE group or the RTLE group (Table 5).

Discussion
The objective of this study was to demonstrate the effectiveness of Kinarm at detecting cognitive impairment in a well-defined population of people with TLE.We successfully discovered significant relationships between Kinarm and neuropsychological tasks in 4 of the 6 neurocognitive domains assessed in our screening -executive function, attention, visuospatial function and motor performance.The remaining neurocognitive domains, language and memory, were not assessed by Kinarm.

Kinarm's ability to assess executive function and attention
Tasks assessing executive function and attention from the neuropsychological and Kinarm screenings overlap significantly, with only a few tasks more specific to attention without an executive function component (trail A, OH).In our study, GP, trail B and RBANS attention were the key neuropsychological tasks used to assess combined executive function and attention.Several studies have established moderate to large correlations between GP and screening tasks used to assess executive function and attention [ 40 41].Meanwhile, trail B is an effective tool for measuring executive function and attention as it requires the subject to use their mental flexibility and set switching [31].Lastly, RBANS attention index score is comprised of the tasks digit span and coding, both of which are effective tools for assessing parts of executive function and attention [42,43].
Kinarm has previously been shown to effectively assess executive function and attention using tasks like RVGR, OHA, and trail B [31,44,45].These tasks have been demonstrated to be effective at assessing executive function and attention in several population groups, such as individuals with chronic kidney disease or traumatic brain injuries [37,46].
We confirm a significant correlation between the scores from the neuropsychological screening related to executive function and attention, and similar Kinarm assessment in the population with TLE.This suggests Kinarm as a possible tool for the assessment of executive functioning and attention in people with TLE.
Furthermore, Kinarm was able to identify a similar number of patients as impaired in executive function as the traditional screening methods whilst Kinarm identified more patients as impaired in attention when compared to the neuropsychological screening.This presents the possibility that Kinarm may be as effective, and potentially more sensitive than traditional methods at identifying impairments in patients with TLE.

Kinarm's ability to assess impairments in visuospatial function
RBANS visuospatial is an effective tool for assessing visuospatial function, as there is strong internal reliability and validity for the tasks included in a variety of populations, including dwelling elderly and traumatic brain injury [47 48].
While all the Kinarm tasks used in the assessment had a visuospatial aspect, the only task that significantly correlated with RBANS visuospatial was APM.APM requires the participant to use their spatial skills to match the position as closely as possible with their opposite hand [35].This may be explained by the fact that the Kinarm tasks are more focused on visuomotor skills, while RBANS attention is more focused on pure visuospatial skills.
Our results provide evidence that Kinarm may be a useful tool in assessing visuospatial function in participants with TLE.

Kinarm's ability to assess impairments in motor performance
GP is used to assess motor impairment as it covers a wide range of motor functions including hand-eye coordination, dexterity, and motor speed [49].
Similar to visuospatial function, all the Kinarm tests used in the assessment can assess the participant's motor function.However, the only two tasks to correlate with motor-based tasks from the neuropsychological screening were RVGR and trail B. These tasks a useful tools for assessing motor skills as they require the participant to reach their arms to perform the task [35].
Our results provide evidence that Kinarm may be a useful tool in assessing motor skills in participants with TLE.However it is important to note that while all Kinarm tasks can assess motor performance, only two tasks correlated with GP.This may be explained by the fact that GP also has an executive function aspect to it, as described above, so these tasks may have been correlating more with this domain than motor function.It is also possible that the motor tasks selected for the neuropsychological screening required more fine motor skills than the Kinarm tasks.

Comparison of participants with RTLE and LTLE
Participants with RTLE performed worse than those with LTLE in all but three tasks.Whilst expected for visuospatial function, it was unexpected in tasks related to verbal memory and language as previous research suggests greater impairment in those with LTLE [6].This was further contradicted by our results as the three tasks most closely related to language and memory had no significant differences between those with RTLE and LTLE or found that participants with RTLE performed significantly worse than those with LTLE.A possible explanation is that the language subdomain in RBANS did not represent the optimal approach for assessing language.The language tasks included semantic fluency and picture naming, simple tasks that many individuals could perform well despite having impairments making it insensitive to detecting impairment.For example, in picture naming, all but one patient had a perfect score.Another possible explanation is that the age of onset of TLE could be a larger predictor of impairment in language and verbal memory than the laterality of the seizures [50].In our study, however, the median age of onset and duration of epilepsy for both LTLE and RTLE were not significantly different and nearly identical values, which disputes this claim.Another potential explanation for these results could be the difference in the highest achieved education between the two groups.One patient from the RTLE group had any education above Grade 11-12, while four of the seventeen patients from the LTLE group did.While our results are only on the threshold for significance, this should still be further investigated as neither RBANS nor Kinarm are corrected for education level.

Lack of correlation between the duration of epilepsy and impairment
We found that there were no significant relationships between the duration of epilepsy in overall cognitive function.Previous research Fig. 4. A-D) Scatterplots with a line of best fit displaying the relationship between tasks from neuropsychological screening and Kinarm assessment that assess similar neurocognitive domains.Fig. 5. A-F) Scatterplots with a line of best fit displaying the relationship between tasks from neuropsychological screening and Kinarm assessment that assess similar neurocognitive domains.
showed that with greater duration, there are more profound reductions in cognitive abilities [51].This has been suggested to be the result of the neurodegeneration that occurs as the result of epilepsy [52].The lack of relationship may reflect a contribution from numerous other factors that we did not control for, such as frequency of seizures, education, and antiseizure medications [51].It could also be a consequence of the relatively small sample size employed in this study.

Limitations
Studies have shown that antiseizure medications (ASM) can have profound effects on cognitive function, with certain ASMs having more pronounced effects than others [53].For example, carbamazepine can more severely affect motor speed, topiramate has a more general effect on cognitive abilities and other ASMs have been found to have little effect at all [53].Considering this, the different ASMs participants are taking may have influenced our results, causing subjects to perform more poorly than would be expected.
RBANS is a brief screening task, taking only ~ 30 min to complete, when compared to a complete neuropsychological assessment which gathers data about each domain using at least two different measures.This means it may only capture surface-level or obvious deficiencies and miss more subtle impairments.This brief screening tool was used in our study as we required a short assessment that covered a wide variety of neurocognitive domains.Additionally, the individuals administering the tasks were not licensed neuropsychologists, so tasks that did not require a license were selected.Future studies should consider more extensive assessments.
Kinarm can measure multiple parameters at once.In our study, we did not investigate the potential usage of these individual parameters, instead using the Task Score, which summarises all parameters into an overall performance score.This was to avoid a multiple comparisons problem.We suggest that future studies with much larger sample sizes investigate the usage of these additional parameters.
Many of the standard tasks from Kinarm were originally intended to primarily assess sensorimotor abilities, whilst also requiring cognitive functions.Thus many of the tasks cover multiple neurocognitive domains, whereas neuropsychological tasks may be more specific to one domain.Therefore, there is potential that some of the correlations we saw were not the result of tasks assessing the same neurocognitive domains, but rather correlating with another domain.This may have contributed to the increased number of individuals being identified as impaired.
Lastly, the current Kinarm tasks do not address language or memory.However, a recently developed paired associates learning task will be used in future studies to assess memory.Language continues to be a challenge as no Kinarm tasks are available, but a brief pen-and-paper language task could be utilized if needed.

Significance and conclusion
An area of neuropsychological screenings that deserves further study is the use of technology in these screenings.Our findings demonstrate that Kinarm may be an effective tool to assess a variety of neurocognitive domains, including executive function, attention, visuospatial function, and motor performance, in participants with TLE.This has significant implications as Kinarm assessments could be utilised for cognitive screening evaluations of people with TLE to detect occult cognitive impairment as the time commitment and training requirements are markedly less demanding than formal neuropsychological assessment.

Declaration of competing interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Stephen Scott is the co-founder and CSO of Kinarm which commercializes the robotic technology used in the present study.The other authors have no conflicts of interest to report.

Fig. 1 .
Fig. 1.End-point model of Kinarm.Participants are seated and grasp the handles of the robot.They are directed to look down at the screen, and their hands are covered from their view.

Fig. 2 .
Fig. 2. A) Scatterplot of T-scores for Grooved Pegboard, trail A (neuropsychological), trail B (neuropsychological), and finger tapping separated by laterality.Yintercept at 33.5 (red line) indicates cut-off for impairment (impairment below the red line).B) Scatterplot of index scores and total scaled score from RBANS separated by laterality.Y-intercept at 75 (red line) indicates cut-off for impairment (impairment on or below the red line).C) Scatterplot of Task Scores for the Kinarm tasks separated by laterality.Y-intercept at 1.96 (red line) indicates a cut-off for impairment (impairment above the red line).(For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 3 .
Fig. 3. Correlation matrix between the neuropsychological and Kinarm tasks, non-significant values are not shown.

Table 2
Describes the neurocognitive domains assessed by each of the neuropsychological and Kinarm tasks used in our assessment.RBANS is the Repeatable Battery for the Assessment of Neuropsychological Status.Kinarm assessment were conducted by the same person, either a student or a research assistant.The study protocol was approved by the Queen's University and Affiliated Hospital Health Sciences Research Ethics Board (ANAT-024-05, DMED-2390-20). and

Table 3
Summary of participant demographics and clinical details.

Table 4
The means of each task, and the means of each task separated by laterality.T-scores and their significance represent the difference in the performance of the two laterality groups.Significant values are represented in red.