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Improving Balance in Adults With Intellectual

Developmental Disorder via Virtual Environments

Article in Perceptual and Motor Skills · October 2021

DOI: 10.1177/00315125211049733

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Article

Perceptual and Motor Skills

2021, Vol. 128(6) 2638–2653
Improving Balance in ! The Author(s) 2021
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DOI: 10.1177/00315125211049733
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Disorder via Virtual

Environments

Meir Lotan1 and Patrice L. Weiss2

Abstract
Balance problems have been found among 57% of adults with Intellectual
Developmental Disorder (IDD). Moreover, these adults have only partially partici-
pated in conventional activity programs. There is a clear need for new interventions
that will enhance these individuals’ interest and motivation toward improving their
balance skills. Virtual gaming training experiences are a promising prospect in that
regard. The purpose of this study was to examine the effect of virtual reality games
on improving balance for adults with IDD. We recruited 31 individuals with mild-
moderate IDD who had fallen at least twice in the year prior to initiating this
intervention, and we evaluated these participants using the Timed Up and Go
(TUG) test. The participants were randomly assigned to control and experimental
groups, and only the latter group took part in a series of twelve 30-minute bi-weekly
virtual game sessions, designed to improve balance using the SeeMe virtual game
system. We found significant (p < .001) pre-post improvements in balance abilities in
the experimental group and no significant pre-post change in the control group
(p < .77). These data suggest that virtual game technology is a viable tool for
improving balance among adults with IDD.

1
Department of Physical Therapy, Faculty for Health Sciences, Ariel University, Ariel, Israel
2
Department of Occupational Therapy, University of Haifa, Haifa, Israel
Corresponding Author:
Meir Lotan, Department of Physical Therapy, Faculty for Health Sciences, Ariel University, Ariel 40700,
Israel.
Email: ml_pt_rs@netvision.net.il
Lotan and Weiss 2639

Keywords
Intellectual disability, Balance, Virtual reality

Introduction
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-
5; American Psychiatric Association, 2013), three criteria must be met to diag-
nose Intellectual and Developmental Disorder (IDD): (a) deficits in intellectual
functioning; (b) deficits in three domains of adaptive functioning including con-
ceptual (academic), social, and practical abilities; and (c) symptom onset occur-
ring during the developmental period. The prevalence of IDD in the general
population has been reported to vary from 1-3% (Harris, 2006; King et al.,
2009; Maulik et al., 2011). In a review of 52 articles, Maulik et al. (2011) found
that the overall prevalence of IDD was 1.37%, regardless of age or gender.
Of relevance to the IDD population (see below) are falls. A fall is defined as,
“An unplanned descent to the floor (or to an extension of the floor) . . .” (Currie,
2008, p. 3). Fall prevention requires adequate balance, which is a complex ability
entailing continually adapting reactions to incoming sensory information from
the visual, proprioceptive and vestibular systems (Hsieh et al., 2001; Katz &
Lazcano-Ponce, 2008; Rubenstein & Josephson, 2006). As individuals with IDD
present an array of disabilities (e.g., ataxia, paresis, movement disorders, epi-
lepsy, sensory limitations), they are more prone to falls than peers without IDD
(Willgoss et al., 2010). The incidence of falls within the general older adult
population is around 33%, while the incidence of falls among older adults
with IDD is about 57% (Willgoss et al., 2010). Thirty-two percent of all falls
by individuals with IDD result in injury or death (Chiba et al., 2009; Willgoss
et al., 2010). Moreover, falls are associated with fall-related psychological con-
cerns for both the individual at risk (Payette et al., 2016) and family members
and caregivers. Fall-related psychological concerns lead to activity avoidance
that, in turn, reduces physical fitness and increases the likelihood of a sedentary
lifestyle that tends to be typical of individuals with IDD (Chang et al., 2004;
Chiba et al., 2009; Harlein et al., 2009; Rubenstein & Josephson, 2006). Efforts
to prevent falls through intensive physical activity training for individuals with
IDD may be impeded by difficulty persuading them to cooperate willingly with
these interventions, meaning that encouragement and highly motivating pro-
grams are often needed (Lotan, 2007; Temple, 2007). For all these reasons,
virtual gaming as a motivating physical activity has been proposed (Yalon-
Chamovitz & Weiss, 2008).
Since the mid-1990s, daily life for many adults has become permeated with
technology-driven activities, especially due to the wide availability of mobile
devices and of low-cost personal computers that can run relevant software for
2640 Perceptual and Motor Skills 128(6)

a variety of rehabilitation populations (e.g., Standen et al., 2001). Virtual game

technology, and more specifically, virtual gaming, has become commonplace,
and it is now part of a clinician’s repertoire of available rehabilitative tools. As
numerous clinicians and researchers continue to examine ways to increase phys-
ical activity participation and reduce the sedentary lifestyle of individuals with
IDD (Oppewal et al., 2018), virtual game technology represents new means of
achieving both goals.
Virtual gaming may be described as the use of computer-based interactive
simulations to present users with practice opportunities for engaging in realistic
activities through artificial environments (Rizzo & Kim, 2005; Weiss et al.,
2006). Virtual games provide players with an experience in two or three-
dimensional simulated virtual environments (VEs) with which they can interact
and respond at different levels of motor and cognitive ability to perform tasks
that are motivating, meaningful and purposeful (Eden & Bezer, 2011; Parsons &
Mitchell, 2002; Rheingold, 1991; Tam et al., 2005; Weiss et al., 2003).
To date, a number of VEs have been used for people with IDD, permitting an
examination of the potential of virtual reality and virtual games for teaching life
skills, such as route learning (Mengue-Topio et al., 2011), street crossing
(Wright & Wolery, 2011), preparation for giving witness evidence in a court
of law (Cooke et al., 2002), coping during natural disasters such as earthquakes
(Tarnanas & Manos, 2001), shopping (Tam et al., 2005), improving physical
fitness (Lotan et al., 2009; 2011), augmenting sensorimotor functioning (Wuang
et al., 2011), and increasing cognitive skills, such as assessing sequential time
passage (Passig, 2009) and spatial perception (Akhutina et al., 2003). Other
researchers have studied the practicality of VEs for social skills training
(Parsons & Mitchell, 2002; Standen et al., 1998) and as a medium for leisure
activities (Walker & Sylwester, 1998; Yalon-Chamovitz & Weiss, 2008). In their
review of various virtual reality rehabilitation applications for people with IDD,
Standen and Brown (2005) supportively concluded that those few empirical
studies that have examined VE use for people with IDD have shown it to be
potentially effective and meaningful. Or as so eloquently expressed by the title of
their article, “Virtual Reality in the Rehabilitation of People with Intellectual
Disabilities,” virtual reality has a role in removing the barriers that impede
rehabilitation for people with intellectual disability.
Despite the severely limiting balance problems that are common among indi-
viduals with IDD (Chiba et al., 2009; Willgoss et al., 2010) and the efficacy of
virtual gaming for improving balance in other populations (Mao et al., 2014), no
prior study has reported virtual game use for balance improvement among
individuals with IDD. While virtual gaming appears to provide a readily avail-
able, low-cost, easy-to-operate, adaptable and motivating approach, no research
has yet explored the use of VE-based games to affect balance problems in
individuals with IDD. Thus, this study was intended to fill this research gap.
We compared an experimental group of participants with IDD who received
Lotan and Weiss 2641

exposure to virtual game balance-improvement training with a control group of

participants with IDD who received no virtual game training. We hypothesized
that our experimental group would show significant balance improvements rel-
ative to the control group.

Method
Ethics
This protocol received ethical approval from the Institutional Review Board of
the University of Haifa (229/13), from the head scientist at the Ministry of
Welfare and Social Affairs, and from the management of the Bnei-Zion and
Neve Menashe residential centers. A parent or legal guardian of each participant
signed a written statement of informed consent before the research commenced
for that participant.

Participants
All participants’ mild-moderate levels of IDD were determined by the national
placement committee, under the auspice of the ministry of welfare. We randomly
assigned 16 adult participants to an experimental virtual game-treatment group
(8 males, 8 females; age range: 30–77 years, Mage ¼ 51.8, SD ¼ 11.2 years) and 15
adult participants to a no-treatment control group (8 males, 7 females; age range:
24–63 years, Mage ¼ 45.6, SD ¼ 13.8 years). A research assistant who was blind to
the treatment program, participant assessments and data analyses made these
random assignments by selecting the participant’s names from a hat, while blind-
folded. We based the sample size on the number of participants used in previous
intervention programs of this kind and have managed to present statistically sig-
nificant results (n ¼ 12; 4; and 20 respectively) (Brien & Sveistrup, 2011; Bryanton
et al., 2006; Delasta Lazzari et al., 2015).
Participant inclusion criteria included a requirement that the participant have
experienced more than two falls in the year preceding the intervention, with no
sustained injury that prevented them from engaging in the light-moderate phys-
ical activity demands of the intervention program. This criterion was set to
avoid accidental falls during the participants’ research engagement. Other inclu-
sion criteria were cognitive abilities sufficient for understanding the virtual game
requirements, demonstrated sufficient visual and auditory acuity (with correc-
tion, if necessary) to see the monitor display and hear the auditory feedback,
and demonstrated shoulder range of motion greater than 130 flexion and
abduction. These criteria were based on our previous research findings that
individuals at a level lower than mild IDD were unable to fully enjoy and
actively use virtual gaming (Lotan et al., 2011). All participants were approved
to enter the research procedure by the residence physician. Participants were
2642 Perceptual and Motor Skills 128(6)

excluded if they presented neuromuscular or cardiovascular pathology that pre-

vented them from participating in a moderate level of physical activity via video
gaming. After assigning participants to the experimental and control groups, we
experienced no participant drop-outs. In addition to participation in this study
protocol, both groups continued their regular daily activities such as going to
sheltered work activities each morning and participating in afternoon leisure
activities (which were similar for all participants). See Table 1 for participant
characteristics.

Instrumentation
SeeMe Virtual Games. SeeMe is a camera tracking, video-capture, gesture-
operated virtual gaming system, run with a Microsoft Kinect three-
dimensional (3 D) camera, laptop computer and a connection to any large
monitor/TV (further details can be found at the website: http://www.virtual-
reality-rehabilitation.com/products/seeme/tasks-overview/gym).
This system presents a suite of video games that have been customized for a
range of rehabilitation populations, including those with neurological and
orthopedic conditions. The SeeMe games may be adapted to accommodate
different levels of cognitive and motor difficulty, enable the recording of game

Table 1. Demographic and Medical Characteristics of Participants.

Research (n ¼ 16) Control (n ¼ 15) Significance

Male/female 8(50%)/8 8(53%)/7 (two sided)

Age range (mean  SD) 30–77 (51.8  11.6) 24–63 (45.6  14.2) p ¼ .23
IDD level (Mi/Mo) 6/10 4/11 p ¼ .704
IDD level (sever/prof) – – 1.000
Independent ambulation 16 15 1.000
Walking aid 2 2 1.000
Pre-intervention falls 3.5 (3.3) 3.9 (5.17) p ¼ .78
per participant, Mean (SD)
Secondary diagnosis
(other than IDD)
Number of participants
(percentage %)
Autism 2(12.5) 1(6) 1.000
CP 3 (18.8) 26.6 (4) .685
Epilepsy (26.6)4 3 (18.8) 1.000
Hearing impairment 1 (6) 1 (6) 1.000
Visual impairment (26.6)4 3 (18.8) 1.000
Gastric issues (37.5) 6 7 (46.6) .733
Scoliosis 1 (6) 2(12.5) .600
Specific syndromes (26.6)4 (26.6)4 1.000
Lotan and Weiss 2643

results, and allow for user follow-up training from session-to-session. The games
are operated by movements of the upper and/or lower extremity and trunk, as
designated by the operator, usually a therapist. All SeeMe games used in this
study were able to challenge balance abilities of the participants and included
Warm Up (introducing the virtual games to the user), Window Cleaner (requir-
ing the user to move upper body and limbs in wide lateral movements), React
(a ball randomly appears at the side of the screen for a limited time – requiring
the user to move upper body and limbs in wide quick lateral movements), Raft
(drifting on a river trying to catch randomly appearing fish and avoiding ran-
domly floating barrels - requiring the user to move laterally to both sides quickly
and in sync with object movements on the screen), Gym (hitting or kicking a
square randomly appearing at different heights and angels from the participant’s
avatar - requiring the user to quickly move upper and lower limbs to all direc-
tions, including standing on one leg) and Sorter (ball with different colors
dropping from above needs to be sorted into the appropriate color container -
requiring the user to move upper body and limbs in wide coordinated lateral
movements). The selection of virtual games was based on two preliminary inter-
actions/familiarization session with the participants in which the participants
selected the games that were of greatest interest to them. These sessions were not
part of the research protocol, described below.

Outcome Measure
Timed Up and Go Test (TUG). The TUG test assesses balance by measuring the
time it takes for an individual to get up from a sitting position on a chair, walk
in a straight line for three meters towards a mark on the floor, turn around, go
back towards the chair, and sit down again. The TUG has high psychometric
support when used for individuals with IDD (Salb et al., 2015) or without IDD
(Boer & Moss, 2016), and it has been used frequently among individuals with
IDD in numerous intervention programs (Enkelaar et al., 2012; Taylor et al.,
2011). The test is especially adapted to people with IDD, as it contains simple
daily living activities that are easy for individuals with IDD to understand. We
provided participants with explanations regarding test performance before the
initiation of this test. The test can be performed with an assistive device (e.g.,
cane, walker), but not with the help of another person. The TUG has specific
norms, according to which a person who takes 10 seconds to complete the
TUG is at moderate risk for falling and a person who takes 12 seconds to
complete it is at high risk for falling (Enkelaar et al., 2012; Taylor et al., 2011).

Procedures
The participants who were allocated to the virtual gaming group received two
30-minute sessions per week for 12 weeks. They played each game for a duration
of three minutes. The order of games was selected in accordance with each
2644 Perceptual and Motor Skills 128(6)

participant’s preference for each session, although all games had to be played.
During the session the investigator stood behind each participant using a trans-
fer belt around the participant’s chest in a way that ensured safety yet did not
impede performance (as demonstrated during initial pilot trials); the balance
task was therefore both challenging and safe. An evaluator who was blinded
to the experimental procedure and the participants’ group allocations assessed
participants in both groups for balance (TUG) prior to and following the inter-
vention. The TUG evaluation included four tests (including two familiarization
trials) for each participant at each evaluation cycle, with the mean of the last two
tests used as the outcome measure.

Data Analysis
We analyzed data using the Statistical Program for the Social Sciences (SPSS,
Version 23.0, IBM Inc., Chicago, IL USA). Statistical analyses included the
computation of descriptive statistics (means and standard deviations) for the
demographic and physical performance variables. We checked the normality of
the data distributions with the Kolmogorov-Smirnov test and found them to
meet criteria for assumptions of normality and homogeneity, allowing the use
of parametric tests. We conducted independent t-tests (continuous variables) to
determine group differences. Bivariate analyses included one-way analysis of
variance tests for balance test comparisons between control and experimental
groups, with group demographic differences treated as covariates (analysis of
covariance). Effect sizes were also calculated (Lakens, 2013), and we considered
an effect size at a power of less than 0.5 to be a small effect, an effect size at
power between 0.5–0.8 as a moderate effect size, and an effect size at power
larger than 0.80 as a large effect (Cohen, 1988). We set statistical significance at
p < .05 level for all calculations.

Results
Prior to intervention, we found no statistically significant differences between
the control and experimental groups on comparisons of the participants’ age,
gender, cognitive ability level, number of falls before the intervention, and use of
walking aids versus independent walking. Using Student’s two-way t-tests, dif-
ferences for the pre-intervention TUG tests between the experimental group
(M ¼ 14.6, SD ¼5.2) and the control group (M ¼ 14.5, SD ¼ 5.1) were not
statistically significant. Effect size was calculated according to Cohen’s d:
(14.5–14.6)/5.150243 ¼ 0.019417 (Lakens, 2013).
As shown in Table 2, comparing pre-intervention (M ¼ 14.5, SD ¼ 5.1) and
post-intervention (M ¼ 14.3, SD ¼ 5.9) TUG scores for the control group
revealed no statistically significant difference (p ¼ .933). Effect size was calcu-
lated according to Cohen’s d: ¼ (14.5–14.3)/5.514526 ¼ 0.036268 (Lakens, 2013).
Lotan and Weiss 2645

Table 2. TUG Means (and Standard Deviations) for Experimental and Control Group
Participants.

Pre-intervention Post-intervention
seconds seconds p Value Effect size

Experimental 14.6 (5.2) 11.1 (4.9) p ¼ .001** 0.7

Control 14.5 (5.1) 14.3 (5.9) p ¼ .77 0.03
p-Value p ¼ .49 p ¼ .05*
Effect size 0.02 0.64
Effect size (ES)index: Small ES: 0.2 Moderate ES: 0.5 Large ES: 0.8

There was, however, a statistically significant difference between the pre-

intervention (M ¼ 14.6, SD ¼ 5.2) and post-intervention (M ¼ 11.1, SD ¼ 4.9)
TUG scores for the experimental group, reflecting a significant improvement
for this group, (t ¼ (15) ¼ 5.255; p < .001. Cohen’s Effect size is: Cohen’s d ¼
(14.6–11.1)/5.052227 ¼ 0.7 (Lakens, 2013).
There was also a statistically significant (p ¼ .0049) change score (after-before)
at the post-intervention TUG test between the experimental group (M ¼ 11.1,
SD ¼ 4.9) and the control group (M ¼ 14.3, SD ¼ 5.9), t (3.772) ¼ 28.97.
Cohen’s effect size was: Cohen’s d ¼ (14.3–11.1)/5.423099 ¼ 0.6 (Lakens, 2013).

Discussion
In this study, a group of participants with IDD, residing in residential care
centers, who had a history of multiple falls, received 12 bi-weekly, 30-minute
sessions, aimed at improving balance via virtual gaming. We compared this
group to a no-treatment control group of similar participants with IDD. The
groups were compared and found to be comparable on pre-intervention varia-
bles such as: balance, number of falls and use of walking aids. When comparing
pre-intervention and post-intervention testing with the TUG test, only the
experimental (i.e., virtual game training) group showed a significant improve-
ment in balance following the intervention.
These results suggest that repeated bi-weekly virtual gaming sessions can be
effective for enhancing balance skills of individuals with mild to moderate IDD.
This result has important implications for this population, and it emphasizes the
strength of virtual gaming as an effective way to intensify and facilitate exercise
adherence to enable positive and significant exercise results for individuals with
IDD. The power of virtual gaming as a useful and effective way to implement
physical activity programs corresponds with previous research (Yalon-
Chamovitz & Weiss, 2008) demonstrating that virtual gaming of this kind
(Lotan et al., 2009, 2011) improved physical fitness on the Twelve Minute
2646 Perceptual and Motor Skills 128(6)

Walk Test (McGavin et al., 1976), Total Heart Beat Index (Hood et al., 2002),
and Energy Expenditure Index (Piccinini et al., 2006).
Other findings also support the present results. For instance, 12 children
with cerebral palsy (CP) participated in a VR gaming-based exercise program.
The participants reported feelings of fun and enjoyment during the VR exer-
cises. Moreover, the project found that the participating children completed
many repetitions of the exercises. Our results are similar to those suggesting
that VR gaming improved exercise compliance, and enhanced exercise effective-
ness (Bryanton et al., 2006). In a different study all four adolescents with phys-
ical disability showed significant improvements in various functional, mobility
and balance abilities after involvement in a short-term intensive VR-gaming
program (Brien & Sveistrup, 2011).
Physical fitness and balance skills of individuals with IDD have been well
documented (Bonavolonta et al., 2019; Chiba et al., 2009; Fernhall et al., 1996;
Graham & Reid, 2000; Willgoss et al., 2010), and such prior findings reinforced
a need to discover and implement regular, effective and intensive exercise pro-
grams for this population (CDC, 1997; Lotan, 2006; Rimmer, 2004). Given
secondary health risks associated with chronically poor physical fitness, a sed-
entary lifestyle (Draheim et al., 2002) and associated falls (Chiba et al., 2009;
Willgoss et al., 2010), this need has been seen as urgent. Among individuals with
IDD, there are limitations to physical activity programs imposed by the physical
environment (Ruuskanen & Parkatti, 1994), especially for those who live in
residential settings (Temple, 2007). Poor health may be both a result of and a
further contribution to a sedentary lifestyle that further interferes with preven-
tative participation in exercise programs (Ruuskanen & Parkatti, 1994).
Similarly, individuals with IDD often receive insufficient support and encour-
agement for engagement in exercise from family members or caregivers (Heller
et al., 2002). A key factor in this engagement is the need to find attractive and
reinforcing physical activities (Temple, 2007) that have personal value for par-
ticipants (Gignac, 2003). Findings from this study and others (Booth et al., 2014;
Lotan et al., 2009, 2011) suggest that virtual gaming addresses these concerns.
The ability of virtual gaming to motivate individuals with IDD and to promote
their cooperation with and enjoyment of physical activity is likely to play an
important role in helping these individuals become more physically active (da
Cunha et al., 2018; Lotan et al., 2009, 2011; McMahon & McMahon, 2016).

Limitations and Directions for Future Research

Among our most important limitations was a reliance on a relatively small
sample size of 31 participants with IDD (divided into experimental and no-
treatment control groups). We modeled this sample size after other studies
with small numbers of participants, but we did not conduct a statistical power
analysis. Moreover, this small sample limits generalization of our findings to
Lotan and Weiss 2647

other populations, meaning that our results should be interpreted cautiously,

pending replication by other researchers, as was also suggested by Bonavolonta
et al. (2019). Of course, this caution extends especially to generalizations to
individuals with IDD who have lower intellectual functioning (e.g., those with
severe and profound IDD). While it is difficult to recruit large numbers of
participants from this population, future studies should strive to increase
sample size. A more diverse sample might also help address the mediating
role of other demographic characteristics (e.g., gender, uncontrolled
co-morbidities, etc.) in this population. We note that there were some non-
statistically significant differences in the pre-intervention scores between partic-
ipants in our control and research groups, mostly regarding their age and
severity of balance problems. While these tendencies suggested that some par-
ticipants in the control group may have been more physically fit, despite our
random assignment of participants to groups, our findings suggest that this
apparent limitation proved to be less important for participants in the present
intervention than it might be for any future investigators. Additionally, our
exclusive reliance on the TUG test to measure balance changes is a weakness
that future researchers should address. Also, had we measured participants’
affect and/or motivation, we might have been more certain that they found
virtual gaming pleasurable and motivating. Nevertheless, prior findings found
this type of intervention enjoyable for individuals with IDD (Yalon-Chamovitz
& Weiss, 2008) Finally, we included no follow-up data with which to better
understand whether virtual gaming gains would persist over time. Despite pre-
vious findings suggesting that results of similar interventions persisted, at least
for a month post-intervention (Bryanton et al., 2006), future investigators might
better address the long-term effects of interventions of this kind and compare
them to other interventions rather than to a passive control group in order to
better gauge the relative value of virtual gaming.

Conclusion
In conclusion, we found a virtual gaming intervention system (SeeMe) to be
both feasible and beneficial for improving balance skills among adults with
mild-moderate IDD who were living within residential settings. We recommend
replicating and extending this study with larger numbers of more diverse par-
ticipants with IDD and with a wider array of clinically applicable field tests.
Meanwhile, there is considerable promise for virtual gaming methods of improv-
ing the clinical management of individuals with IDD and there are opportunities
for additional research in this realm.
Acknowledgments
The authors would like to thank all participants taking part in the present intervention,
and their parents/legal guardians authorizing their participance.
2648 Perceptual and Motor Skills 128(6)

Authors’ Note
The present work has been carried out in accordance with The Code of Ethics of the
World Medical Association (Declaration of Helsinki) for experiments involving humans.
Informed consent was obtained for experimentation with human subjects (in the present
project by legal guardians of all participants). The privacy rights of human subjects have
been observed.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.

ORCID iD
Meir Lotan https://orcid.org/0000-0003-1330-5148

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Author Biographies
Meir Lotan is an associate professor at the physical therapy department at Ariel University. ML’s
research interests include developing and introducing cutting edge physical therapy services (activity
applications; virtual environments; smart wearable shirts) for individuals with intellectual and devel-
opmental disability, and children with Autism. ML published in numerous Journals.

Patrice L. Weiss is an emeritus professor at the University of Haifa (Haifa, Israel) and a senior
research consultant at ALYN Hospital Pediatric and Adolescent Rehabilitation Center (Jerusalem,
Israel). She has published original research in journals including the Journal of NeuroEngineering
Rehabilitation, Frontiers, Disability & Rehabilitation: Assistive Technology and Transactions on
Neural Systems & Rehabilitation Engineering.

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