Perspectives and possible applications of the rubber hand and virtual hand illusion in non-invasive rehabilitation: Technological improvements and their consequences

Threatening an Illusory Limb: An Event-related Potential Study of the Rubber Hand Illusion

BACKGROUND

The rubber hand illusion (RHI) is a well-established method for studying body ownership: Given adequate concordance of visual, sensory, and proprioceptive stimuli, the individual experiences a rubber hand as his or her own.

OBJECTIVE

To study the effects of a threat to the rubber hand.

METHODS

We created a typical RHI paradigm but added threatening pain: Both the real hand of an individual and the rubber hand were stroked with a brush, either synchronously (RHI-inducing condition) or asynchronously (control condition), but only the rubber hand was then pricked with a needle to create a threatening pain condition. Event-related potentials (ERPs) were recorded in a group of 23 typically-developed individuals. ERP effects were source-localized using low-resolution electromagnetic tomography.

RESULTS

The individuals consistently reported experience of the RHI during the experiment when the brush strokes were applied synchronously to both the real hand and the rubber hand. ERP analysis revealed that synchronous brush stroking gave rise to higher amplitude of frontal ERPs in the 100-200 ms range than asynchronous brush stroking, which was interpreted as reflecting the RHI. In the threatening pain condition, ERPs showed a greater positivity at frontocentral electrodes, source localized in the supplementary motor area (SMA).

CONCLUSION

SMA activation could reflect a control mechanism over reflexive motor activity, facilitating a possible threat-related response. Further studies should address ERP effects and the extent of the RHI to standard and threat stimuli in a correlative fashion to further elucidate the functional significance of the neurophysiological findings.

Experimental evaluation of the impact of sEMG interfaces in enhancing embodiment of virtual myoelectric prostheses

INTRODUCTION

Despite recent technological advances that have led to sophisticated bionic prostheses, attaining embodied solutions still remains a challenge. Recently, the investigation of prosthetic embodiment has become a topic of interest in the research community, which deals with enhancing the perception of artificial limbs as part of users' own body. Surface electromyography (sEMG) interfaces have emerged as a promising technology for enhancing upper-limb prosthetic control. However, little is known about the impact of these sEMG interfaces on users' experience regarding embodiment and their interaction with different functional levels.

METHODS

To investigate this aspect, a comparison is conducted among sEMG configurations with different number of sensors (4 and 16 channels) and different time delay. We used a regression algorithm to simultaneously control hand closing/opening and forearm pronation/supination in an immersive virtual reality environment. The experimental evaluation includes 24 able-bodied subjects and one prosthesis user. We assess functionality with the Target Achievement Control test, and the sense of embodiment with a metric for the users perception of self-location, together with a standard survey.

RESULTS

Among the four tested conditions, results proved a higher subjective embodiment when participants used sEMG interfaces employing an increased number of sensors. Regarding functionality, significant improvement over time is observed in the same conditions, independently of the time delay implemented.

CONCLUSIONS

Our work indicates that a sufficient number of sEMG sensors improves both, functional and subjective embodiment outcomes. This prompts discussion regarding the potential relationship between these two aspects present in bionic integration. Similar embodiment outcomes are observed in the prosthesis user, showing also differences due to the time delay, and demonstrating the influence of sEMG interfaces on the sense of agency.

How Positioning Wearable Haptic Interfaces on Limbs Influences Virtual Embodiment

With increasing use of computer applications and robotic devices in our everyday life, and with the advent of metaverse, there is an urgent need of developing new types of interfaces that facilitate a more intuitive interaction in physical and virtual space. In this work, we investigate the influence of the location of haptic feedback devices on embodiment of virtual hands and user load during an interactive pick-and-place task. To do this, we conducted a user study with a 3x2 repeated measure experiment design: feedback position is varied between the distal phalanx of the index finger and the thumb, the proximal phalanx of the index finger and the thumb, and the wrist. These conditions of feedback are tested with the stimuli applied synchronously to the participant in one case, and with an additional delay of 350 ms in the second case. The results show that the location of the haptic feedback device does not affect embodiment, whereas the delay, i.e., whether the feedback is applied synchronously or asynchronously, affects embodiment. This suggests that for pick-and-place tasks, haptic feedback devices can be placed on the user's wrist without compromising performance making the hands to remain free, allowing unobstructed hand visibility for precise motion tracking, thereby improving accuracy.

Role of Immersive Virtual Reality in Motor Behaviour Decision-Making in Chronic Pain Patients

Primary chronic pain is a major contributor to disability worldwide, with an estimated prevalence of 20-33% of the world's population. The high socio-economic impact of musculoskeletal pain justifies seeking an appropriate therapeutic strategy. Immersive virtual reality (VR) has been proposed as a first-line intervention for chronic musculoskeletal pain. However, the growing literature has not been accompanied by substantial progress in understanding how VR exerts its impact on the pain experience and what neurophysiological mechanisms might be involved in the clinical effectiveness of virtual reality interventions in chronic pain patients. The aim of this review is: (i) to establish the state of the art on the effects of VR on patients with chronic pain; (ii) to identify neuroplastic changes associated with chronic pain that may be targeted by VR intervention; and (iii) to propose a hypothesis on how immersive virtual reality could modify motor behavioral decision-making through an interactive experience in patients with chronic pain.

Human-Robot Body Experience: An Artificial Intelligence Perspective

Human body experience is remarkably flexible, which enables us to integrate passive tools as well as intelligent robotic devices into our body representation. Accordingly, it can serve as a role model to make (assistive) robots interact seamlessly with their users or to provide (humanoid) robots with a human-like self-perception and behavior generation. This article discusses the potential of understanding human body experience and applying it to robotics. Particular focus is set on how to use artificial intelligence techniques and create intelligent artificial agents from insights about human body experience. The discussion is based on a summary of the author’s habilitation thesis and combines theoretical and experimental perspectives from psychology, cognitive science and neuroscience as well as computer science, engineering, and artificial intelligence. From this, it derives directions for future developments towards creating artificial body intelligence with human-like capabilities.

The effects of embodying wildlife in virtual reality on conservation behaviors

Efforts to mitigate environmental threats are often inversely related to the magnitude of casualty, human or otherwise. This “compassion fade” can be explained, in part, by differential processing of large- versus small-scale threats: it is difficult to form empathic connections with unfamiliar masses versus singular victims. Despite robust findings, little is known about how non-human casualty is processed, and what strategies override this bias. Across four experiments, we show how embodying threatened megafauna-Loggerhead sea turtles (Caretta Caretta)-using virtual reality can offset and reverse compassion fade. After observing compassion fade during exposure to non-human casualty in virtual reality (Study 1; N = 60), we then tested a custom virtual reality simulation designed to facilitate body transfer with a threatened Loggerhead sea turtle (Study 2; N = 98). Afterwards, a field experiment (Study 3; N = 90) testing the simulation with varied number of victims showed body transfer offset compassion fade. Lastly, a fourth study (N = 25) found that charitable giving among users embodying threatened wildlife was highest when exposed to one versus several victims, though this effect was reversed if victims were of a different species. The findings demonstrate how animal embodiment in virtual reality alters processing of environmental threats and non-human casualty, thereby influencing conservation outcomes.

Development of a Guidance System for Motor Imagery Enhancement Using the Virtual Hand Illusion

Motor imagery (MI) is widely used to produce input signals for brain-computer interfaces (BCI) due to the similarities between MI-BCI and the planning-execution cycle. Despite its usefulness, MI tasks can be ambiguous to users and MI produces weaker cortical signals than motor execution. Existing MI guidance systems, which have been reported to provide visual guidance for MI and enhance MI, still have limitations: insufficient immersion for MI or poor expandability to MI for another body parts. We propose a guidance system for MI enhancement that can immerse users in MI and will be easy to extend to other body parts and target motions with few physical constraints. To make easily extendable MI guidance system, the virtual hand illusion is applied to the MI guidance system with a motion tracking sensor. MI enhancement was evaluated in 11 healthy people by comparison with another guidance system and conventional motor commands for BCI. The results showed that the proposed MI guidance system produced an amplified cortical signal compared to pure MI (p < 0.017), and a similar cortical signal as those produced by both actual execution (p > 0.534) and an MI guidance system with the rubber hand illusion (p > 0.722) in the contralateral region. Therefore, we believe that the proposed MI guidance system with the virtual hand illusion is a viable alternative to existing MI guidance systems in various applications with MI-BCI.

Validation and revision of the questionnaire to explore human factors and their technical potential for lower limb prosthetics

BACKGROUND

A variety of instruments exist to measure human factors for lower limb amputation and prosthesis research. Yet, there is no valid or reliable tool available that focuses on technical potentials.

OBJECTIVE

This study aimed to validate and revise the Questionnaire to Explore Human Factors and their Technical Potential.

STUDY DESIGN

Cross-sectional study METHODS:: A total of 150 persons with lower limb amputation from Germany participated in the study. Statistical properties, including Cronbach's alpha, item difficulty, item-total correlation, and distribution of missing values were calculated. Thresholds for acceptable psychometric properties were defined, unsuitable items were removed, and problematic items were reviewed regarding formulation.

RESULTS

The Cronbach's alpha for subscales within the Questionnaire to Explore Human Factors and their Technical Potential were between 0.72 and 0.89. A total of 56 items showed acceptability, and 14 items had problematic item property values. Four of those items were reformulated, five were excluded, six were left in the scale, and an additional one was added to the scale.

CONCLUSION

Evaluation of the Questionnaire to Explore Human Factors and their Technical Potential indicates it exhibits good internal consistency and acceptable psychometric properties. The scale was revised and is recommended to explore aspects of technical prosthesis development.

CLINICAL RELEVANCE

Our results show that the revised Questionnaire to Explore Human Factors and their Technical Potential may serve as a reliable and valid means, when designing prostheses, both during development and clinical evaluations and fittings, to assess the technical potential of lower limb prostheses directly according to the needs of users with lower-limb amputations.

Benchmarking Wearable Robots: Challenges and Recommendations From Functional, User Experience, and Methodological Perspectives

Wearable robots (WRs) are increasingly moving out of the labs toward real-world applications. In order for WRs to be effectively and widely adopted by end-users, a common benchmarking framework needs to be established. In this article, we outline the perspectives that in our opinion are the main determinants of this endeavor, and exemplify the complex landscape into three areas. The first perspective is related to quantifying the technical performance of the device and the physical impact of the device on the user. The second one refers to the understanding of the user's perceptual, emotional, and cognitive experience of (and with) the technology. The third one proposes a strategic path for a global benchmarking methodology, composed by reproducible experimental procedures representing real-life conditions. We hope that this paper can enable developers, researchers, clinicians and end-users to efficiently identify the most promising directions for validating their technology and drive future research efforts in the short and medium term.

Embodiment, Presence, and Their Intersections

Subjective experience of human control over remote, artificial, or virtual limbs has traditionally been investigated from two separate angles: presence research originates from teleoperation, aiming to capture to what extent the user feels like actually being in the remote or virtual environment. Embodiment captures to what extent a virtual or artificial limb is perceived as one’s own limb. Unfortunately, the two research fields have not interacted much. This survey intends to provide a coherent overview of the literature at the intersection of these two fields to further that interaction. Two rounds of systematic research in topic-related data bases resulted in 414 related articles, 14 of which satisfy the deliberately strict inclusion criteria: 2 theoretical frameworks that highlighted intersections and 12 experimental studies that evaluated subjective measures for both concepts. Considering the surrounding literature as well, theoretical and experimental potential of embodiment and presence are discussed and suggestions to apply them in teleoperation research are derived. While increased publication activity is observed between 2016 and 2018, potentially caused by affordable virtual reality technologies, various open questions remain. To tackle them, human-in-the-loop experiments and three guiding principles for teleoperation system design (mechanical fidelity, spatial bodily awareness, and self-identification) are suggested.

The Bayesian causal inference model benefits from an informed prior to predict proprioceptive drift in the rubber foot illusion

Bayesian cognitive modeling has become a prominent tool for the cognitive sciences aiming at a deeper understanding of the human mind and applications in cognitive systems, e.g., humanoid or wearable robotics. Such approaches can capture human behavior adequately with a focus on the crossmodal processing of sensory information. The rubber foot illusion is a paradigm in which such integration is relevant. After experimental stimulation, many participants perceive their real limb closer to an artificial replicate than it actually is. A measurable effect of this recalibration on localization is called the proprioceptive drift. We investigate whether the Bayesian causal inference model can estimate the proprioceptive drift observed in empirical studies. Moreover, we juxtapose two models employing informed prior distributions on limb location against an existing model assuming uniform prior distribution. The model involving empirically informed prior information yields better predictions of the proprioceptive drift regarding the rubber foot illusion when evaluated with separate experimental data. Contrary, the uniform model produces implausibly narrow position estimates that seem due to the precision ratio between the contributing sensory channels. We conclude that an informed prior on limb localization is a plausible and necessary modification to the Bayesian causal inference model when applied to limb illusions. Future research could overcome the remaining discrepancy between model predictions and empirical observation by investigating the changes in sensory precision as a function of distance between the eyes and respective limbs.

Can Wearable Haptic Devices Foster the Embodiment of Virtual Limbs?

Increasing presence is one of the primary goals of virtual reality research. A crucial aspect is that users are capable of distinguishing their self from the external virtual world. The hypothesis we investigate is that wearable haptics play an important role in the body experience and could thereby contribute to the immersion of the user in the virtual environment. A within-subject study (n=32) comparing the embodiment of a virtual hand with different implementations of haptic feedback (force feedback, vibrotactile feedback, and no haptic feedback) is presented. Participants wore a glove with haptic feedback devices at thumb and index finger. They were asked to put virtual cubes on a moving virtual target. Touching a virtual object caused vibrotactile-feedback, force-feedback or no feedback depending on the condition. These conditions were provided both synchronously and asynchronously. Embodiment was assessed quantitatively with the proprioceptive drift and subjectively via a questionnaire. Results show that haptic feedback significantly improves the subjective embodiment of a virtual hand and that force feedback leads to stronger responses to certain subscales of subjective embodiment. These outcomes are useful guidelines for wearable haptic designer and represent a basis for further research concerning human body experience, in reality, and in virtual environments.

How Cognitive Models of Human Body Experience Might Push Robotics

In the last decades, cognitive models of multisensory integration in human beings have been developed and applied to model human body experience. Recent research indicates that Bayesian and connectionist models might push developments in various branches of robotics: assistive robotic devices might adapt to their human users aiming at increased device embodiment, e.g., in prosthetics, and humanoid robots could be endowed with human-like capabilities regarding their surrounding space, e.g., by keeping safe or socially appropriate distances to other agents. In this perspective paper, we review cognitive models that aim to approximate the process of human sensorimotor behavior generation, discuss their challenges and potentials in robotics, and give an overview of existing approaches. While model accuracy is still subject to improvement, human-inspired cognitive models support the understanding of how the modulating factors of human body experience are blended. Implementing the resulting insights in adaptive and learning control algorithms could help to taylor assistive devices to their user's individual body experience. Humanoid robots who develop their own body schema could consider this body knowledge in control and learn to optimize their physical interaction with humans and their environment. Cognitive body experience models should be improved in accuracy and online capabilities to achieve these ambitious goals, which would foster human-centered directions in various fields of robotics.

Paradoxes in rehabilitation

Paradoxical enhancement and paradoxical recovery of function after brain injury harmonize well with the concept of "ultrabilitation" and its focus on novel forms of flourishing in rehabilitation settings. I consider three sets of paradoxes which may impact on brain injury rehabilitation. Firstly, I consider post-traumatic growth after brain injury and its key determinants. Secondly, I review the role of illusions in rehabilitation and the paradox that some clinical conditions may be improved by invoking perceptual distortions. Thirdly, I consider paradoxical recovery profiles after brain injury, since knowledge of such paradoxical profiles may help inform attempts at rehabilitation of some patients. Finally, I consider how some of these paradoxes relate to components of ultrabilitation, and in addition to the nascent field of positive neuropsychology and the concept of resilience after brain injury.Implications for rehabilitationIllusions can sometimes be harnessed as a therapeutic tool in rehabilitation.There may be spontaneous, positive outcomes of an injury or illness, in the form of "post-traumatic growth", and these should be considered as part of a holistic therapeutic approach in rehabilitation.Some patients make an exceptional recovery from a severe brain insult, and lessons could be learned from such cases, such as disciplined use of compensatory strategies, which could have broader implications for neurorehabilitation.

Effect of Specific Over Nonspecific VR-Based Rehabilitation on Poststroke Motor Recovery: A Systematic Meta-analysis

Background. Despite the rise of virtual reality (VR)-based interventions in stroke rehabilitation over the past decade, no consensus has been reached on its efficacy. This ostensibly puzzling outcome might not be that surprising given that VR is intrinsically neutral to its use—that is, an intervention is effective because of its ability to mobilize recovery mechanisms, not its technology. As VR systems specifically built for rehabilitation might capitalize better on the advantages of technology to implement neuroscientifically grounded protocols, they might be more effective than those designed for recreational gaming. Objective. We evaluate the efficacy of specific VR (SVR) and nonspecific VR (NSVR) systems for rehabilitating upper-limb function and activity after stroke. Methods. We conducted a systematic search for randomized controlled trials with adult stroke patients to analyze the effect of SVR or NSVR systems versus conventional therapy (CT). Results. We identified 30 studies including 1473 patients. SVR showed a significant impact on body function (standardized mean difference [SMD] = 0.23; 95% CI = 0.10 to 0.36; P = .0007) versus CT, whereas NSVR did not (SMD = 0.16; 95% CI = −0.14 to 0.47; P = .30). This result was replicated in activity measures. Conclusions. Our results suggest that SVR systems are more beneficial than CT for upper-limb recovery, whereas NSVR systems are not. Additionally, we identified 6 principles of neurorehabilitation that are shared across SVR systems and are possibly responsible for their positive effect. These findings may disambiguate the contradictory results found in the current literature.

Effects of transcutaneous electrical nerve stimulation and visuotactile synchrony on the embodiment of an artificial hand

The rubber hand illusion (RHI) is an experimental paradigm known to produce a bodily illusion. Transcutaneous electrical nerve stimulation (TENS) combined with the RHI induces a stronger illusion than the RHI alone. Visuotactile stimulus synchrony is an important aspect of the RHI. However, the effect of TENS and visuotactile stimulus synchrony in TENS combined with the RHI remains unknown. The purpose of this study was to investigate the effects of TENS and visuotactile stimulus synchrony on the embodiment of an artificial hand when using TENS combined with the RHI. The participants underwent four experimental conditions in random order: TENS/noTENS × Synchronous/Asynchronous. TENS was set at an intensity such that it generated a feeling of electrical paresthesia in the radial nerve area of the hand but did not cause pain, i.e., 100-Hz pulse frequency, 80-µs pulse duration, and a constant pulse pattern. A visuotactile stimulus, either temporally synchronous or asynchronous, was generated using paintbrush strokes. To evaluate the outcome measures, the participants completed a questionnaire report and proprioceptive drift assessments (motor response and perceptual response). There were significant main effects of TENS and visuotactile synchrony, but no interaction between these factors, on the results of the questionnaire and the perceptual response. In contrast, there was no significant effect on the result of the motor response. These findings indicate that TENS and visuotactile synchrony might affect differently the embodiment of an artificial hand when using TENS combined with the RHI.

Monitoring brain potentials to guide neurorehabilitation of tracking impairments

Motor impairments come in different forms. One class of motor impairments, relates to accuracy of tracking a moving object, as, for instance, when chasing in an attempt to catch it. Here we look at neural signals associated with errors in tracking, and the implications for brain-computer-interfaces that target impairment-tailored rehabilitation. As a starting point, we characterized EEG signals evoked by tracking errors during continuous natural motion, in healthy participants. Participants played a virtual 3D, ecologically valid haptic tennis game, and had to track a moving tennis ball in order to hit and send the ball towards the opponent's court. Sudden changes in the motion of the tennis ball elicited error related potentials. These were characterized by a negative peak at 135 msec and two positive peaks at 211 and 336 msec. The negative peak had a parietal scalp distribution, and the positive had a centro-frontal distribution. sLORETA source estimation for the peaks suggested brain activity in the somatosensory, motor, visual and anterior cingulate cortex. Implications are double: changes in the error potential characteristics provide an assessment strategy for rehabilitation; and the identified error potential can be used in the Brain computer interface feedback loop for tailored rehabilitation. Taken together, these results provide a methodology of rehabilitation systems specifically tailored to the unique impairment.

Actual and Illusory Perception in Parkinson's Disease and Dystonia: A Narrative Review

Sensory information is continuously processed so as to allow behavior to be adjusted according to environmental changes. Before sensory information reaches the cortex, a number of subcortical neural structures select the relevant information to send to be consciously processed. In recent decades, several studies have shown that the pathophysiological mechanisms underlying movement disorders such as Parkinson's disease (PD) and dystonia involve sensory processing abnormalities related to proprioceptive and tactile information. These abnormalities emerge from psychophysical testing, mainly temporal discrimination, as well as from experimental paradigms based on bodily illusions. Although the link between proprioception and movement may be unequivocal, how temporal tactile information abnormalities and bodily illusions relate to motor disturbances in PD and dystonia is still a matter of debate. This review considers the role of altered sensory processing in the pathophysiology of movement disorders, focusing on how sensory alteration patterns differ between PD and dystonia. We also discuss the evidence available and the potential for developing new therapeutic strategies based on the manipulation of multi-sensory information and bodily illusions in patients with these movement disorders.

Functional Brain Connectivity during Multiple Motor Imagery Tasks in Spinal Cord Injury

Reciprocal communication of the central and peripheral nervous systems is compromised during spinal cord injury due to neurotrauma of ascending and descending pathways. Changes in brain organization after spinal cord injury have been associated with differences in prognosis. Changes in functional connectivity may also serve as injury biomarkers. Most studies on functional connectivity have focused on chronic complete injury or resting-state condition. In our study, ten right-handed patients with incomplete spinal cord injury and ten age- and gender-matched healthy controls performed multiple visual motor imagery tasks of upper extremities and walking under high-resolution electroencephalography recording. Directed transfer function was used to study connectivity at the cortical source space between sensorimotor nodes. Chronic disruption of reciprocal communication in incomplete injury could result in permanent significant decrease of connectivity in a subset of the sensorimotor network, regardless of positive or negative neurological outcome. Cingulate motor areas consistently contributed the larger outflow (right) and received the higher inflow (left) among all nodes, across all motor imagery categories, in both groups. Injured subjects had higher outflow from left cingulate than healthy subjects and higher inflow in right cingulate than healthy subjects. Alpha networks were less dense, showing less integration and more segregation than beta networks. Spinal cord injury patients showed signs of increased local processing as adaptive mechanism. This trial is registered with NCT02443558.

Initial validation of a virtual blood draw exposure paradigm for fear of blood and needles

Fear of blood, injections, and needles commonly prevents or delays individuals' receipt of health care, such as vaccines or blood draws. Innovative methods are needed to overcome these fears and reduce anxiety related to activities of this nature. The present study describes initial testing of an arm illusion paradigm that may prove useful during early phases of graded exposure for people with blood and needle fear. Seventy-four undergraduate students aged 18-29 years were tested. In line with study aims, results indicated that the virtual blood draw paradigm promoted strong perceptions of arm ownership and elicited significant changes in physiological indices (blood pressure, heart rate, electrodermal activity, respiratory rate) in response to key procedure elements (e.g., needle insertion). Further, bivariate correlations indicated that individual differences in self-reported blood and needle fear collected prior to the illusion paradigm were significantly associated with presyncopal symptoms reported following the procedure. In regression analyses, self-reported measures of blood and needle fear explained unique variance in presyncopal symptoms even after controlling for general state anxiety. These findings provide initial support for the virtual blood draw paradigm as a promising tool to help provide graded exposure to medical procedures involving needles and blood draw.

Towards Rehabilitation Robotics: Off-the-Shelf BCI Control of Anthropomorphic Robotic Arms

Advances in neural interfaces have demonstrated remarkable results in the direction of replacing and restoring lost sensorimotor function in human patients. Noninvasive brain-computer interfaces (BCIs) are popular due to considerable advantages including simplicity, safety, and low cost, while recent advances aim at improving past technological and neurophysiological limitations. Taking into account the neurophysiological alterations of disabled individuals, investigating brain connectivity features for implementation of BCI control holds special importance. Off-the-shelf BCI systems are based on fast, reproducible detection of mental activity and can be implemented in neurorobotic applications. Moreover, social Human-Robot Interaction (HRI) is increasingly important in rehabilitation robotics development. In this paper, we present our progress and goals towards developing off-the-shelf BCI-controlled anthropomorphic robotic arms for assistive technologies and rehabilitation applications. We account for robotics development, BCI implementation, and qualitative assessment of HRI characteristics of the system. Furthermore, we present two illustrative experimental applications of the BCI-controlled arms, a study of motor imagery modalities on healthy individuals' BCI performance, and a pilot investigation on spinal cord injured patients' BCI control and brain connectivity. We discuss strengths and limitations of our design and propose further steps on development and neurophysiological study, including implementation of connectivity features as BCI modality.

[Neurofeedback-based motor imagery training for rehabilitation after stroke]

Mental training, including motor observation and motor imagery, has awakened much academic interest. The presumed functional equivalence of motor imagery and motor execution has given hope that mental training could be used for motor rehabilitation after a stroke. Results obtained from randomized controlled trials have shown mixed results. Approximately half of the studies demonstrate positive effects of motor imagery training but the rest do not show an additional benefit. Possible reasons why motor imagery training has so far not become established as a robust therapeutic approach are discussed in detail. Moreover, more recent approaches, such as neurofeedback-based motor imagery or closed-loop systems are presented and the potential importance for motor learning and rehabilitation after a stroke is discussed.

Movement visualisation in virtual reality rehabilitation of the lower limb: a systematic review

BACKGROUND

Virtual reality (VR) based applications play an increasing role in motor rehabilitation. They provide an interactive and individualized environment in addition to increased motivation during motor tasks as well as facilitating motor learning through multimodal sensory information. Several previous studies have shown positive effect of VR-based treatments for lower extremity motor rehabilitation in neurological conditions, but the characteristics of these VR applications have not been systematically investigated. The visual information on the user's movement in the virtual environment, also called movement visualisation (MV), is a key element of VR-based rehabilitation interventions. The present review proposes categorization of Movement Visualisations of VR-based rehabilitation therapy for neurological conditions and also summarises current research in lower limb application.

METHODS

A systematic search of literature on VR-based intervention for gait and balance rehabilitation in neurological conditions was performed in the databases namely; MEDLINE (Ovid), AMED, EMBASE, CINAHL, and PsycInfo. Studies using non-virtual environments or applications to improve cognitive function, activities of daily living, or psychotherapy were excluded. The VR interventions of the included studies were analysed on their MV.

RESULTS

In total 43 publications were selected based on the inclusion criteria. Seven distinct MV groups could be differentiated: indirect MV (N = 13), abstract MV (N = 11), augmented reality MV (N = 9), avatar MV (N = 5), tracking MV (N = 4), combined MV (N = 1), and no MV (N = 2). In two included articles the visualisation conditions included different MV groups within the same study. Additionally, differences in motor performance could not be analysed because of the differences in the study design. Three studies investigated different visualisations within the same MV group and hence limited information can be extracted from one study.

CONCLUSIONS

The review demonstrates that individuals' movements during VR-based motor training can be displayed in different ways. Future studies are necessary to fundamentally explore the nature of this VR information and its effect on motor outcome.

Body distortions in Anorexia Nervosa: Evidence for changed processing of multisensory bodily signals

Body size and shape distortion is a core feature of Anorexia Nervosa (AN) - patients experience their body as fat while objectively being very thin. The cause of this distortion is unclear and disturbances in body perception could be involved. Body perception comprises estimating shape and location of one's body and requires integrating multisensory signals. We investigated if and how body location perception is changed and tested 23 AN patients and 23 healthy controls (HC) in a Rubber Hand Illusion (RHI) reaching paradigm. We presented two types of multisensory conflicts (visual-proprioceptive hand location; visual-tactile touch synchrony) and tested if the impact of visual-proprioceptive and visual-tactile signals on hand location perception differs between AN and HC groups. We found significant group differences in shifts of reaching trajectories, indicating that the influence of proprioceptive signals on hand location estimates is reduced in AN. Hand location estimates were relatively more biased towards external visual information, and shorter illness durations predicted a larger visual bias. Although touch synchrony also significantly influenced hand location estimates, this effect did not differ between groups. Our findings provide compelling evidence that multisensory body location perception - specifically the processing of visual-proprioceptive signals - is changed in AN.

A preliminary investigation into psychophysiological effects of threatening a perceptually embodied rubber hand in healthy human participants

BACKGROUND AND AIMS

Threatening a perceptually embodied rubber hand with noxious stimuli has been shown to generate levels of anxiety similar to that experienced when a real hand is threatened. The aim of this study was to investigate skin conductance response, self-reported anxiety and the incidence, type and location of sensations when a perceptually embodied rubber hand was exposed to threatening and non-threatening stimuli.

METHODS

A repeated measures cross-over design was used whereby 20 participants (≥18 years, 14 females) received a threatening (syringe needle) and non-threatening (soft brush) stimulus to a perceptually embodied rubber hand. Perceptual embodiment was achieved using a soft brush to synchronously stroke the participant's real hand (out of view) and a rubber hand (in view). Then the investigator approached the rubber hand with a syringe needle (threat) or soft brush (non-threat).

RESULTS

Repeated measures ANOVA found that approaching the perceptually embodied rubber hand with either stimulus produced statistically significant reductions in the rated intensity of response to the following questions (p<0.01): 'How strongly does it feel like the rubber hand is yours?'; 'How strongly does it feel like the rubber hand is part of your body?'; and 'How strongly does it feel you can move the rubber hand?'. However, there were no statistically significant differences in scores between needle and brush stimuli. Repeated measures ANOVA on skin conductance response found statistically significant effects for experimental Events (baseline; stroking; perceptual embodiment; stimuli approaching rubber hand; stimuli touching rubber hand; p<0.001) but not for Condition (needle versus brush p=0.964) or experimental Event×Condition interaction (p=0.160). Ten of the 20 participants (50%) reported that they experienced a sensation arising from the rubber hand when the rubber hand was approached and touched by either the needle and/or brush but these sensations lacked precision in location, timing, and nature.

CONCLUSION AND IMPLICATIONS

Our preliminary findings suggest that the increase in arousal in response to stimuli entering the peripersonal space may not be selective for threat. There was tentative evidence that more intense sensations were experienced when a perceptually embodied rubber hand was approached by a threatening stimulus. Our findings provide initial insights and should serve as a catalyst for further research.

Crossmodal illusions in neurorehabilitation

In everyday life, many diverse bits of information, simultaneously derived from the different sensory channels, converge into discrete brain areas, and are ultimately synthetized into unified percepts. Such multisensory integration can dramatically alter the phenomenal experience of both environmental events and our own body. Crossmodal illusions are one intriguing product of multisensory integration. This review describes and discusses the main clinical applications of the most known crossmodal illusions in rehabilitation settings. We consider evidence highlighting the contribution of crossmodal illusions to restore, at least in part, defective mechanisms underlying a number of disorders of body representation related to pain, sensory, and motor impairments in neuropsychological and neurological diseases, and their use for improving neuroprosthetics. This line of research is enriching our understanding of the relationships between multisensory functions and the pathophysiological mechanisms at the basis of a number of brain disorders. The review illustrates the potential of crossmodal illusions for restoring disarranged spatial and body representations, and, in turn, different pathological symptoms.

An Investigation of the Effects of Different Pulse Patterns of Transcutaneous Electrical Nerve Stimulation (TENS) on Perceptual Embodiment of a Rubber Hand in Healthy Human Participants With Intact Limbs

OBJECTIVE

The aim of this study was to investigate the strength of perceptual embodiment achieved during an adapted version of the rubber hand illusion (RHI) in response to a series of modified transcutaneous electrical nerve stimulation (TENS) pulse patterns with dynamic temporal and spatial characteristics which are more akin to the mechanical brush stroke in the original RHI.

MATERIALS AND METHODS

A repeated-measures counterbalanced experimental study was conducted where each participant was exposed to four TENS interventions: continuous pattern TENS; burst pattern TENS (fixed frequency of 2 bursts per second of 100 pulses per second); amplitude-modulated pattern TENS (intensity increasing from zero to a preset level, then back to zero again in a cyclical fashion); and sham (no current) TENS. Participants rated the intensity of the RHI using a three-item numerical rating scale (each item was ranked from 0 to 10). Friedman's analysis of ranks (one-factor repeated measure) was used to test the differences in perceptual embodiment between TENS innervations; alpha was set at p ≤ 0.05.

RESULTS

There were statistically significant differences in the intensity of misattribution and perceptual embodiment between sham and active TENS interventions, but no significant differences between the three active TENS conditions (amplitude-modulated TENS, burst TENS, and continuous TENS). Amplitude-modulated and burst TENS produced significantly higher intensity scores for misattribution sensation and perceptual embodiment compared with sham (no current) TENS, whereas continuous TENS did not.

CONCLUSION

The findings provide tentative, but not definitive, evidence that TENS parameters with dynamic spatial and temporal characteristics may produce more intense misattribution sensations and intense perceptual embodiment than parameters with static characteristics (e.g., continuous pulse patterns).