Relationship Between Baseline Rectal Tumor Length and Magnetic Resonance Tumor Regression Grade Response to Chemoradiotherapy: A Subanalysis of the TRIGGER Feasibility Study.

BACKGROUND: It is widely believed that small rectal tumors are more likely to have a good response to neoadjuvant treatment, which may influence the selection of patients for a 'watch and wait' strategy. OBJECTIVE: The aim of this study was to investigate whether there is a relationship between baseline tumor length on magnetic resonance imaging (MRI) and response to chemoradiotherapy. METHOD: The 96 patients with locally advanced rectal cancer randomised (2:1-intervention:control) in the TRIGGER feasibility study where eligible. Baseline tumor length was defined as the maximal cranio-caudal length on baseline MRI (mm) and was recorded prospectively at study registration. Magnetic resonance tumor regression grade (mrTRG) assessment was performed on the post-chemoradiotherapy (CRT) MRI 4-6 weeks (no later than 10 weeks) post completion of CRT. This was routinely reported for patients in the intervention (mrTRG-directed management) arm and reported for the purposes of this study by the central radiologist in the control arm patients. Those with an mrTRG I/II response were defined as 'good responders' and those with an mrTRG III-V response were defined as 'poor responders'. RESULTS: Overall, 94 patients had a post-CRT MRI performed and were included. Forty-three (46%) patients had a good response (mrTRG I/II) and 51 (54%) patients had a poor response (mrTRG III/IV). The median tumor length of good responders was 43 mm versus 50 mm (p < 0.001), with considerable overlap in tumor lengths between groups. CONCLUSION: Baseline tumor length on MRI is not a clinically useful biomarker to predict mrTRG tumor response to CRT and therefore patient suitability for a deferral of surgery trial.

What we imagine learning from watching others: how motor imagery modulates competency perceptions resulting from the repeated observation of a juggling action.

Although motor learning can occur from observing others perform a motor skill (action observation; AO), observers' confidence in their own ability to perform the skill can be falsely increased compared to their actual ability. This illusion of motor competence (i.e., 'over-confidence') may arise because the learner does not gain access to sensory feedback about their own performance-a source of information that can help individuals understand their veridical motor capabilities. Unlike AO, motor imagery (MI; the mental rehearsal of a motor skill) is thought to be linked to an understanding of movement consequences and kinaesthetic information. MI may thus provide the learner with movement-related diagnostic information, leading to greater accuracy in assessing ability. The present study was designed to evaluate the effects of MI when paired with AO in assessments of one's own motor capabilities in an online observation task. Two groups rated their confidence in performing a juggling task following repeated observations of the action without MI (OBS group; n = 45) or with MI following observation (OBS+MI; n = 39). As predicted, confidence increased with repeated observation for both groups, yet increased to a greater extent in the OBS relative to the OBS+MI group. The addition of MI appeared to reduce confidence that resulted from repeated AO alone. Data support the hypothesis that AO and MI are separable and that MI allows better access to sensory information than AO. However, further research is required to assess changes in confidence that result from MI alone and motor execution.

Effective practice and instruction: A skill acquisition framework for excellence.

We revisit an agenda that was outlined in a previous paper in this journal focusing on the importance of skill acquisition research in enhancing practice and instruction in sport. In this current narrative review, we reflect on progress made since our original attempt to highlight several potential myths that appeared to exist in coaching, implying the existence of a theory-practice divide. Most notably, we present five action points that would impact positively on coaches and practitioners working to improve skill learning across sports, as well as suggesting directions for research. We discuss the importance of practice quality in enhancing learning and relate this concept to notions of optimising challenge. We discuss how best to assess learning, the right balance between repetition and practice that is specific to competition, the relationship between practice conditions, instructions, and individual differences, and why a more "hands-off" approach to instruction may have advantages over more "hands-on" methods. These action points are considered as a broad framework for advancing skill acquisition for excellence (SAFE) in applied practice. We conclude by arguing the need for increased collaboration between researchers, coaches, and other sport practitioners.

Assessment of the 2020 NICE criteria for preoperative radiotherapy in patients with rectal cancer treated by surgery alone in comparison with proven MRI prognostic factors: a retrospective cohort study.

BACKGROUND: Selection of patients for preoperative treatment in rectal cancer is controversial. The new 2020 National Institute for Health and Care Excellence (NICE) guidelines, consistent with the National Comprehensive Cancer Network guidelines, recommend preoperative radiotherapy for all patients except for those with radiologically staged T1-T2, N0 tumours. We aimed to assess outcomes in non-irradiated patients with rectal cancer and to stratify results on the basis of NICE criteria, compared with known MRI prognostic factors now omitted by NICE. METHODS: For this retrospective cohort study, we identified patients undergoing primary resectional surgery for rectal cancer, without preoperative radiotherapy, at Basingstoke Hospital (Basingstoke, UK) between Jan 1, 2011, and Dec 31, 2016, and at St Marks Hospital (London, UK) between Jan 1, 2007, and Dec 31, 2017. Patients with MRI-detected extramural venous invasion, MRI-detected tumour deposits, and MRI-detected circumferential resection margin involvement were categorised as MRI high-risk for recurrence (local or distant), and their outcomes (disease-free survival, overall survival, and recurrence) were compared with patients defined as high-risk according to NICE criteria (MRI-detected T3+ or MRI-detected N+ status). Kaplan-Meier and Cox proportional hazards analyses were used to compare the groups. FINDINGS: 378 patients were evaluated, with a median of 66 months (IQR 44-95) of follow up. 22 (6%) of 378 patients had local recurrence and 68 (18%) of 378 patients had distant recurrence. 248 (66%) of 378 were classified as high-risk according to NICE criteria, compared with 121 (32%) of 378 according to MRI criteria. On Kaplan-Meier analysis, NICE high-risk patients had poorer 5-year disease-free survival compared with NICE low-risk patients (76% [95% CI 70-81] vs 87% [80-92]; hazard ratio [HR] 1·91 [95% CI 1·20-3·03]; p=0·0051) but not 5-year overall survival (80% [74-84] vs 88% [81-92]; 1·55 [0·94-2·53]; p=0·077). MRI criteria separated patients into high-risk versus low-risk groups that predicted 5-year disease-free survival (66% [95% CI 57-74] vs 88% [83-91]; HR 3·01 [95% CI 2·02-4·47]; p<0·0001) and 5-year overall survival (71% [62-78] vs 89% [84-92]; 2·59 [1·62-3·88]; p<0·0001). On multivariable analysis, NICE risk assessment was not associated with either disease-free survival or overall survival, whereas MRI criteria predicted disease-free survival (HR 2·74 [95% CI 1·80-4·17]; p<0·0001) and overall survival (HR 2·44 [95% CI 1·51-3·95]; p=0·00027). 139 NICE high-risk patients who were defined as low-risk based on MRI criteria had similar disease-free survival as 118 NICE low-risk patients; therefore, 37% (139 of 378) of patients in this study cohort would have been overtreated with NICE 2020 guidelines. Of the 130 patients defined as low-risk by NICE guidelines, 12 were defined as high-risk on MRI risk stratification and would have potentially been missed for treatment. INTERPRETATION: Compared to previous guidelines, implementation of the 2020 NICE guidelines will result in significantly more patients receiving preoperative radiotherapy. High-quality MRI selects patients with good outcomes (particularly low local recurrence) without radiotherapy, with little margin for improvement. Overuse of radiotherapy could occur with this unselective approach. The high-risk group, with the most chance of benefiting from preoperative radiotherapy, is not well selected on the basis of NICE 2020 criteria and is better identified with proven MRI prognostic factors (extramural venous invasion, tumour deposits, and circumferential resection margin). FUNDING: None.

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.

An extended challenge-based framework for practice design in sports coaching.

The challenge-point framework as a model for thinking about motor learning was first proposed in 2004. Although it has been well-cited, surprisingly this framework has not made its way into much of the applied sport science literature. One of the reasons for this omission is that the original framework had not been encapsulated into a paper accessible for sports practitioners. The framework had mostly a theoretical focus, providing a mechanistic summary of motor learning research. Our aims in this paper were to explain and elaborate on the challenge point framework to present an applied framework guiding practice design. We connect the framework to other theories that involve predictive coding, where information is attended when it disconfirms current predictions, providing a strong signal for learning. We also consider how two new dimensions (learners' motivation and practice specificity) need to be considered when designing practice settings. By moving around the different dimensions of functional difficulty, motivation, and specificity, coaches can optimize practice to achieve different learning goals. Specifically, we present three general "types" of practice: practice to learn, to transfer to competition, and to maintain current skills. Practical examples are given to illustrate how this framework can inform coach practice.

Topical Review: Perceptual-cognitive Skills, Methods, and Skill-based Comparisons in Interceptive Sports.

SIGNIFICANCE: We give a comprehensive picture of perceptual-cognitive (PC) skills that could contribute to performance in interceptive sports. Both visual skills that are low level and unlikely influenced by experience and higher-level cognitive-attentional skills are considered, informing practitioners for identification and training and alerting researchers to gaps in the literature.Perceptual-cognitive skills and abilities are keys to success in interceptive sports. The interest in identifying which skills and abilities underpin success and hence should be selected and developed is likely going to grow as technologies for skill testing and training continue to advance. Many different methods and measures have been applied to the study of PC skills in the research laboratory and in the field, and research findings across studies have often been inconsistent. In this article, we provide definitional clarity regarding whether a skill is primarily visual attentional (ranging from fundamental/low-level skills to high-level skills) or cognitive. We review those skills that have been studied using sport-specific stimuli or tests, such as postural cue anticipation in baseball, as well as those that are mostly devoid of sport context, considered general skills, such as dynamic visual acuity. In addition to detailing the PC skills and associated methods, we provide an accompanying table of published research since 1995, highlighting studies (for various skills and sports) that have and have not differentiated across skill groups.

The developmental and professional activities of female international soccer players from five high-performing nations.

We study the developmental and professional activities engaged in by 86 female adult soccer players from the senior national teams of Australia, Canada, England, Sweden, and the United States of America. Players completed the Participation History Questionnaire (PHQ) to elicit the amount and type of activities engaged in across their developmental and professional years, including milestones, soccer-specific activity and engagement in other sport activity. Greater specialisation than diversification characterised their childhood developmental activities, including all players starting in soccer in childhood and accumulating more hours in soccer activity than other sports during this period. However, interindividual variation further characterised these childhood activities, with a proportion of players diversifying into other sports and/or soccer play to a greater or lesser degree during childhood when compared to the other players. The amount of coach-led soccer practice increased for all players across their development culminating in an average of 15-16 h/wk across a 40-week season in early adulthood. In contrast, the amount of engagement in other sports and soccer peer-led play varied between players but generally decreased across adolescence to negligible amounts in late adolescence. Findings are commensurate with the deliberate practice framework and early engagement.

Whose turn is it anyway? The moderating role of response-execution certainty on the joint Simon effect.

When a two-choice "Simon task" is distributed between two people, performance in the shared go/no-go task resembles performance in the whole task alone. This finding has been described as the joint Simon effect (JSE). Unlike the individual go/no-go task, not only is the typical joint Simon task shared with another person, but also the imperative stimuli dictate whose turn it is to respond. Therefore, in the current study, we asked whether removing the agent discrimination component of the joint Simon task influences co-representation. Participants performed the typical joint Simon task, which was compared to two turn-taking versions of the task. For these turn-taking tasks, pairs predictably alternated turns on consecutive trials, with their respective imperative stimulus presented either on 100% of their turns (fully predictable group) or on 83% of their turns (response-uncertainty group, 17% no-go catch trials). The JSE was absent in the fully predictable, turn-taking task, but emerged similarly under the response-uncertainty condition and the typical joint Simon task condition where there is both turn and response-execution-related uncertainty. These results demonstrate that conflict related to agent discrimination is likely not a critical factor driving the JSE, whereas conflict surrounding the need to execute a response (and hence the degree of preparation) appears fundamental to co-representation.

Mu Suppression Is Sensitive to Observational Practice but Results in Different Patterns of Activation in Comparison with Physical Practice.

Research has shown the effectiveness of observational practice for motor learning, but there continues to be debate about the mechanisms underlying effectiveness. Although cortical processes can be moderated during observation, after both physical and observational practice, how these processes change with respect to behavioural measures of learning has not been studied. Here we compared short-term physical and observational practice during the acquisition and retention of a novel motor task to evaluate how each type of practice modulates EEG mu rhythm (8-13 Hz). Thirty healthy individuals were randomly assigned to one of three groups: (1) physical practice (PP), (2) observational practice (OP), and (3) no practice (NP) control. There were four testing stages: baseline EEG, practice, postpractice observation, and delayed retention. There was significant bilateral suppression of mu rhythm during PP but only left lateralized mu suppression during OP. In the postpractice observation phase, mu suppression was bilateral and larger after PP compared to that after OP. NP control showed no evidence of suppression and was significantly different to both the OP and PP groups. When comparing the three groups in retention, the groups did not differ with respect to tracing times, but the PP group showed fewer errors, especially in comparison to the NP group. Therefore, although the neurophysiological measures index changes in the OP group, which are similar but moderated in comparison to PP, changes in these processes are not manifest in observational practice outcomes when assessed in a delayed retention test.

Coach ratings of skills and their relations to practice, play and successful transitions from youth-elite to adult-professional status in soccer.

Elite soccer players (~15 yr) from professional academies in the UK were rated on technical, tactical, physical and creative skills by coaches at time 1 (T1). Players estimated accumulated hours in soccer practice (coach-led activities) and play (self-led activities) during childhood. Coach-ratings were again collected 2.5 yr later (T2) for players that received a professional contract (~17 yr). Adult-professional status was determined at T3 (~ 20 yr). Skill ratings distinguished across the three "future" groups (academy-only, youth-professional only and adult-professional), for all but creative skill. For players that transitioned to youth-professional, medium sized correlations were noted between childhood practice amounts and technical and creative skill ratings at T1, although practice amounts correlated more strongly with skill ratings at T2. Play amounts were not related to any skills. Within groups of youth elite athletes, domain-specific play in childhood, and to a lesser degree practice, were generally not good discriminators of specific-skills. The effects of sport-specific practice on the development (and discriminability) of skills takes time to emerge. We consider the implications for talent development models and purported links between play and creativity.

An action-incongruent secondary task modulates prediction accuracy in experienced performers: evidence for motor simulation.

We provide behavioral evidence that the human motor system is involved in the perceptual decision processes of skilled performers, directly linking prediction accuracy to the (in)ability of the motor system to activate in a response-specific way. Experienced and non-experienced dart players were asked to predict, from temporally occluded video sequences, the landing position of a dart thrown previously by themselves (self) or another (other). This prediction task was performed while additionally performing (a) an action-incongruent secondary motor task (right arm force production), (b) a congruent secondary motor task (mimicking) or (c) an attention-matched task (tone-monitoring). Non-experienced dart players were not affected by any of the secondary task manipulations, relative to control conditions, yet prediction accuracy decreased for the experienced players when additionally performing the force-production, motor task. This interference effect was present for 'self' as well as 'other' decisions, reducing the accuracy of experienced participants to a novice level. The mimicking (congruent) secondary task condition did not interfere with (or facilitate) prediction accuracy for either group. We conclude that visual-motor experience moderates the process of decision making, such that a seemingly visual-cognitive prediction task relies on activation of the motor system for experienced performers. This fits with a motor simulation account of action prediction in sports and other tasks, and alerts to the specificity of these simulative processes.

What we think we learn from watching others: the moderating role of ability on perceptions of learning from observation.

Despite increased interest in the processes guiding action observation and observational learning, we know little about what people think they learn from watching, how well perceptions of learning marry with actual ability and how ability perceptions develop across multiple observation trials. Based on common coding ideas, we would think that ability and perceptions of ability from watching should be well matched. We conducted two studies to answer these questions that involved repeated observation of a 2-ball juggling task. After each video observation, observers judged if they could perform the skill and gave a confidence score (0-100%). In Experiment 1, an Observe-only group was compared to an Observe + Physical practice and No-practice group. Both observer groups showed a better physical approximation of the juggling action after practice and in retention and their confidence increased in a linear fashion. Confidence showed a small, yet significant relationship to actual success. In Experiment 2, we limited physical practice to 5 attempts (across 50 observation trials). In general, people who had high perceptions of ability following a demonstration were overconfident, whereas those with lower perceptions of ability were accurate in their assessments. Confidence generally increased across practice, particularly for trials following observation rather than physical practice. We conclude that while perceptions of ability and actual ability show congruence across trials and individuals, observational practice increases people's confidence in their ability to perform a skill, even despite physical experiences to the contrary.

Manipulating visual-motor experience to probe for observation-induced after-effects in adaptation learning.

Observers can learn to move in novel, adapted environments after watching a learning or expert model. Although this is an effective practice technique, it is unclear how this learning is achieved and if observers update an internal model of their visual-motor environment, as shown through the presence of after-effects (i.e., negative carry-over effects when aiming in a normal environment following exposure to perturbed conditions). For such updating to occur via observational practice, it has been reasoned that the observer requires the motor capabilities to perform the task they are observing. To test this, we first trained three groups to physically move in clockwise (CW) or counterclockwise (CCW) rotated environments. When immediately returned to a normal environment, after-effects were seen. We then attempted to wash out these effects before allowing two of these groups (CW and CCW), and a naïve observation only group, to watch a video of an actor performing in a CW environment. This observation phase was immediately followed by another test for after-effects and a direct test of learning when aiming in the rotated environment. Consistent with previous data, there were direct learning effects due to observation. Although after-effects increased for the experienced observers, these were small and were not significantly different from a physical practice only group that did not undergo the observation phase. Therefore, even with a motor repertoire for the rotated environment, there was a lack of evidence that observational practice results in implicit (re)updating of an internal model for aiming.

Throwing in the dark: improved prediction of action outcomes following motor training without vision of the action.

Traditional models of action understanding emphasise the idea that long-term exposure to a wide array of visual patterns of particular actions allows for effective action anticipation or prediction. More recently, a greater emphasis has been placed on the motor system's role in the perceptual understanding and prediction of action outcomes. There have been attempts to isolate the contributions of visual and motor experience in action prediction, but to date, these studies have relied on comparisons of motor-visual experience to visual-only (observational) experience. We conducted a learning study, where visual experience was directly manipulated during practice. Novice participants practised throwing darts to 3 specific areas of a dartboard. A group trained without vision of their action, only feedback about the final landing position, significantly improved in their ability to predict the landing position of a thrown dart, from temporally occluded video clips. The performance of this 'no-vision' group did not differ from a Full-vision group and was significantly more accurate than an observation-only and a no-practice control group (with the latter two groups not improving pre- to post-practice). These results suggest that motor experience specifically modulates the perceptual prediction of action outcomes. This is thought to occur through simulative mechanisms, whereby observed actions are mapped onto the observer's own motor representations.

Practice and play as determinants of self-determined motivation in youth soccer players.

Based upon predictions derived from the Developmental Model of Sports Participation, we tested whether hours in domain-specific play (self-led activities) and practice (coach-led activities) during childhood (~5-12 year) in an elite group of youth soccer players from the UK (N = 144) were related to motivation. Independent analysis of three different age groups (Under 13, 15 and 17 year) did not show relations between play and practice activities during childhood and global measures of motivation. However, secondary analysis showed that when controlling for years in soccer, years in the UK Academy system were negatively related to global indices of self-determined motivation (SDI) and positively related to controlled motivation for the oldest players. Despite predictions, there was no evidence that play during childhood was positively related to more SDI. Prospective research is recommended to enable more robust conclusions about the role of early developmental practice activities, especially early specialisation in a high-performance system, on both skill and psychosocial development.

Effector-specific improvements in action prediction in left-handed individuals after short-term physical practice.

Research has established the influence of short-term physical practice for enhancing action prediction in right-handed (RH) individuals. In addition to benefits of physical practice for these later assessed perceptual-cognitive skills, effector-specific interference has been shown through action-incongruent secondary tasks (motor interference tasks). Here we investigated this experience-driven facilitation of action predictions and effector-specific interference in left-handed (LH) novices, before and after practicing a dart throwing task. Participants watched either RH (n = 19) or LH (n = 24) videos of temporally occluded dart throws, across a control condition and three secondary-task conditions: tone-monitoring, RH or LH force monitoring. These conditions were completed before and after physical practice throwing with the LH. Significantly greater improvement in prediction accuracy was shown post-practice for the LH- versus RH-video group. Consistent with previous work, effector-specific interference was shown, exclusive to the LH-video group. Only when doing the LH force monitoring task did the LH-video group show secondary task interference in prediction accuracy. These data support the idea that short-term physical practice resulted in the development of an effector-specific motor representation. The results are also consistent with other work in RH individuals (showing RH motor interference) and hence rule out the interpretation that these effector specific effects are due to the disruption of more generalized motor processes, thought to be lateralized to the left-hemisphere of the brain.

Distinct Effects of Brain Activation Using tDCS and Observational Practice: Implications for Motor Rehabilitation.

Complex motor skills can be acquired while observing a model without physical practice. Transcranial direct-current stimulation (tDCS) applied to the primary motor cortex (M1) also facilitates motor learning. However, the effectiveness of observational practice for bimanual coordination skills is debated. We compared the behavioural and brain causal connectivity patterns following three interventions: primary motor cortex stimulation (M1-tDCS), action-observation (AO) and a combined group (AO+M1-tDCS) when acquiring a bimanual, two-ball juggling skill. Thirty healthy young adults with no juggling experience were randomly assigned to either video observation of a skilled juggler, anodal M1-tDCS or video observation combined with M1-tDCS. Thirty trials of juggling were performed and scored after the intervention. Resting-state EEG data were collected before and after the intervention. Information flow rate was applied to EEG source data to measure causal connectivity. The two observation groups were more accurate than the tDCS alone group. In the AO condition, there was strong information exchange from (L) parietal to (R) parietal regions, strong bidirectional information exchange between (R) parietal and (R) occipital regions and an extensive network of activity that was (L) lateralized. The M1-tDCS condition was characterized by bilateral long-range connections with the strongest information exchange from the (R) occipital region to the (R) temporal and (L) occipital regions. AO+M1-tDCS induced strong bidirectional information exchange in occipital and temporal regions in both hemispheres. Uniquely, it was the only condition that was characterized by information exchange between the (R) frontal and central regions. This study provides new results about the distinct network dynamics of stimulating the brain for skill acquisition, providing insights for motor rehabilitation.

Video games and rehabilitation: using design principles to enhance engagement in physical therapy.

Patient nonadherence with therapy is a major barrier to rehabilitation. Recovery is often limited and requires prolonged, intensive rehabilitation that is time-consuming, expensive, and difficult. We review evidence for the potential use of video games in rehabilitation with respect to the behavioral, physiological, and motivational effects of gameplay. In this Special Interest article, we offer a method to evaluate effects of video game play on motor learning and their potential to increase patient engagement with therapy, particularly commercial games that can be interfaced with adapted control systems. We take the novel approach of integrating research across game design, motor learning, neurophysiology changes, and rehabilitation science to provide criteria by which therapists can assist patients in choosing games appropriate for rehabilitation. Research suggests that video games are beneficial for cognitive and motor skill learning in both rehabilitation science and experimental studies with healthy subjects. Physiological data suggest that gameplay can induce neuroplastic reorganization that leads to long-term retention and transfer of skill; however, more clinical research in this area is needed. There is interdisciplinary evidence suggesting that key factors in game design, including choice, reward, and goals, lead to increased motivation and engagement. We maintain that video game play could be an effective supplement to traditional therapy. Motion controllers can be used to practice rehabilitation-relevant movements, and well-designed game mechanics can augment patient engagement and motivation in rehabilitation. We recommend future research and development exploring rehabilitation-relevant motions to control games and increase time in therapy through gameplay.Video Abstract available (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A61) for more insights from the authors.