An innovative therapeutic educational program to support older drivers with cognitive disorders: Description of a randomized controlled trial study protocol.

Older drivers face the prospect of having to adjust their driving habits because of health problems, which can include neurocognitive disorders. Self-awareness of driving difficulties and the interaction between individual with neurocognitive disorders and natural caregiver seem to be important levers for the implementation of adaptation strategies and for the subsequent voluntary cessation of driving when the cognitive disorders become too severe. This study aims to evaluate an educational program for patient/natural caregiver dyads who wish to implement self-regulation strategies in driving activity, and to improve self-awareness of driving ability. The ACCOMPAGNE program is based on seven group workshops, which target the dyad. The workshops deal with the impact of cognitive, sensory and iatrogenic disorders on driving. They tackle questions about responsibility, and about autonomy and social life. They also provide alternative solutions aimed at maintaining outward-looking activities even if driving is reduced or stopped. A randomized controlled trial is planned to evaluate the effectiveness of the program 2 months and 6 months after inclusion, and to compare this to the effectiveness of conventional approaches. The main outcome of this trial (i.e., the implementation of self-regulated driving strategies), will be measured based on scores on the "Current Self-Regulatory Practices" subscale of the Driver Perception and Practices Questionnaire. The Driving Habits Questionnaire will be used to measure secondary outcomes (indicators of driving changes; indicators of changes in mood, quality of life and caregiver burden; and self-awareness of driving abilities). Indicators will be collected for both patients and natural caregivers. This cognitive, social and psychological program should allow older individuals with cognitive disorders to drive more safely, and help to maintain the quality of life and mood of both patient and natural caregiver despite driving limitations. The patient's care path would be optimized, as he/she would become an actor in the process of giving up driving, which will, most certainly, be needed at some point in the progress of neurocognitive disorders. This process ranges from becoming aware of driving difficulties, to implementing self-regulation strategies, through to complete cessation of driving when necessary. Clinical trial registration number: NCT04493957.

Involvement of visual signals in kinaesthesia: A virtual reality study.

Body movements are invariably accompanied by various proprioceptive, visual, tactile and/or motor signals. It is therefore difficult to completely dissociate these various signals from each other in order to study their specific involvement in the perception of movement (kinaesthesia). Here, we manipulated visual motion signals in a virtual reality display by using a humanoid avatar. The visual signals of movement could therefore be manipulated freely, relative to the participant's actual movement or lack of movement. After an embodiment phase in which the avatar's movements were coupled to the participant's voluntary movements, kinaesthetic illusions were evoked by moving the avatar's right forearm (flexion or extension) while the participant's right arm remained static. The avatar's left forearm was hidden from view. In parallel, somaesthetic signals could be masked by agonist-antagonist co-vibration or be amplified (by agonist vibration only or antagonist vibration only) so that the real impact of visual cues of movement in kinaesthesia could be studied. In a study of 24 participants, masking the somaesthetic signals (which otherwise provide signals indicating that the arm is static) was associated with a greater intensity and shorter latency of the visually evoked illusions. These results confirm the importance of carefully considering somaesthetic signals when assessing the contribution of vision to kinaesthesia. The use of a combination of virtual reality and somaesthetic signal manipulation might be of clinical value.

Multisensory integration of visual cues from first- to third-person perspective avatars in the perception of self-motion.

In the perception of self-motion, visual cues originating from an embodied humanoid avatar seen from a first-person perspective (1st-PP) are processed in the same way as those originating from a person's own body. Here, we sought to determine whether the user's and avatar's bodies in virtual reality have to be colocalized for this visual integration. In Experiment 1, participants saw a whole-body avatar in a virtual mirror facing them. The mirror perspective could be supplemented with a fully visible 1st-PP avatar or a suggested one (with the arms hidden by a virtual board). In Experiment 2, the avatar was viewed from the mirror perspective or a third-person perspective (3rd-PP) rotated 90° left or right. During an initial embodiment phase in both experiments, the avatar's forearms faithfully reproduced the participant's real movements. Next, kinaesthetic illusions were induced on the static right arm from the vision of passive displacements of the avatar's arms enhanced by passive displacement of the participant's left arm. Results showed that this manipulation elicited kinaesthetic illusions regardless of the avatar's perspective in Experiments 1 and 2. However, illusions were more likely to occur when the mirror perspective was supplemented with the view of the 1st-PP avatar's body than with the mirror perspective only (Experiment 1), just as they are more likely to occur in the latter condition than with the 3rd-PP (Experiment 2). Our results show that colocalization of the user's and avatar's bodies is an important, but not essential, factor in visual integration for self-motion perception.

Functional properties of extended body representations in the context of kinesthesia.

A person's internal representation of his/her body is not fixed. It can be substantially modified by neurological injuries and can also be extended (in healthy participants) to incorporate objects that have a corporeal appearance (such as fake body segments, e.g. a rubber hand), virtual whole bodies (e.g. avatars), and even objects that do not have a corporeal appearance (e.g. tools). Here, we report data from patients and healthy participants that emphasize the flexible nature of body representation and question the extent to which incorporated objects have the same functional properties as biological body parts. Our data shed new light by highlighting the involvement of visual motion information from incorporated objects (rubber hands, full body avatars and hand-held tools) in the perception of one's own movement (kinesthesia). On the basis of these findings, we argue that incorporated objects can be treated as body parts, especially when kinesthesia is involved.

From Embodiment of a Point-Light Display in Virtual Reality to Perception of One's Own Movements.

Humans can recognize living organisms and understand their actions solely on the basis of a small animated set of well-positioned points of light, i.e. by recognizing biological motion. Our aim was to determine whether this type of recognition and integration also occurs during the perception of one's own movements. The participants (60 females) were immersed with a virtual reality headset in a virtual environment, either dark or illuminated, in which they could see a humanoid avatar from a first-person perspective. The avatar's forearms were either realistic or represented by three points of light. Embodiment was successfully achieved through a 1-min period during which either the realistic or point-light avatar's forearms faithfully reproduced voluntary flexion-extension movements. Then, the "virtual mirror paradigm" was used to evoke kinesthetic illusions. In this paradigm, a passive flexion-extension of the participant's left arm was coupled with the movements of the avatar's forearms. This combined visuo-proprioceptive stimulation, was compared with unimodal stimulation (either visual or proprioceptive stimulation only). We found that combined visuo-proprioceptive stimulation with realistic avatars evoked more vivid kinesthetic illusions of a moving right forearm than unimodal stimulations, regardless of whether the virtual environment was dark or illuminated. Kinesthetic illusions also occurred with point-light avatars, albeit less frequently and a little less intense, and only when the visual environment was optimal for slow motion detection of the point-light display (lit environment). We conclude that kinesthesia does not require visual access to an elaborate representation of a body segment. Access to biological movement can be sufficient.

The respective contributions of visual and proprioceptive afferents to the mirror illusion in virtual reality.

The reflection of passive arm displacement in a mirror is a powerful means of inducing a kinaesthetic illusion in the static arm hidden behind the mirror. Our recent research findings suggest that this illusion is not solely visual in origin but results from the combination of visual and proprioceptive signals from the two arms. To determine the respective contributions of visual and proprioceptive signals to this illusion, we reproduced the mirror paradigm in virtual reality. As in the physical version of the mirror paradigm, one of the participant's arms (the left arm, in our study) could be flexed or extended passively. This movement was combined with displacements of the avatar's left and right forearms, as viewed in a first-person perspective through a virtual reality headset. In order to distinguish between visual and proprioceptive contributions, two unimodal conditions were applied separately: displacement of the avatar's forearms in the absence of physical displacement of the left arm (the visual condition), and displacement of the left forearm while the avatar's forearms were masked (the proprioceptive condition). Of the 34 female participants included in the study, 28 experienced a kinaesthetic mirror illusion in their static (right) arm. The strength of the illusion (expressed in terms of speed and duration) evoked by the bimodal condition was much higher than that observed in either of the two unimodal conditions. Our present results confirm that the involvement of visual signals in the mirror illusion-often considered as a prototypic visual illusion-has been overstated. The mirror illusion also involves non-visual signals (bilateral proprioceptive-somaesthetic signals, in fact) that interact with the visual signals and strengthen the kinaesthetic effect.