Evaluating the impact of virtual reality game training on upper limb motor performance in children and adolescents with developmental coordination disorder: a scoping review using the ICF framework.

OBJECTIVE: This scoping review aims to explore published literature testing Virtual Reality (VR) interventions for improving upper limb motor performance in children and adolescents with Developmental Coordination Disorder (DCD). Our primary focus was on the types of VR systems used and the measurement tools employed within the International Classification of Functioning, Disability and Health Children and Youth Version (ICF-CY) domains in these studies. METHODS: A comprehensive search of six electronic databases up to 11th January 2024 was conducted using predefined terms. Inclusion and exclusion criteria were applied to determine study eligibility, with two authors independently assessing titles, abstracts, and full-text articles. RESULTS: Out of 788 potential studies, 14 met the eligibility criteria. Studies predominantly utilized non-immersive VR (nVR) systems, for example, commercial platforms such as Nintendo Wii. Most interventions targeted general motor coordination or balance, with only four studies specifically focusing on upper limb motor performance. The Movement Assessment Battery for Children-2 was the predominant assessment tool. However, the use of game scores and trial durations raised concerns about the accuracy of assessments. The majority of studies reported no significant improvement in upper limb motor performance following VR interventions, though some noted improvements in specific tasks or overall outcomes. CONCLUSION: The findings suggest that, while nVR interventions are being explored for paediatric motor rehabilitation, their impact on enhancing upper limb motor performance in children with DCD is unclear. The variability in intervention designs, outcome measures, and the predominant focus on general motor skills rather than specific upper limb improvements highlight the need for more targeted research in this area. IMPACT: This review underscores the importance of developing precise and clinically relevant measurement tools in a broader range of VR technologies to optimize the use of VR in therapy for children with DCD. Future research should aim for more rigorous study designs and emerging immersive technologies to maximize therapeutic benefits.

New evidence for the sensorimotor mismatch theory of weight perception and the size-weight illusion.

The size-weight illusion is a phenomenon where a smaller object is perceived heavier than an equally weighted larger object. The sensorimotor mismatch theory proposed that this illusion occurs because of a mismatch between efferent motor commands and afferent sensory feedback received when lifting large and small objects (i.e., the application of too little and too much lifting force, respectively). This explanation has been undermined by studies demonstrating a separation between the perceived weight of objects and the lifting forces that are applied on them. However, this research suffers from inconsistencies in the choice of lifting force measures reported. Therefore, we examined the contribution of sensorimotor mismatch in the perception of weight in the size-weight illusion and in non-size-weight illusion stimuli and evaluated the use of a lifting force aggregate measure comprising the four most common lifting force measures used in previous research. In doing so, the sensorimotor mismatch theory was mostly supported. In a size-weight illusion experiment, the lifting forces correlated with weight perception and, contrary to some earlier research, did not adapt over time. In a non-size-weight illusion experiment, switches between lifting light and heavy objects resulted in perceiving the weight of these objects differently compared to no switch trials, which mirrored differences in the manner participants applied forces on the objects. Additionally, we reveal that our force aggregate measure can allow for a more sensitive and objective examination of the effects of lifting forces on objects.

Peripheral and bimanual reaching in a stroke survivor with left visual neglect and extinction.

Whether attentional deficits are accompanied by visuomotor impairments following posterior parietal lesions has been debated for quite some time. This single-case study investigated reaching in a stroke survivor (E.B.) with left visual neglect and visual extinction following right temporo-parietal-frontal strokes. Unlike most neglect patients, E.B. did not present left hemiparesis, homonymous hemianopia nor show evidence of motor neglect or extinction allowing us to examine, for the first time, if lateralised attentional deficits co-occur with deficits in peripheral and bimanual reaching. First, we found a classic optic ataxia field effect: E.B.'s accuracy was impaired when reaching to peripheral targets in her neglected left visual field (regardless of the hand used). Second, we found a larger bimanual cost for movement time in E.B. than controls when both hands reached to incongruent locations. E.B.'s visuomotor profile is similar to the one of patients with optic ataxia showing that attentional deficits are accompanied by visuomotor deficits in the affected field.

The effects of partial sleep restriction and subsequent caffeine ingestion on neurovascular coupling.

Habitual poor sleep is associated with cerebrovascular disease. Acute sleep deprivation alters the ability to match brain blood flow to metabolism (neurovascular coupling [NVC]) but it is not known how partial sleep restriction affects NVC. When rested, caffeine disrupts NVC, but its effects in the sleep-restricted state are unknown. The purpose of this study was therefore to investigate the effects of partial sleep restriction and subsequent caffeine ingestion on NVC. A total of 17 adults (mean [standard deviation] age 27 [5] years, nine females) completed three separate overnight conditions with morning supplementation: habitual sleep plus placebo (Norm_Pl), habitual sleep plus caffeine (Norm_Caf), and partial (50% habitual sleep) restriction plus caffeine (PSR_Caf). NVC responses were quantified as blood velocity through the posterior (PCAv) and middle (MCAv) cerebral arteries using transcranial Doppler ultrasound during a visual search task and cognitive function tests, respectively. NVC was assessed the evening before and twice the morning after each sleep condition-before and 1-h after caffeine ingestion. NVC responses as a percentage increase in PCAv and MCAv from resting baseline were not different at any timepoint, across all conditions (p > 0.053). MCAv at baseline, and PCAv at baseline, peak, and total area under the curve were lower 1-h after caffeine in both Norm_Caf and PSR_Caf as compared to Norm_Pl (p < 0.05), with no difference between Norm_Caf and PSR_Caf (p > 0.14). In conclusion, NVC was unaltered after 50% sleep loss, and caffeine did not modify the magnitude of the response in the rested or sleep-deprived state. Future research should explore how habitual poor sleep affects cerebrovascular function.

Investigating how prior knowledge influences perception and action in developmental coordination disorder.

Developmental coordination disorder (DCD) is characterised by a broad spectrum of difficulties in performing motor tasks. It has recently been proposed that a specific deficit in sensorimotor prediction and feedforward planning might underpin these motoric impairments. The purpose of this study was to use a naturalistic object lifting paradigm to examine whether deficits in sensorimotor prediction might underpin the broad spectrum of difficulties individuals with DCD face when interacting with objects in their environment. We recruited 60 children with probable DCD and 61 children without DCD and measured perceptions of heaviness and fingertip force rate application when interacting with objects which varied in their apparent weight. If deficits in sensorimotor prediction do underpin the broad-ranging motor difficulties seen in DCD, we would expect to see a reduced effect of visual size cues on fingertip force rates and illusory misperceptions of object heaviness. We found no evidence of differences in any metrics of sensorimotor prediction between children with (n = 46) and without DCD (n = 61). Furthermore, there was no correlation between any metrics of sensorimotor prediction and motor performance (as assessed by the standard diagnostic movement assessment battery). Illusory misperceptions of object weight also did not appear to differ between groups. These findings suggest that issues with sensorimotor prediction are unlikely to affect the performance of simple real-world movements in those with DCD.

Testing predictive coding theories of autism spectrum disorder using models of active inference.

Several competing neuro-computational theories of autism have emerged from predictive coding models of the brain. To disentangle their subtly different predictions about the nature of atypicalities in autistic perception, we performed computational modelling of two sensorimotor tasks: the predictive use of manual gripping forces during object lifting and anticipatory eye movements during a naturalistic interception task. In contrast to some accounts, we found no evidence of chronic atypicalities in the use of priors or weighting of sensory information during object lifting. Differences in prior beliefs, rates of belief updating, and the precision weighting of prediction errors were, however, observed for anticipatory eye movements. Most notably, we observed autism-related difficulties in flexibly adapting learning rates in response to environmental change (i.e., volatility). These findings suggest that atypical encoding of precision and context-sensitive adjustments provide a better explanation of autistic perception than generic attenuation of priors or persistently high precision prediction errors. Our results did not, however, support previous suggestions that autistic people perceive their environment to be persistently volatile.

Using immersive virtual reality to remotely examine performance differences between dominant and non-dominant hands.

Circle drawing may be a useful task to study upper-limb function in patient populations. However, previous studies rely on expensive and bulky robotics to measure performance. For clinics or hospitals with limited budgets and space, this may be unfeasible. Virtual reality (VR) provides a portable and low-cost tool with integrated motion capture. It offers potentially a more feasible medium by which to assess upper-limb motor function. Prior to use with patient populations, it is important to validate and test the capabilities of VR with healthy users. This study examined whether a VR-based circle drawing task, completed remotely using participant's own devices, could capture differences between movement kinematics of the dominant and non-dominant hands in healthy individuals. Participants (n = 47) traced the outline of a circle presented on their VR head-mounted displays with each hand, while the positions of the hand-held controllers were continuously recorded. Although there were no differences observed in the size or roundness of circles drawn with each hand, consistent with prior literature our results did show that the circles drawn with the dominant hand were completed faster than those with the non-dominant hand. This provides preliminary evidence that a VR-based circle drawing task may be a feasible method for detecting subtle differences in function in clinical populations. Supplementary Information: The online version contains supplementary material available at 10.1007/s10055-023-00794-z.

O hand, where art thou? Mapping hand location across the visual field during common activities.

Humans employ visually-guided actions during a myriad of daily activities. These ubiquitous but precise manual actions rely on synergistic work between eye and hand movements. During this close cooperation between hands and eyes, the hands persist in sight in a way which is unevenly distributed across our visual field. One common assertion is that most hand actions occur in the lower visual field (LVF) because the arms are anatomically lower than the head, and objects typically rest on waist-high table surfaces. While experimental work has shown that humans are more efficient at reaching for and grasping targets located below their visual midline (Goodale and Danckert, Exp Brain Res 137:303-308, 2001), there is almost no empirical data detailing where the hands lie in the visual fields during natural hand actions. To build a comprehensive picture of hand location during natural visually guided manual actions, we analyzed data from a large-scale open-access dataset containing 100 h of non-scripted manual object interactions during domestic kitchen tasks filmed from a head-mounted camera. We found a clear vertical visual asymmetry with hands located in the lower visual scene (LVS) in more than 70% of image frames, particularly in ipsilateral space. These findings provide the first direct evidence for the established assumption that hands spend more time in the lower than in the upper visual field (UVF). Further work is required to determine whether this LVF asymmetry differs across the lifespan, in different professions, and in clinical populations.

The efficacy of virtual reality interventions compared with conventional physiotherapy in improving the upper limb motor function of children with cerebral palsy: a systematic review of randomised controlled trials.

PURPOSE: Cerebral palsy (CP) is the commonest motor disability affecting children. This study reviewed the evidence for virtual reality (VR) intervention compared with conventional physiotherapy in upper limb function of children with CP. METHODS: Searches were undertaken in MEDLINE, EMBASE, PEDro, CENTRAL, Web of Science, CINAHL, ERIC, ICTRP, EU-CTR, ClinicalTrials.gov and EThOS databases. Only randomised-controlled trials (RCTs) were included. Two reviewers independently screened the search results, assessed full-text articles, extracted data and appraised the methodological quality by using the Cochrane collaboration's risk of bias (RoB2) tool. Albatross plots were used to synthesise the data. RESULTS: Seven RCTs, examining motor function in a total of 202 children with CP, included. Four trials used the Quality of Upper Extremity Skills Test (QUEST) as an outcome measure, and three trials used grip strength. These outcome measures were utilised to develop two Albatross plots. Data from the plots showed contradictory findings of the included studies. CONCLUSIONS: The effect of VR in the upper limb rehabilitation of children with CP remains unclear. All included studies used commercial non-immersive VR games. Future high-quality clinical research is needed to explore the extent to which non-immersive and immersive VR is feasible and effective with children and adolescents.IMPLICATIONS FOR REHABILITATIONThe current evidence supporting the use of VR as a rehabilitative tool is weak and uncertain.The current use of VR relies only on commercial non-immersive VR (off-shelf) games, which are not adjustable to meet the demands and goals of therapy programmes.Future research is needed to study the therapeutic feasibility of immersive VR with children and adolescents.

Investigating how Explicit Contextual Cues Affect Predictive Sensorimotor Control in Autistic Adults.

Research suggests that sensorimotor difficulties in autism could be reduced by providing individuals with explicit contextual information. To test this, we examined autistic visuomotor control during a virtual racquetball task, in which participants hit normal and unexpectedly-bouncy balls using a handheld controller. The probability of facing each type of ball was varied unpredictably over time. However, during cued trials, participants received explicit information about the likelihood of facing each uncertain outcome. When compared to neurotypical controls, autistic individuals displayed poorer task performance, atypical gaze profiles, and more restricted swing kinematics. These visuomotor patterns were not significantly affected by contextual cues, indicating that autistic people exhibit underlying differences in how prior information and environmental uncertainty are dynamically modulated during movement tasks.

Enhancing motor imagery practice using synchronous action observation.

In this paper, we discuss a variety of ways in which practising motor actions by means of motor imagery (MI) can be enhanced via synchronous action observation (AO), that is, by AO + MI. We review the available research on the (mostly facilitatory) behavioural effects of AO + MI practice in the early stages of skill acquisition, discuss possible theoretical explanations, and consider several issues related to the choice and presentation schedules of suitable models. We then discuss considerations related to AO + MI practice at advanced skill levels, including expertise effects, practical recommendations such as focussing attention on specific aspects of the observed action, using just-ahead models, and possible effects of the perspective in which the observed action is presented. In section "Coordinative AO + MI", we consider scenarios where the observer imagines performing an action that complements or responds to the observed action, as a promising and yet under-researched application of AO + MI training. In section "The dual action simulation hypothesis of AO + MI", we review the neurocognitive hypothesis that AO + MI practice involves two parallel action simulations, and we consider opportunities for future research based on recent neuroimaging work on parallel motor representations. In section "AO + MI training in motor rehabilitation", we review applications of AO, MI, and AO + MI training in the field of neurorehabilitation. Taken together, this evidence-based, exploratory review opens a variety of avenues for future research and applications of AO + MI practice, highlighting several clear advantages over the approaches of purely AO- or MI-based practice.

The sensorimotor theory of pathological pain revisited.

Harris (1999) proposed that pain can arise in the absence of tissue damage because changes in the cortical representation of the painful body part lead to incongruences between motor intention and sensory feedback. This idea, subsequently termed the sensorimotor theory of pain, has formed the basis for novel treatments for pathological pain. Here we review the evidence that people with pathological pain have changes to processes contributing to sensorimotor function: motor function, sensory feedback, cognitive representations of the body and its surrounding space, multisensory processing, and sensorimotor integration. Changes to sensorimotor processing are most evident in the form of motor deficits, sensory changes, and body representations distortions, and for Complex Regional Pain Syndrome (CRPS), fibromyalgia, and low back pain. Many sensorimotor changes are related to cortical processing, pain, and other clinical characteristics. However, there is very limited evidence that changes in sensorimotor processing actually lead to pain. We therefore propose that the theory is more appropriate for understanding why pain persists rather than how it arises.

The effects of TMS over the anterior intraparietal area on anticipatory fingertip force scaling and the size-weight illusion.

When lifting an object skillfully, fingertip forces need to be carefully scaled to the object's weight, which can be inferred from its apparent size and material. This anticipatory force scaling ensures smooth and efficient lifting movements. However, even with accurate motor plans, weight perception can still be biased. In the size-weight illusion, objects of different size but equal weight are perceived to differ in heaviness, with the small object perceived to be heavier than the large object. The neural underpinnings of anticipatory force scaling to object size and the size-weight illusion are largely unknown. In this study, we tested the role of anterior intraparietal cortex (aIPS) in predictive force scaling and the size-weight illusion, by applying continuous theta burst stimulation (cTBS) prior to participants lifting objects of different sizes. Participants received cTBS over aIPS, the primary motor cortex (control area), or Sham stimulation. We found no evidence that aIPS stimulation affected the size-weight illusion. Effects were, however, found on anticipatory force scaling, where grip force was less tuned to object size during initial lifts. These findings suggest that aIPS is not involved in the perception of object weight but plays a transient role in the sensorimotor predictions related to object size. NEW & NOTEWORTHY Skilled object manipulation requires forming anticipatory motor plans according to the object's properties. Here, we demonstrate the role of anterior intraparietal sulcus (aIPS) in anticipatory grip force scaling to object size, particularly during initial lifting experience. Interestingly, this role was not maintained after continued practice and was not related to perceptual judgments measured with the size-weight illusion.

Using Immersive Virtual Reality to Examine How Visual and Tactile Cues Drive the Material-Weight Illusion.

The material-weight illusion (MWI) demonstrates how our past experience with material and weight can create expectations that influence the perceived heaviness of an object. Here we used mixed-reality to place touch and vision in conflict, to investigate whether the modality through which materials are presented to a lifter could influence the top-down perceptual processes driving the MWI. University students lifted equally-weighted polystyrene, cork and granite cubes whilst viewing computer-generated images of the cubes in virtual reality (VR). This allowed the visual and tactile material cues to be altered, whilst all other object properties were kept constant. Representation of the objects' material in VR was manipulated to create four sensory conditions: visual-tactile matched, visual-tactile mismatched, visual differences only and tactile differences only. A robust MWI was induced across all sensory conditions, whereby the polystyrene object felt heavier than the granite object. The strength of the MWI differed across conditions, with tactile material cues having a stronger influence on perceived heaviness than visual material cues. We discuss how these results suggest a mechanism whereby multisensory integration directly impacts how top-down processes shape perception.

Transcranial direct current stimulation and sporting performance: A systematic review and meta-analysis of transcranial direct current stimulation effects on physical endurance, muscular strength and visuomotor skills.

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that has been linked with a range of physiological and cognitive enhancements relevant to sporting performance. As a number of positive and null findings have been reported in the literature, the present meta-analysis sought to synthesise results across endurance, strength and visuomotor skill domains to investigate if tDCS improves any aspect of sporting performance. Online database searches in August 2020 identified 43 full-text studies which examined the acute effects of tDCS compared to sham/control conditions on physical endurance, muscular strength, and visuomotor skills in healthy adults. Meta-analysis indicated a small overall effect favouring tDCS stimulation over sham/control (standardized mean difference (SMD) = 0.25, CI95%[.14;.36]). Effects on strength (SMD = 0.31, CI95%[.10;.51]) and visuomotor (SMD = 0.29, CI95%[.00;.57]) tasks were larger than endurance performance (SMD = 0.18, CI95%[.00;.37]). Meta-regressions indicated effect sizes were not related to stimulation parameters, but other factors such as genetics, gender, and experience may modulate tDCS effects. The results suggest tDCS has the potential to be used as an ergogenic aid in conjunction with a specified training regime.

Normal manual straight ahead pointing in Complex Regional Pain Syndrome.

There is evidence to suggest that people with Complex Regional Pain Syndrome (CRPS) can have altered body representations and spatial cognition. One way of studying these cognitive functions is through manual straight ahead (MSA) pointing, in which participants are required to point straight ahead of their perceived body midline without visual feedback of the hand. We therefore compared endpoint errors from MSA pointing between people with CRPS (n = 17) and matched controls (n = 18), and examined the effect of the arm used (Side of Body; affected/non-dominant, non-affected/dominant). For all participants, pointing errors were biased towards the hand being used. We found moderate evidence of no difference between Groups on endpoint errors, and moderate evidence of no interaction with Side of Body. The differences in variability between Groups were non-significant/inconclusive. Correlational analyses showed no evidence of a relationship between MSA endpoint errors and clinical parameters (e.g. CRPS severity, duration, pain) or questionnaire measures (e.g. body representation, "neglect-like symptoms", upper limb disability). This study is consistent with earlier findings of no difference between people with CRPS and controls on MSA endpoint errors, and is the first to provide statistical evidence of similar performance of these two groups. Our results do not support a relationship between clinical or self-reported measures (e.g. "neglect-like symptoms") and any directional biases in MSA. Our findings may have implications for understanding neurocognitive changes in CRPS.

An examination of active inference in autistic adults using immersive virtual reality.

The integration of prior expectations, sensory information, and environmental volatility is proposed to be atypical in Autism Spectrum Disorder, yet few studies have tested these predictive processes in active movement tasks. To address this gap in the research, we used an immersive virtual-reality racquetball paradigm to explore how visual sampling behaviours and movement kinematics are adjusted in relation to unexpected, uncertain, and volatile changes in environmental statistics. We found that prior expectations concerning ball 'bounciness' affected sensorimotor control in both autistic and neurotypical participants, with all individuals using prediction-driven gaze strategies to track the virtual ball. However, autistic participants showed substantial differences in visuomotor behaviour when environmental conditions were more volatile. Specifically, uncertainty-related performance difficulties in these conditions were accompanied by atypical movement kinematics and visual sampling responses. Results support proposals that autistic people overestimate the volatility of sensory environments, and suggest that context-sensitive differences in active inference could explain a range of movement-related difficulties in autism.

Characterising sensorimotor adaptation in Complex Regional Pain Syndrome.

It has been suggested that sensorimotor conflict contributes to the maintenance of some pathological pain conditions, implying that there are problems with the adaptation processes that normally resolve such conflict. We tested whether sensorimotor adaptation is impaired in people with Complex Regional Pain Syndrome (CRPS) by characterising their adaption to lateral prismatic shifts in vision. People with unilateral upper-limb CRPS Type I (n = 17), and pain-free individuals (n = 18; matched for age, sex, and handedness) completed prism adaptation with their affected/non-dominant and non-affected/dominant arms. We examined 1) the rate at which participants compensated for the optical shift during prism exposure (i.e., strategic recalibration), 2) endpoint errors made directly after prism adaptation (sensorimotor realignment) and the retention of these errors, and 3) kinematic markers associated with strategic control. Direct comparisons between people with CRPS and controls revealed no evidence of any differences in strategic recalibration, including no evidence for differences in a kinematic marker associated with trial-by-trial changes in movement plans during prism exposure. All participants made significant endpoint errors after prism adaptation exposure, indicative of sensorimotor realignment. Overall, the magnitude of this realignment did not differ between people with CRPS and pain-free controls. However, when endpoint errors were considered separately for each hand, people with CRPS made greater errors (indicating more rather than less realignment) when using their affected hand than their non-affected hand. No such difference was seen in controls. Taken together, these findings provide no evidence of impaired strategic control or sensorimotor realignment in people with CRPS. In contrast, they provide some indication that there could be a greater propensity for sensorimotor realignment in the CRPS-affected arm, consistent with more flexible representations of the body and peripersonal space. Our study challenges an implicit assumption of the theory that sensorimotor conflict might underlie some pathological pain conditions.

Visuo-motor attention during object interaction in children with developmental coordination disorder.

Developmental coordination disorder (DCD) describes a condition of poor motor performance in the absence of intellectual impairment. Despite being one of the most prevalent developmental disorders, little is known about how fundamental visuomotor processes might function in this group. One prevalent idea is children with DCD interact with their environment in a less predictive fashion than typically developing children. A metric of prediction which has not been examined in this group is the degree to which the hands and eyes are coordinated when performing manual tasks. To this end, we examined hand and eye movements during an object lifting task in a group of children with DCD (n = 19) and an age-matched group of children without DCD (n = 39). We observed no differences between the groups in terms of how well they coordinated their hands and eyes when lifting objects, nor in terms of the degree by which the eye led the hand. We thus find no evidence to support the proposition that children with DCD coordinate their hands and eyes in a non-predictive fashion. In a follow-up exploratory analysis we did, however, note differences in fundamental patterns of eye movements between the groups, with children in the DCD group showing some evidence of atypical visual sampling strategies and gaze anchoring behaviours during the task.

Predictive sensorimotor control in autism.

Autism spectrum disorder has been characterized by atypicalities in how predictions and sensory information are processed in the brain. To shed light on this relationship in the context of sensorimotor control, we assessed prediction-related measures of cognition, perception, gaze and motor functioning in a large general population (n = 92; Experiment 1) and in clinically diagnosed autistic participants (n = 29; Experiment 2). In both experiments perception and action were strongly driven by prior expectations of object weight, with large items typically predicted to weigh more than equally-weighted smaller ones. Interestingly, these predictive action models were used comparably at a sensorimotor level in both autistic and neurotypical individuals with varying levels of autistic-like traits. Specifically, initial fingertip force profiles and resulting action kinematics were both scaled according to participants' pre-lift heaviness estimates, and generic visual sampling behaviours were notably consistent across groups. These results suggest that the weighting of prior information is not chronically underweighted in autism, as proposed by simple Bayesian accounts of the disorder. Instead, our results cautiously implicate context-sensitive processing mechanisms, such as precision modulation and hierarchical volatility inference. Together, these findings present novel implications for both future scientific investigations and the autism community.