Virtual Reality and Active Video Game Integration within an Intensive Bimanual Therapy Program for Children with Hemiplegia.

AIMS: To describe the nature of custom and non-custom virtual reality and active video game (VR/AVG) implementation within a Hand-Arm Bimanual Intensive Therapy Including Lower Extremities (HABIT-ILE) intervention program for children with hemiplegia. METHODS: Six children aged 8-11 years participated in a 10-day HABIT-ILE intervention (65 h; 6.5 planned VR/AVG hours). VR/AVG implementation details were recorded daily and summarized with descriptive statistics; active motor engagement was quantified as minutes of active game participation. Post-intervention interviews with interventionists were analyzed with qualitative content analysis. RESULTS: On average, participants received 79% of the planned VR/AVG dosage (314/400 planned minutes, range 214-400 min), of which the per-session active motor engagement average was 68% (27 min, SD 12 min). Participation involved equivalent amounts of custom (49%) and non-custom (51%) VR/AVG system use. Material and verbal adaptations facilitated alignment with HABIT-ILE principles. Interventionists identified type of task (gross versus fine motor), children's perceived motivation, and VR/AVG attributes as factors influencing active motor engagement and alignment with HABIT-ILE principles. CONCLUSIONS: Describing individual and technological challenges of VR/AVG integration within HABIT-ILE can advance knowledge about VR/AVG use in intensive interventions and identify directions for subsequent research.

Do Exercise Programs Improve Fitness, Mobility, and Functional Capacity in Adults With Lower Limb Amputation? A Systematic Review on the Type and Minimal Dose Needed.

OBJECTIVE: To answer the following questions: (1) Do physical activity (PA) and exercise improve fitness, mobility, and functional capacity among adults with lower limb amputation (LLA) and (2) What is the type and minimum dose of PA (frequency, intensity and duration) needed? DESIGN: Systematic review. SETTING: Outpatient intervention, outside of the prosthetic rehabilitation phase. PARTICIPANTS: Adults with lower limb amputation living in the community. INTERVENTION: Any physical activity or exercise intervention. OUTCOMES AND MEASURES: Any fitness, mobility, or functional capacity indicators and measurements. RESULTS: Twenty-three studies were included, totaling 408 adults with LLA. Studies evaluated the effect of structured PA sessions on fitness, mobility, and functional capacity. The highest evidence is for mixed exercise programs, that is, programs combining aerobic exercise with strengthening or balance exercise. There is moderate confidence that 1-3 sessions of 20-60 minutes of exercise per week improves balance, walking speed, walking endurance, and transfer ability in adults with LLA above the ankle. As for flexibility, cardiorespiratory health, lower-limb muscles strength, and functional capacity, there was low confidence that exercise improves these fitness components because of the lack of studies. CONCLUSION: Exercise 1-3 times per week may improve balance, walking speed, walking endurance, and transfer ability in adults with LLA, especially when combining aerobic exercises with lower limb strengthening or balance exercises. There is a need for most robust studies focusing on the effect of PA on cardiorespiratory health, muscles strength, flexibility, and functional status.

The Challenge of Diffusion Magnetic Resonance Imaging in Cerebral Palsy: A Proposed Method to Identify White Matter Pathways.

Cerebral palsy (CP), a neuromotor disorder characterized by prenatal brain lesions, leads to white matter alterations and sensorimotor deficits. However, the CP-related diffusion neuroimaging literature lacks rigorous and consensual methodology for preprocessing and analyzing data due to methodological challenges caused by the lesion extent. Advanced methods are available to reconstruct diffusion signals and can update current advances in CP. Our study demonstrates the feasibility of analyzing diffusion CP data using a standardized and open-source pipeline. Eight children with CP (8-12 years old) underwent a single diffusion magnetic resonance imaging (MRI) session on a 3T scanner (Achieva 3.0T (TX), Philips Healthcare Medical Systems, Best, The Netherlands). Exclusion criteria were contraindication to MRI and claustrophobia. Anatomical and diffusion images were acquired. Data were corrected and analyzed using Tractoflow 2.3.0 version, an open-source and robust tool. The tracts were extracted with customized procedures based on existing atlases and freely accessed standardized libraries (ANTs, Scilpy). DTI, CSD, and NODDI metrics were computed for each tract. Despite lesion heterogeneity and size, we successfully reconstructed major pathways, except for a participant with a larger lesion. Our results highlight the feasibility of identifying and quantifying subtle white matter pathways. Ultimately, this will increase our understanding of the clinical symptoms to provide precision medicine and optimize rehabilitation.

Feedback for the prevention and rehabilitation of work-related musculoskeletal disorders: A systematic review.

BACKGROUND: Work-related musculoskeletal disorders (WRMSDs) remain a challenge despite research aimed at improving their prevention and treatment. Extrinsic feedback has been suggested for the prevention and rehabilitation of WRMSDs to improve sensorimotor control, and ultimately to reduce pain and disability. However, there are few systematic reviews on the effectiveness of extrinsic feedback for WRMSDs. OBJECTIVE: To perform a systematic review investigating the effect of extrinsic feedback for the prevention and rehabilitation of WRMSDs. METHODS: Five databases (CINAHL, Embase, Ergonomics Abstract, PsycInfo, PubMed) were searched. Studies of various designs assessing the effects of extrinsic feedback during work tasks on three outcomes (function, symptoms, sensorimotor control) in the context of prevention and rehabilitation of WRMSDs were included. RESULTS: Forty-nine studies were included, for a total sample of 3387 participants (including 925 injured) who performed work-related tasks in the workplace (27 studies) or in controlled environments (22 studies). The use of extrinsic feedback was shown to be effective in controlled environments for short-term prevention of functional limitations and sensorimotor alterations (very limited to moderate evidence) and for improving, in injured participants, function, symptoms and sensorimotor control (moderate evidence). In the workplace, it was shown to be effective for short-term prevention of functional limitations (limited evidence). There was conflicting evidence regarding its effect for WRMSD rehabilitation in the workplace. CONCLUSION: Extrinsic feedback is an interesting complementary tool for the prevention and rehabilitation of WRMSDs in controlled environments. More evidence is needed regarding its effect for the prevention and rehabilitation of WRMSDs in the workplace.

Influence of daily physical activity on fine motor skills of adults around a Fitts task.

INTRODUCTION: Achieving our daily tasks depends on the speed-accuracy conflict. Physical activity plays a role in the development of our motor skills. However, the relationship between physical activity level (PAL) and fine motor skills remains largely unexplored.

Evaluation of pediatric-specific resources to support utilization of the Wheelchair Skills Training Program by the users of the resources: a descriptive qualitative study.

BACKGROUND: Children's ability to engage in meaningful activities is positively influenced by their ability to move independently. Preliminary evidence in children suggests that wheelchair skills training improves wheelchair skills, which are important for independent mobility. The Wheelchair Skills Training Program is a standardized program to teach wheelchair skills. However, it is underutilized in pediatric rehabilitation settings. To increase its utilization, 3 pediatric-specific Wheelchair Skills Training Program resources related to indoor skills were developed (i.e., a storybook, four instructional posters, and a training workbook). This study aimed to describe occupational therapists' (OTs) and pediatric manual wheelchair users' (PMWUs) perceived satisfaction with the storybook, instructional posters and training workbook, and to explore their perceptions regarding the usability, relevance, and feasibility of these resources in pediatric rehabilitation settings. METHODS: A descriptive qualitative design was used. Convenience samples of OTs and PMWUs were recruited in a rehabilitation center and affiliated schools. A focus group with OTs and semi-structured interviews with PMWUs were conducted by videoconference to obtain participants' feedback on the resource prototypes and suggestions for improvement. Data were deductively analyzed using the Framework method. RESULTS: Eight OTs and 5 PMWUs expressed general satisfaction with the resources, describing them as usable, relevant, and feasible to integrate into wheelchair skills training with novice wheelchair users and younger children. All OTs and 3 PMWUs expressed the desire to use the resources for wheelchair skills training. Two PMWUs perceived the resources were not relevant to them because they already mastered the skills. The participants suggested minor modifications for improving the resources (e.g., more action in the story, increased precision of illustrations related to the characters' position in the wheelchair). CONCLUSION: OTs and PMWUs were satisfied with the resources, perceiving them to be applicable for training wheelchair skills among young children and novice wheelchair users. The resources represent a concrete solution to facilitate the use of the Wheelchair Skills Training Program in pediatric rehabilitation settings. Additional resources are needed to better reach older and more experienced PMWUs (i.e., of intermediate and advanced skill levels).

HABIT+tDCS: a study protocol of a randomised controlled trial (RCT) investigating the synergistic efficacy of hand-arm bimanual intensive therapy (HABIT) plus targeted non-invasive brain stimulation to improve upper extremity function in school-age children with unilateral cerebral palsy.

INTRODUCTION: Unilateral spastic cerebral palsy (USCP) is characterised by movement deficits primarily on one body side. The best available upper extremity (UE) therapies are costly and intensive. Thus, there is an urgent need for better, more efficient and thus more accessible therapies. Transcranial direct current stimulation (tDCS) is non-invasive and may enhance physical rehabilitation approaches. The aim of this study is to determine whether tDCS targeted to the hemisphere with corticospinal tract (CST) connectivity enhances the efficacy of UE training in children with USCP. Our central hypothesis is that hand-arm bimanual intensive therapy (HABIT) combined with a tDCS montage targeting the hemisphere with CST connectivity to the impaired UE muscles will improve UE function more than HABIT plus sham stimulation. We will test this by conducting a randomised clinical trial with clinical and motor cortex physiology outcomes. METHODS AND ANALYSES: 81 children, aged 6-17 years, will be randomised to receive 2 mA anodal tDCS targeted to the affected UE motor map, 2 mA cathodal tDCS to the contralesional motor cortex or sham tDCS during the first 20 min of each HABIT session (10 hours: 2 hours/day for 5 days). Primary outcomes will be Box and Blocks Test, Assisting Hand Assessment and motor cortex excitability, determined with single-pulse transcranial magnetic stimulation. Secondary outcomes include ABILHAND-Kids, Canadian Occupational Performance Measure, Cooper Stereognosis, Dimension of Mastery Questionnaire and Participation and Environment Measure-Children and Youth. All measures will be collected before, immediately and 6 months after treatment. A group × test session Analysis of Variance will test differences among groups on all measures. ETHICS AND DISSEMINATION: The study has been approved by the BRANY Institutional Review Board (#18-10-285-512). We will leverage our subject and family relationships to maximise dissemination and share results with the academic and patient/family advocacy groups. TRIAL REGISTRATION NUMBER: NCT03402854.

Upper Limb Motor Planning in Individuals with Cerebral Palsy Aged between 3 and 21 Years Old: A Systematic Review.

Individuals with cerebral palsy have difficulties performing activities of daily living. Beyond motor execution impairments, they exhibit motor planning deficits contributing to their difficulties. The objective of this review is to synthesize the behavioral evidence of motor planning deficits during an upper limb motor task in children, adolescents and young adults with cerebral palsy aged between 3 and 21 years. METHODS: The inclusion criteria were: (1) including individuals with cerebral palsy from 3 to 21 years old; (2) assessing upper limb motor planning. Six databases were screened. The quality assessment of the studies was performed. RESULTS: Forty-six studies and 686 participants were included. Five articles have been identified as very high quality, 12 as high, 20 as moderate, six as low, three as very low. Force planning studies reported a deficit for the more affected hand but adequate performances for the less affected hand. Object-manipulation studies reported hand posture planning deficits irrespectively of the hand assessed. CONCLUSIONS: Motor planning deficits has been shown in the more affected hand for force scaling, while the results for other variables showed overall deficits. Hence, variables affected by motor planning deficits in both hands should be considered in children with cerebral palsy to optimize intervention.

Impact of Sensory Deficits on Upper Limb Motor Performance in Individuals with Cerebral Palsy: A Systematic Review.

People living with cerebral palsy (CP) exhibit motor and sensory impairments that affect unimanual and bimanual functions. The importance of sensory functions for motor control is well known, but the association between motor and sensory functions remains unclear in people living with CP. The objective of this systematic review was to characterize the relationship between sensory deficits and upper limb motor function in individuals living with CP. METHODS: Five databases were screened. The inclusion criteria were: (1) including people living with CP, (2) reporting measurements of upper limb motor and sensory functions. A qualitative analysis of the studies' level of evidence was done. RESULTS: Thirty-three articles were included. Twenty-five articles evaluated tactile functions, 10 proprioceptive functions and 7 visual functions; 31 of the articles reported on unimanual functions and 17 of them reported on bimanual functions. Tactile functions showed a moderate to high association; it was not possible to reach definitive conclusions for proprioceptive and visual functions. CONCLUSIONS: The heterogeneity of the results limits the ability to draw definitive conclusions. Further studies should aim to perform more comprehensive assessments of motor and sensory functions, to determine the relative contribution of various sensory modalities to simple and more complex motor functions.

Intensive Bimanual Intervention for Children Who Have Undergone Hemispherectomy: A Pilot Study.

PURPOSE: To conduct a pilot study to assess the feasibility and effectiveness of an intensive bimanual intervention on upper limb function in children who have undergone hemispherectomy. METHODS: Thirteen children received 90 hours of intensive bimanual training (Hand-Arm Bimanual Intensive Therapy, HABIT). The Jebsen-Taylor Test of Hand Function (JTTHF), Box and Block Test (BBT), Assisting Hand Assessment (AHA), ABILHAND-Kids, and Canadian Occupational Performance Measure (COPM) were assessed by a masked clinician twice before, immediately, and 6 months after treatment. RESULTS: Significant improvements over time were found in the JTTHF, AHA, ABILHAND-Kids, and COPM. CONCLUSION: Completion of HABIT was feasible for children with hemispherectomy. Improvement of bimanual function and functional goals can be related to the nature of the activities prioritized in HABIT training.

Corpus Callosum Integrity Relates to Improvement of Upper-Extremity Function Following Intensive Rehabilitation in Children With Unilateral Spastic Cerebral Palsy.

BACKGROUND: The corpus callosum (CC) plays an important role in upper extremity (UE) function. The impact on UE function in children with unilateral spastic cerebral palsy (USCP) and improvements following intensive interventions remain unknown. OBJECTIVES: To examine the (1) relationship between UE function and CC integrity and (2) relationship between CC integrity and changes in UE function following intensive interventions. METHODS: We retrospectively analyzed clinical and neuroimaging data from a sample of convenience of 44 participants (age 9.40 ± 3.10 years) from 2 larger trials. Participants received 90 hours of Hand-Arm Bimanual Intensive Therapy (HABIT) or Constraint-Induced Movement Therapy (CIMT). Unimanual dexterity (Jebsen-Taylor Test of Hand Function [JTTHF]) and bimanual performance (Assisting Hand Assessment [AHA]) were assessed preintervention and postintervention. CC tractography was reconstructed with diffusion tensor imaging (DTI) and segmented into 3 regions (genu, midbody, splenium). Pearson correlations and regression were used to assess the relationship between outcomes and DTI parameters (ie, fractional anisotropy [FA], number of streamlines, and mean, radial, and axial diffusivity). RESULTS: Both groups improved in bimanual performance (P < .01). The CIMT group improved in unimanual dexterity (P < .01). Baseline unimanual dexterity and bimanual performance correlated with FA and number of streamlines for most CC regions (P < .05). Following CIMT, pre-post changes in JTTHF were negatively correlated with axial and radial diffusivity of the CC, and AHA with splenium and number of streamlines for the CC, midbody, and splenium (all P < .05). Following HABIT, midbody FA was positively correlated with pre-post AHA changes (r = 0.417; P = .042). CONCLUSIONS: CC integrity is important for UE function in children with USCP.

Improvements in Upper Extremity Function Following Intensive Training Are Independent of Corticospinal Tract Organization in Children With Unilateral Spastic Cerebral Palsy: A Clinical Randomized Trial.

Background/Objectives: Intensive training of the more affected upper extremity (UE) has been shown to be effective for children with unilateral spastic cerebral palsy (USCP). Two types of UE training have been particularly successful: Constraint-Induced Movement Therapy (CIMT) and Bimanual training. Reorganization of the corticospinal tract (CST) early during development often occurs in USCP. Prior studies have suggested that children with an ipsilateral CST controlling the affected UE may improve less following CIMT than children with a contralateral CST. We tested the hypothesis that improvements in UE function after intensive training depend on CST laterality. Study Participants and Setting: Eighty-two children with USCP, age 5 years 10 months to 17 years, University laboratory setting. Materials/Methods: Single-pulse transcranial magnetic stimulation (TMS) was used to determine each child's CST connectivity pattern. Children were stratified by age, sex, baseline hand function and CST connectivity pattern, and randomized to receive either CIMT or Bimanual training, each of which were provided in a day-camp setting (90 h). Hand function was tested before, immediately and 6 months after the intervention with the Jebsen-Taylor Test of Hand Function, the Assisting Hand Assessment, the Box and Block Test, and ABILHAND-Kids. The Canadian Occupational Performance Measure was used to track goal achievement and the Pediatric Evaluation of Disability Inventory was used to assess functioning in daily living activities at home. Results: In contrast to our hypothesis, participants had statistically similar improvements for both CIMT and Bimanual training for all measures independent of their CST connectivity pattern (contralateral, ipsilateral, or bilateral) (p < 0.05 in all cases). Conclusions/Significance: The efficacy of CIMT and Bimanual training is independent of CST connectivity pattern. Children with an ipsilateral CST, previously thought to be maladaptive, have the capacity to improve as well as children with a contralateral or bilateral CST following intensive CIMT or Bimanual training. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02918890.

Integration of Motor Learning Principles Into Virtual Reality Interventions for Individuals With Cerebral Palsy: Systematic Review.

BACKGROUND: Increasing evidence supports the use of virtual reality systems to improve upper limb motor functions in individuals with cerebral palsy. While virtual reality offers the possibility to include key components to promote motor learning, it remains unclear if and how motor learning principles are incorporated into the development of rehabilitation interventions using virtual reality. OBJECTIVE: The objective of this study was to determine the extent to which motor learning principles are integrated into virtual reality interventions targeting upper limb function in individuals with cerebral palsy. METHODS: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search was performed in 10 databases using a combination of keywords related to cerebral palsy, virtual reality, video games, and rehabilitation. Studies were divided into 2 categories: commercial video game platforms and devices and custom virtual reality systems. Study quality was assessed using the modified Downs and Black checklist. RESULTS: The initial search yielded 1497 publications. A total of 26 studies from 30 publications were included, with most studies classified as "fair" according to the modified Downs and Black checklist. The majority of studies provided enhanced feedback and variable practice and used functionally relevant and motivating virtual tasks. The dosage varied greatly (total training time ranged from 300 to 3360 minutes), with only 6 studies reporting the number of movement repetitions per session. The difficulty progression and the assessment of skills retention and transfer were poorly incorporated, especially for the commercial video games. CONCLUSIONS: Motor learning principles should be better integrated into the development of future virtual reality systems for optimal upper limb motor recovery in individuals with cerebral palsy. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42020151982; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020151982.

Active Video Games and Low-Cost Virtual Reality: An Ideal Therapeutic Modality for Children With Physical Disabilities During a Global Pandemic.

Current guidelines against spread of coronavirus (COVID-19) interrupt non-essential rehabilitation services. Thus, individuals with physical disabilities such as children with cerebral palsy can no longer benefit from physical rehabilitation during this undetermined period. Using either a synchronous or asynchronous format, in collaboration with a therapist via telerehabilitation, we suggest that active video games and low-cost virtual reality are a promising delivery mode for at-home rehabilitation in the context of a global pandemic. This therapeutic modality, incorporated into an at-home individualized treatment plan, provides a means to lessen the impact of an interruption in rehabilitation services while not loosing the pre-pandemic, in-person physical activity gains. Growing evidence supports active video games and low-cost virtual reality as viable therapeutic interventions for children with physical disabilities. These technologies are especially well-accepted by pediatric populations for the ludic and motivating features that lend themselves to nearly seamless incorporation into telerehabilitation. Advantages for rehabilitation of active video games and low-cost virtual reality include a rich, challenging, multi-modal training environment in which high numbers of movement repetitions can be accomplished, and a unique opportunity to foster engaged practice actions that go beyond household activities. We offer suggestions for the clinician about how to adopt active video games and low-cost virtual reality into your practice during a global pandemic.

Relationship Between Integrity of the Corpus Callosum and Bimanual Coordination in Children With Unilateral Spastic Cerebral Palsy.

Children with unilateral spastic cerebral palsy (USCP) have shown impaired bimanual coordination. The corpus callosum (CC) connects the two hemispheres and is critical for tasks that require inter-hemisphere communication. The relationship between the functional bimanual coordination impairments and structural integrity of the CC is unclear. We hypothesized that better integrity of the CC would relate to better bimanual coordination performance during a kinematic bimanual drawer-opening task. Thirty-nine children with USCP (Age: 6-17 years old; MACS levels: I-III) participated in the study. Measurement of the CC integrity was performed using diffusion tensor imaging. The CC was measured as a whole and was also divided into three regions: genu, midbody, and splenium. Fractional anisotropy, axial diffusivity (AD), radial diffusivity, mean diffusivity, number of voxels, and number of streamlines were evaluated in whole and within each region of the CC. 3-D kinematic analyses of bimanual coordination were also assessed while children performed the bimanual task. There were negative correlations between bimanual coordination measures of total movement time and AD of whole CC (p = 0.037), number of streamlines and voxels of splenium (p = 0.038, 0.032, respectively); goal synchronization and AD of whole CC (p = 0.04), and number of streamlines and voxels of splenium (p = 0.001, 0.01, respectively). The current results highlight the possible connection between the integrity of the CC, especially between the splenium region and temporal bimanual coordination performance for children with USCP.

Gait Segmentation of Data Collected by Instrumented Shoes Using a Recurrent Neural Network Classifier.

The authors present a Recurrent Neural Network classifier model that segments the walking data recorded with instrumented footwear. The signals from 3 piezoresistive sensors, a 3-axis accelerometer, and Euler angles are used to generate temporal gait characteristics of a user. The model was tested using a data set collected from 28 adults containing 4198 steps. The mean errors for heel strikes and toe-offs were -5.9 ± 37.1 and 11.4 ± 47.4 milliseconds. These small errors show that the algorithm can be reliably used to segment the gait recordings and to use this segmentation to estimate temporal parameters of the subjects.

Validation of reaching in a virtual environment in typically developing children and children with mild unilateral cerebral palsy.

AIM: To compare three reaching movements made in two planes between a low-cost, game-based virtual reality and a matched physical environment in typically developing children and children with cerebral palsy (CP). To determine if differences in kinematics are related to sensory deficits. METHOD: An observational study in which 27 children (typically developing, n=17, mean age 13y, [SD] 2y 2mo, range 9y 3mo-17y 2mo; CP, n=10, mean age 13y 8mo, [SD] 1y 8mo, range 11y 1mo-17y 1mo, Manual Ability Classification System levels I-II) performed 15 trials of three gestures in each of a virtual reality and a matched physical environment. Upper-limb and trunk kinematics were recorded using an electromagnetic system (G4, Polhemus, six markers, 120Hz). RESULTS: Compared to the physical environment, movements in virtual reality made by typically developing children were slower (p=0.002), and involved less trunk flexion (p=0.002) and rotation (p=0.026). Children with CP had more curved trajectories (p=0.005) and used less trunk flexion (p=0.003) and rotation (p=0.005). Elbow and shoulder kinematics differed from 2.8% to 155.4% between environments in both groups. Between groups, there were small, clinically insignificant differences with only the vertical gesture being longer in typically developing children. Children with CP who had greater tactile impairment used more trunk displacement. INTERPRETATION: Clinicians and researchers need to be aware of differences in movement variables when setting goals or designing protocols for improving reaching in children with CP using low-cost, game-based virtual reality systems. WHAT THIS PAPER ADDS: Upper-limb kinematics differed in each group when reaching in physical versus virtual environments. There were small differences in movements made by children with mild unilateral cerebral palsy (CP) compared to typically developing children. Differences in reaching kinematics should be considered when goal setting using virtual reality interventions for children with mild unilateral CP.

Extrinsic feedback and upper limb motor skill learning in typically-developing children and children with cerebral palsy: Review.

BACKGROUND: Improvment of upper limb motor skills occurs through motor learning that can be enhanced by providing extrinsic feedback. Different types and frequencies of feedback are discussed but specific guidelines for use of feedback for motor learning in typically-developing (TD) children and children with Cerebral Palsy (CP) are not available. OBJECTIVE: Identify the most effective modalities and frequencies of feedback for improving upper limb motor skills in TD children and children with CP. METHODS: Ovid MEDLINE, Cochrane, PEDro and PubMed-NCBI were searched from 1950 to December 2015 to identify English-language articles addressing the role of extrinsic feedback on upper limb motor learning in TD children and children with CP. Nine studies were selected with a total of 243 TD children and 102 children with CP. Study quality was evaluated using the Downs and Black scale and levels of evidence were determined with Sackett's quality ratings. RESULTS: There was a lack of consistency in the modalities and frequencies of feedback delivery used to improve motor learning in TD children and in children with CP. Moreover, the complexity of the task to be learned influenced the degree of motor learning achieved. CONCLUSION: A better understanding of the influence of feedback on motor learning is needed to optimize motor skill acquisition in children with CP.

The effect of viewing a virtual environment through a head-mounted display on balance.

INTRODUCTION: In the next few years, several head-mounted displays (HMD) will be publicly released making virtual reality more accessible. HMD are expected to be widely popular at home for gaming but also in clinical settings, notably for training and rehabilitation. HMD can be used in both seated and standing positions; however, presently, the impact of HMD on balance remains largely unknown. It is therefore crucial to examine the impact of viewing a virtual environment through a HMD on standing balance. OBJECTIVES: To compare static and dynamic balance in a virtual environment perceived through a HMD and the physical environment. The visual representation of the virtual environment was based on filmed image of the physical environment and was therefore highly similar. DESIGN: This is an observational study in healthy adults. RESULTS: No significant difference was observed between the two environments for static balance. However, dynamic balance was more perturbed in the virtual environment when compared to that of the physical environment. CONCLUSIONS: HMD should be used with caution because of its detrimental impact on dynamic balance. Sensorimotor conflict possibly explains the impact of HMD on balance.