The study of visuomotor adaptation (VMA) capabilities has been encompassed in various experimental protocols aimed at investigating human motor control strategies and/or cognitive functions. VMA-oriented frameworks can have clinical applications, primarily in the investigation and assessment of neuromotor impairments caused by conditions such as Parkinson’s disease or post-stroke, which affect the lives of tens of thousands of people worldwide. Therefore, they can enhance the understanding of the specific mechanisms of such neuromotor disorders, thus being a potential biomarker for recovery, with the aim of being integrated with conventional rehabilitative programs. Virtual Reality (VR) can be entailed in a framework targeting VMA since it allows the development of visual perturbations in a more customizable and realistic way. Moreover, as has been demonstrated in previous works, a serious game (SG) can further increase engagement thanks to the use of full-body embodied avatars. Most studies implementing VMA frameworks have focused on upper limb tasks and have utilized a cursor as visual feedback for the user. Hence, there is a paucity in the literature about VMA-oriented frameworks targeting locomotion tasks. In this article, the authors present the design, development, and testing of an SG-based framework that addresses VMA in a locomotion activity by controlling a full-body moving avatar in a custom VR environment. This workflow includes a set of metrics to quantitatively assess the participants’ performance. Thirteen healthy children were recruited to evaluate the framework. Several quantitative comparisons and analyses were run to validate the different types of introduced visuomotor perturbations and to evaluate the ability of the proposed metrics to describe the difficulty caused by such perturbations. During the experimental sessions, it emerged that the system is safe, easy to use, and practical in a clinical setting. Despite the limited sample size, which represents the main limitation of the study and can be compensated for with future recruitment, the authors claim the potential of this framework as a useful instrument for quantitatively assessing either motor or cognitive impairments. The proposed feature-based approach gives several objective parameters as additional biomarkers that can integrate the conventional clinical scores. Future studies might investigate the relation between the proposed biomarkers and the clinical scores for specific disorders such as Parkinson’s disease and cerebral palsy.

Background: Mild cognitive impairment (MCI) affects up to 40% of patients with Parkinson’s disease (PD), yet conventional rehabilitation often lacks engagement. The OPERA project developed a novel Bio-cooperative Robotic Platform (PRoBio), integrating a service robot and a virtual reality-based rehabilitation for personalized cognitive training. This work presents two preliminary user-centred studies aimed to assess PRoBio usability and acceptability. Methods: to gather qualitative feedback on robotic and virtual reality technologies, through ad hoc questionnaires, developed according to participatory design principles and user-centered evaluation literature, Study 1 (Focus group) involved 23 participants: 10 PD patients (F = 6; mean age = 68.9 ± 8.2 years), 5 caregivers (F = 3; mean age = 49.0 ± 15.5), 8 healthcare professionals (F = 6; mean age = 40.0 ± 12.0). Study 2 (Living Lab) tested the final version of PRoBio platform with 6 healthy volunteers (F = 3; mean age = 50.3 ± 11.0) and 8 rehabilitation professionals (F = 3; mean age = 32.8 ± 9.9), assessing usability and acceptability through validated questionnaires. Results: The focus group revealed common priorities across the three groups, including ease of use, emotional engagement, and personalization of exercises. Living Lab unveiled PRoBio as user-friendly, with high usability, hedonic quality, technology acceptance and low workload. No significant differences were found between groups, except for minor concerns on system responsiveness. Discussion: These preliminary findings support the feasibility, usability, and emotional appeal of PRoBio as a cognitive rehabilitation tool. The positive convergence among the groups suggests its potential for clinical integration. Conclusions: These preliminary results support the feasibility and user-centred design of the PRoBio platform for cognitive rehabilitation in PD. The upcoming usability evaluation in a pilot study with patients will provide critical insights into its suitability for clinical implementation and guide further development.

Introduction: Mild cognitive impairment in Parkinson's disease (PD-MCI) can affect several cognitive domains, including attention, working memory, executive functions, language, visuospatial skills, and episodic memory, resulting in a progressive reduction of autonomy and an increased risk of dementia. Cognitive training may help preserve cognitive abilities, especially when supported by innovative tools; nevertheless, standardized and engaging interventions are still lacking. The OPERA project aims to develop and evaluate the usability of PRoBio, a novel bio-cooperative platform that integrates virtual reality (VR), robotic assistance and physiological monitoring to deliver personalized cognitive rehabilitation for individuals with PD-MCI. Methods and analysis: The OPERA project is a 13-months non-profit, multicentre clinical investigation structured in four phases. Phase 1 (month 2): focus group, involving 23 participants (10 people with PD (PwPD), 5 caregivers, 8 healthcare professionals) to explore usability, expectations and rehabilitation needs. Phase 2 (months 2–7): development of the PRoBio platform, by integrating the “Virtual Reality Rehabilitation System” (VRRS, by Khymeia Group) with the TIAGo robot (by PAL Robotics) to deliver personalized exercises to patients' cognitive profiles, while also monitoring their emotional and physiological state. Phase 3 (month 6): two living labs involving a total of 21 healthy subjects (13 volunteers and 8 rehabilitation professionals) to assess PRoBio's usability in a real setting, with emotional data collection and standardized usability questionnaires completion after use. Phase 4 (months 8–12): usability study assessing PRoBio's usability as the primary objective, involving 10 PD-MCI patients completing a 4-week cognitive rehabilitation program with pre/post clinical and neuropsychological assessments. Descriptive statistics and appropriate inferential tests (parametric or non-parametric) will be applied to usability data, pre/post intervention clinical measures, and physiological and performance data registered by the PRoBio platform ( p < 0.05). Conclusion: The present paper presents the methodological framework of the OPERA project, which brings together partners with complementary expertise to develop and evaluate the PRoBio platform, a novel bio-cooperative system for cognitive rehabilitation in patients with PD-MCI. By integrating VR, robotics and physiological feedback, PRoBio aims to enable personalized, adaptive interventions, offering a more engaging alternative to traditional rehabilitation approaches while advancing research in bidirectional human–robot interaction.

Background/Objectives: Cognitive impairment is highly prevalent among hospitalised adults but often remains under-recognised, particularly in non-neurological rehabilitation settings where clinical attention is mainly focused on physical recovery. Undetected cognitive impairment may adversely affect rehabilitation outcomes, functional recovery, and long-term care planning. Methods: A multicentre, prospective, longitudinal study, with a single-group assignment and a diagnostic purpose, will be conducted across three rehabilitation centres of the Don Carlo Gnocchi Foundation (Italy), enrolling 384 patients aged ≥45 years without severe psychiatric or neurological disorders, other than cognitive impairment, admitted to cardiac, pulmonary, orthopaedic rehabilitation, or intermediate care units for non-neurological conditions. At baseline (T0), all participants will undergo standardised clinical and cognitive screening. Individuals with suspected cognitive impairment, operationally defined as an Equivalent Score (ES) of 1 on the Montreal Cognitive Assessment–MoCA total score and/or an ES of 0 or 1 on at least one MoCA cognitive domain, including the Memory Index Score (MIS), and a random sample of those without, will undergo a comprehensive neuropsychological assessment. Participants with neuropsychologically defined cognitive impairment, based on objective deficits in the comprehensive neuropsychological assessment, will undergo plasma biomarker testing (GFAP, NfL, pTau-217), APOE genotyping, and brain CT. Participants with a MoCA total ES of 0 will be classified as having cognitive impairment on the basis of screening alone. At two prespecified sites, consecutive consenting participants with neuropsychologically defined cognitive impairment will additionally undergo an EEG vigilance protocol, auditory P300 recording, seven-day actigraphy, and overnight polysomnography. Patients with neuropsychologically defined cognitive impairment at T0 will undergo a 12-month follow-up assessment (T1) of the progression of cognitive impairment and plasma biomarkers; those enrolled in the neurophysiological substudy will additionally repeat the EEG vigilance protocol. Expected Results: The study will provide a conservative (lower-bound) estimate of the prevalence of documented and non-documented cognitive impairment, together with an estimate corrected for partial verification bias, in non-neurological rehabilitation settings. It will further characterise the cognitive profiles and examine their correlations with biomarkers of neurodegeneration (GFAP, NfL, pTau-217), APOE genotype, relative EEG spectral power and sleep intrusion measures, P300 latency and amplitude, actigraphy-derived Sleep Efficiency, and polysomnography-derived sleep stage proportions. Longitudinal data will enable the evaluation of cognitive trajectories and their biological correlates. Conclusions: The COGinREHAB study addresses a critical gap in rehabilitation medicine by implementing a structured, multimodal approach to the identification and characterisation of cognitive impairment in patients with non-neurological conditions. Its findings may facilitate earlier detection of cognitive impairment and inform the development of personalised rehabilitation and care pathways. Trial registration: ClinicalTrials.gov, NCT07731334.