Implicit motor learning promotes neural efficiency during laparoscopy

Using neuroimaging to assess brain activity and areas associated with surgical skills: a systematic review

BACKGROUND

Surgical skills acquisition is under continuous development due to the emergence of new technologies, and there is a need for assessment tools to develop along with these. A range of neuroimaging modalities has been used to map the functional activation of brain networks while surgeons acquire novel surgical skills. These have been proposed as a method to provide a deeper understanding of surgical expertise and offer new possibilities for the personalized training of future surgeons. With studies differing in modalities, outcomes, and surgical skills there is a need for a systematic review of the evidence. This systematic review aims to summarize the current knowledge on the topic and evaluate the potential use of neuroimaging in surgical education.

METHODS

We conducted a systematic review of neuroimaging studies that mapped functional brain activation while surgeons with different levels of expertise learned and performed technical and non-technical surgical tasks. We included all studies published before July 1st, 2023, in MEDLINE, EMBASE and WEB OF SCIENCE.

RESULTS

38 task-based brain mapping studies were identified, consisting of randomized controlled trials, case-control studies, and observational cohort or cross-sectional studies. The studies employed a wide range of brain mapping modalities, including electroencephalography, functional magnetic resonance imaging, positron emission tomography, and functional near-infrared spectroscopy, activating brain areas involved in the execution and sensorimotor or cognitive control of surgical skills, especially the prefrontal cortex, supplementary motor area, and primary motor area, showing significant changes between novices and experts.

CONCLUSION

Functional neuroimaging can reveal how task-related brain activity reflects technical and non-technical surgical skills. The existing body of work highlights the potential of neuroimaging to link task-related brain activity patterns with the individual level of competency or improvement in performance after training surgical skills. More research is needed to establish its validity and usefulness as an assessment tool.

The effects of internal representations on performance and fluidity in a motor task

Individuals can differ in the mode in which they experience conscious thought. These differences in visualisation and verbalisation can also be evident during motor control. The Internal Representation Questionnaire (IRQ) was developed to measure propensity to engage certain types of representations, but its ability to predict motor control and links to reinvestment and motor imagery have not been tested. 159 included participants completed the IRQ, movement specific reinvestment scale (MSRS), and a novel online motor task before and after a period of practice. Results showed that the IRQ Verbal and Orthographic factors were significant predictors of scores on the MSRS. The IRQ factor of Manipulational Representations predicted motor performance both before and after practice. The fluidity of executed movements were predicted by the IRQ verbalisation factor where higher propensity to verbalise was associated with higher levels of jitter, but only after a period of practice. Results suggest there may be some informative conceptual overlap between internal verbalisations and reinvestment and that the propensity to manipulate internal representations may be predictive of motor performance in new tasks. The IRQ has potential to be a valuable tool for predicting motor performance.

Use of neuroimaging to measure neurocognitive engagement in health professions education: a scoping review

PURPOSE

To map the current literature on functional neuroimaging use in medical education research as a novel measurement modality for neurocognitive engagement, learning, and expertise development.

METHOD

We searched PubMed, Embase, Cochrane, ERIC, and Web of Science, and hand-searched reference lists of relevant articles on April 4, 2019, and updated the search on July 7, 2020. Two authors screened the abstracts and then full-text articles for eligibility based on inclusion criteria. The data were then charted, synthesized, and analyzed descriptively.

RESULTS

Sixty-seven articles published between 2007 and 2020 were included in this scoping review. These studies used three main neuroimaging modalities: functional magnetic resonance imaging, functional near-infrared spectroscopy, and electroencephalography. Most of the publications (90%, n = 60) were from the last 10 years (2011-2020). Although these studies were conducted in 16 countries, 68.7% (n = 46) were from three countries: the USA (n = 21), UK (n = 15), and Canada (n = 10). These studies were mainly non-experimental (74.6%, n = 50). Most used neuroimaging techniques to examine psychomotor skill development (57%, n = 38), but several investigated neurocognitive correlates of clinical reasoning skills (22%, n = 15).

CONCLUSION

This scoping review maps the available literature on functional neuroimaging use in medical education. Despite the heterogeneity in research questions, study designs, and outcome measures, we identified a few common themes. Included studies are encouraging of the potential for neuroimaging to complement commonly used measures in education research and may help validate/challenge established theoretical assumptions and provide insight into training methods. This review highlighted several areas for further research. The use of these emerging technologies appears ripe for developing precision education, establishing viable study protocols for realistic operational settings, examining team dynamics, and exploring applications for real-time monitoring/intervention during critical clinical tasks.

Providing Task Instructions During Motor Training Enhances Performance and Modulates Attentional Brain Networks

Learning a new motor task is a complex cognitive and motor process. Especially early during motor learning, cognitive functions such as attentional engagement, are essential, e.g., to discover relevant visual stimuli. Drawing participant's attention towards task-relevant stimuli-e.g., with task instructions using visual cues or explicit written information-is a common practice to support cognitive engagement during training and, hence, accelerate motor learning. However, there is little scientific evidence about how visually cued or written task instructions affect attentional brain networks during motor learning. In this experiment, we trained 36 healthy participants in a virtual motor task: surfing waves by steering a boat with a joystick. We measured the participants' motor performance and observed attentional brain networks using alpha-band electroencephalographic (EEG) activity before and after training. Participants received one of the following task instructions during training: (1) No explicit task instructions and letting participants surf freely (implicit training; IMP); (2) Task instructions provided through explicit visual cues (explicit-implicit training; E-IMP); or (3) through explicit written commands (explicit training; E). We found that providing task instructions during training (E and E-IMP) resulted in less post-training motor variability-linked to enhanced performance-compared to training without instructions (IMP). After training, participants trained with visual cues (E-IMP) enhanced the alpha-band strength over parieto-occipital and frontal brain areas at wave onset. In contrast, participants who trained with explicit commands (E) showed decreased fronto-temporal alpha activity. Thus, providing task instructions in written (E) or using visual cues (E-IMP) leads to similar motor performance improvements by enhancing activation on different attentional networks. While training with visual cues (E-IMP) may be associated with visuo-attentional processes, verbal-analytical processes may be more prominent when written explicit commands are provided (E). Together, we suggest that training parameters such as task instructions, modulate the attentional networks observed during motor practice and may support participant's cognitive engagement, compared to training without instructions.

Understanding Motor Skill Learning as Related to Dentistry

Learning dental procedures is a complex task involving the development of fine motor skills. The reported use of theories and/or evidence for designing learning activities to develop the fine motor skills needed for dental practice is limited. The aim of this review is to explore the available body of knowledge related to learning motor skills relevant to dentistry. Evidence from studies investigating motor skill learning highlights the negative impact of self-focus and self-regulation on learning outcomes, particularly during the early stages of learning. The development of activities and schedules that enable novices to demonstrate characteristics similar to experts, without the reported long period of 'deliberate practice', is clearly of value. Outcomes of learning implicitly are important in dentistry because working under stressful conditions is common, either during undergraduate study or in practice. It is suggested that learning implicitly in the simulation stage can reduce disrupted performance when transitioning to clinical settings. Therefore, further investigation of effective methods for learning dental fine motor skills is indicated, using approaches that result in robust performance, even under stressful conditions.

Effect of errorless learning on the acquisition of fine motor skills in pre-clinical endodontics

This study aimed to evaluate the impact of errorless and errorful learning, on acquisition of root canal hand-instrumentation skills. Dental students prepared standardised canals of different diameters and curvatures. Learning involved minimising (errorless: n = 21) or maximising errors (errorful: n = 21). Students who had completed accredited pre-clinical activities provided comparative data (n = 17). During testing, the distal canal of a plastic mandibular molar was prepared, first as a single task and then under multi-tasking conditions. Performance was assessed by preparation accuracy and time. Differences were assessed using anova (P < 0.05). Performance in the experimental groups was similar during learning. When multi-tasking, errorful learners showed a deterioration in preparation accuracy (P < 0.05). In contrast, preparation accuracy and completion times for the errorless and comparative groups remained stable when multi-tasking. Errorless learning resulted in stable performance under multi-tasking conditions. Investigation of alternative approaches to learning motor skills in dentistry is warranted as such approaches may provide better outcomes, especially under demanding conditions.

All talk? Challenging the use of left-temporal EEG alpha oscillations as valid measures of verbal processing and conscious motor control

This study tested the validity of EEG left-temporal alpha power and upper-alpha T7-Fz connectivity as indices of verbal activity and conscious motor control. Participants (n = 20) reached for, and transported, a jar under three conditions: a control condition and two self-talk conditions aimed at eliciting either task-unrelated verbal processing or task-related conscious control, while EEG and hand kinematics were recorded. Compared to the control condition, both self-talk conditions increased self-reported verbal processing, but only the task-related self-talk condition increased left-temporal activity (i.e., alpha power decreased). However, as cortical activity increased across the entire scalp topography, conscious control likely elicits a multitude of processes that may not be explained by left-temporal activity or verbal processing alone, but by a widespread decrease in neural efficiency. No significant effects for T7-Fz connectivity were detected. Results suggest that left-temporal EEG alpha oscillations are unlikely to uniquely reflect verbal processing during conscious motor control.

Principles of Motor Learning to Support Neuroplasticity After ACL Injury: Implications for Optimizing Performance and Reducing Risk of Second ACL Injury

Athletes who wish to resume high-level activities after an injury to the anterior cruciate ligament (ACL) are often advised to undergo surgical reconstruction. Nevertheless, ACL reconstruction (ACLR) does not equate to normal function of the knee or reduced risk of subsequent injuries. In fact, recent evidence has shown that only around half of post-ACLR patients can expect to return to competitive level of sports. A rising concern is the high rate of second ACL injuries, particularly in young athletes, with up to 20% of those returning to sport in the first year from surgery experiencing a second ACL rupture. Aside from the increased risk of second injury, patients after ACLR have an increased risk of developing early onset of osteoarthritis. Given the recent findings, it is imperative that rehabilitation after ACLR is scrutinized so the second injury preventative strategies can be optimized. Unfortunately, current ACLR rehabilitation programs may not be optimally effective in addressing deficits related to the initial injury and the subsequent surgical intervention. Motor learning to (re-)acquire motor skills and neuroplastic capacities are not sufficiently incorporated during traditional rehabilitation, attesting to the high re-injury rates. The purpose of this article is to present novel clinically integrated motor learning principles to support neuroplasticity that can improve patient functional performance and reduce the risk of second ACL injury. The following key concepts to enhance rehabilitation and prepare the patient for re-integration to sports after an ACL injury that is as safe as possible are presented: (1) external focus of attention, (2) implicit learning, (3) differential learning, (4) self-controlled learning and contextual interference. The novel motor learning principles presented in this manuscript may optimize future rehabilitation programs to reduce second ACL injury risk and early development of osteoarthritis by targeting changes in neural networks.

A Transcranial Stimulation Intervention to Support Flow State Induction

Background: Flow states are considered a positive, subjective experience during an optimal balance between skills and task demands. Previously, experimentally induced flow experiences have relied solely on adaptive tasks. Objective: To investigate whether cathodal transcranial direct current stimulation (tDCS) over the left dorsolateral prefrontal cortex (DLPFC) area and anodal tDCS over the right parietal cortex area during video game play will promote an increased experience of flow states. Methods: Two studies had participants play Tetris or first-person shooter (FPS) video games while receiving either real tDCS or sham stimulation. Tetris recruited 21 untrained players who infrequently played video games while the 11 FPS participants played FPS frequently. Flow experience was assessed before and after stimulation. Results: Compared to sham stimulation, real stimulation increased flow experience for both untrained Tetris and trained FPS players. Improved performance effects were only seen with untrained groups. Conclusion: Cathodal and anodal tDCS over the left DLPFC and right parietal areas, respectively may encourage flow experiences in complex real-life motor tasks that occur during sports, games, and everyday life.

Visual attention, EEG alpha power and T7-Fz connectivity are implicated in prosthetic hand control and can be optimized through gaze training

Background

Prosthetic hands impose a high cognitive burden on the user that often results in fatigue, frustration and prosthesis rejection. However, efforts to directly measure this burden are sparse and little is known about the mechanisms behind it. There is also a lack of evidence-based training interventions designed to improve prosthesis hand control and reduce the mental effort required to use them. In two experiments, we provide the first direct evaluation of this cognitive burden using measurements of EEG and eye-tracking (Experiment 1), and then explore how a novel visuomotor intervention (gaze training; GT) might alleviate it (Experiment 2).

Methods

In Experiment 1, able-bodied participants (n = 20) lifted and moved a jar, first using their anatomical hand and then using a myoelectric prosthetic hand simulator. In experiment 2, a GT group (n = 12) and a movement training (MT) group (n = 12) trained with the prosthetic hand simulator over three one hour sessions in a picking up coins task, before returning for retention, delayed retention and transfer tests. The GT group received instruction regarding how to use their eyes effectively, while the MT group received movement-related instruction typical in rehabilitation.

Results

Experiment 1 revealed that when using the prosthetic hand, participants performed worse, exhibited spatial and temporal disruptions to visual attention, and exhibited a global decrease in EEG alpha power (8-12 Hz), suggesting increased cognitive effort. Experiment 2 showed that GT was the more effective method for expediting prosthesis learning, optimising visual attention, and lowering conscious control – as indexed by reduced T7-Fz connectivity. Whilst the MT group improved performance, they did not reduce hand-focused visual attention and showed increased conscious movement control. The superior benefits of GT transferred to a more complex tea-making task.

Conclusions

These experiments quantify the visual and cortical mechanisms relating to the cognitive burden experienced during prosthetic hand control. They also evidence the efficacy of a GT intervention that alleviated this burden and promoted better learning and transfer, compared to typical rehabilitation instructions. These findings have theoretical and practical implications for prosthesis rehabilitation, the development of emerging prosthesis technologies and for the general understanding of human-tool interactions.

Electronic supplementary material

The online version of this article (10.1186/s12984-019-0524-x) contains supplementary material, which is available to authorized users.

Looking East for Mindfulness: A Glimpse of Practices and Research on Shaolin Martial Arts and Related Practices to Advance Sport Psychology

Although mindfulness is currently receiving attention within sport psychology, there is a lack of discussion on the Eastern origins of mindfulness in the extant sport psychology literature. Several mind‒body practices linked to Chinese Chan and Shaolin martial arts are presented in this paper to illustrate their possible relevance to sport psychology. One takeaway message discussed in relation to the flow experience is that mindful performance of Shaolin martial arts is said to be integral to the psychological transformations associated with realisation of Chan (or “suchness,” satori, Enlightenment), supposedly a goal more likely to be pursued by mindfulness practitioners in the Eastern culture than in the West. Research on Dejian mind‒body intervention, dantian breathing and Shaolin internal martial arts such as Baduanjin and Yijinjing are briefly reviewed to examine the potential psychological benefits of such mind‒body practices. Advancement in sport psychology, particularly in relation to mindfulness-related topics, could benefit from a closer examination of Chan and Shaolin martial arts practices.

Getting to grips with endoscopy - Learning endoscopic surgical skills induces bi-hemispheric plasticity of the grasping network

Endoscopic surgery requires skilled bimanual use of complex instruments that extend the peri-personal workspace. To delineate brain structures involved in learning such surgical skills, 48 medical students without surgical experience were randomly assigned to five training sessions on a virtual-reality endoscopy simulator or to a non-training group. Brain activity was probed with functional MRI while participants performed endoscopic tasks. Repeated task performance in the scanner was sufficient to enhance task-related activity in left ventral premotor cortex (PMv) and the anterior Intraparietal Sulcus (aIPS). Simulator training induced additional increases in task-related activation in right PMv and aIPS and reduced effective connectivity from left to right PMv. Skill improvement after training scaled with stronger task-related activation of the lateral left primary motor hand area (M1-HAND). The results suggest that a bilateral fronto-parietal grasping network and left M1-HAND are engaged in bimanual learning of tool-based manipulations in an extended peri-personal space.

Investigating an errorless learning approach for developing dental operative technique skills: A pilot study

INTRODUCTION

Explicit instruction (conscious knowledge/rules) is generally used for learning dental operative skills; however, recent work has demonstrated advantages of learning skills implicitly with minimal accrual of conscious knowledge and reduced attentional demands. Therefore, this study examined the effects of learning handpiece manipulation skills explicitly (errorful) and implicitly (errorless: limited error detection/correction) under conditions of increased attentional demands (ie multitasking and additional instructions).

MATERIALS AND METHODS

Non-dental university students were randomly assigned to errorless (n = 11) or errorful (n = 8) groups. They used pencil lead instead of a bur, with errorless learners shading shapes from simple (small circle) to complex (cross), while errorful learners shaded the shapes in reverse. During testing, they completed simulated cavities in baseline, additional instructions and multitask conditions. Learning performance was calculated as per cent of the shape shaded successfully. Test performance was computed as error in cavity length/depth and was compared with dental students who had completed their operative technique course (n = 14).

RESULTS

Errorless learners were more accurate than errorful learners especially when shading difficult shapes (P = 0.042). With additional instructions, errorless and errorful learners did not differ in cavity depth (P = 0.057) or length (P = 0.540). When multitasking, errorless learners prepared the cavity length (P = 0.048) but not depth (P = 0.920) more accurately than errorful learners. Overall, performance of errorless learners was comparable to dental students.

CONCLUSIONS

These preliminary findings suggest handpiece skills can be acquired implicitly via errorless learning, and it is less attentionally demanding than errorful learning, as evident by maintenance of preparation performance when processing additional relevant instructions and multitasking.

Non-invasive decoding of hand movements from electroencephalography based on a hierarchical linear regression model

A non-invasive brain-computer interface (BCI) is an assistive technology with basic communication and control capabilities that decodes continuous electroencephalography (EEG) signals generated by the human brain and converts them into commands to control external devices naturally. However, the decoding efficiency is limited at present because it is unclear which decoding parameters can be used to effectively improve the overall decoding performance. In this paper, five subjects performed experiments involving self-initiated upper-limb movements during three experimental phases. The decoding method based on a hierarchical linear regression (HLR) model was devised to investigate the influence of decoding efficiency according to the characteristic parameters of brain functional networks. Then the optimal set of channels and most sensitive frequency bands were selected using the p value from a Kruskal-Wallis test in the experimental phases. Eventually, the trajectories of free movement and conical helix movement could be decoded using HLR. The experimental result showed that the Pearson correlation coefficient (R) between the measured and decoded paths is 0.66 with HLR, which was higher than the value of 0.46 obtained with the multiple linear regression model. The HLR from a decoding efficiency perspective holds promise for the development of EEG-based BCI to aid in the restoration of hand movements in post-stroke rehabilitation.

Toward a Model of Human Information Processing for Decision-Making and Skill Acquisition in Laparoscopic Colorectal Surgery

OBJECTIVE

To create a human information-processing model for laparoscopic surgery based on already established literature and primary research to enhance laparoscopic surgical education in this context.

DESIGN

We reviewed the literature for information-processing models most relevant to laparoscopic surgery. Our review highlighted the necessity for a model that accounts for dynamic environments, perception, allocation of attention resources between the actions of both hands of an operator, and skill acquisition and retention. The results of the literature review were augmented through intraoperative observations of 7 colorectal surgical procedures, supported by laparoscopic video analysis of 12 colorectal procedures.

RESULTS

The Wickens human information-processing model was selected as the most relevant theoretical model to which we make adaptions for this specific application. We expanded the perception subsystem of the model to involve all aspects of perception during laparoscopic surgery. We extended the decision-making system to include dynamic decision-making to account for case/patient-specific and surgeon-specific deviations. The response subsystem now includes dual-task performance and nontechnical skills, such as intraoperative communication. The memory subsystem is expanded to include skill acquisition and retention.

CONCLUSIONS

Surgical decision-making during laparoscopic surgery is the result of a highly complex series of processes influenced not only by the operator's knowledge, but also patient anatomy and interaction with the surgical team. Newer developments in simulation-based education must focus on the theoretically supported elements and events that underpin skill acquisition and affect the cognitive abilities of novice surgeons. The proposed human information-processing model builds on established literature regarding information processing, accounting for a dynamic environment of laparoscopic surgery. This revised model may be used as a foundation for a model describing robotic surgery.

Does practicing a skill with the expectation of teaching alter motor preparatory cortical dynamics?

Recent evidence suggests practicing a motor skill with the expectation of teaching it enhances learning by increasing information processing during motor preparation. However, the specific motor preparatory processes remain unknown. The present study sought to address this shortcoming by employing EEG to assess participants' motor preparatory processes while they completed a golf putting pretest, and then practiced putting with the expectation of (a) teaching another participant how to putt the next day (teach group, n = 30), or (b) being tested on their putting the next day (test group, n = 30). Participants' EEG during the 3-s prior to and 1-s after initiating putter movement was analyzed. All participants completed posttests 1 day after the practice session. The teach group exhibited better posttest performance (superior learning) relative to the test group, but no group differences in motor preparatory processing (EEG) emerged. However, participants in both groups exhibited linear decreases in both theta power at frontal midline and upper-alpha power over motor areas during putt initiation. These results suggest a decrease in working memory and action monitoring (frontal midline theta), and an increase in motor programming (motor upper-alpha) during putt initiation. Further, participants in both groups exhibited increased frontal midline theta from pretest to practice, but decreases in both upper motor-alpha and upper-alpha coherence between left/right temporal and motor planning regions. These results suggest participants utilized working memory and action monitoring to a greater extent during practice relative to pretest, while refining their motor programming and verbal-analytic/visuospatial involvement in motor programming.

A decade of imaging surgeons' brain function (part II): A systematic review of applications for technical and nontechnical skills assessment

BACKGROUND

Functional neuroimaging technologies enable assessment of operator brain function and can deepen our understanding of skills learning, ergonomic optima, and cognitive processes in surgeons. Although there has been a critical mass of data detailing surgeons' brain function, this literature has not been reviewed systematically.

METHODS

A systematic search of original neuroimaging studies assessing surgeons' brain function and published up until November 2016 was conducted using Medline, Embase, and PsycINFO databases.

RESULTS

Twenty-seven studies fulfilled the inclusion criteria, including 3 feasibility studies, 14 studies exploring the neural correlates of technical skill acquisition, and the remainder investigating brain function in the context of intraoperative decision-making (n = 1), neurofeedback training (n = 1), robot-assisted technology (n = 5), and surgical teaching (n = 3). Early stages of learning open surgical tasks (knot-tying) are characterized by prefrontal cortical activation, which subsequently attenuates with deliberate practice. However, with complex laparoscopic skills (intracorporeal suturing), prefrontal cortical engagement requires substantial training, and attenuation occurs over a longer time course, after years of refinement. Neurofeedback and interventions that improve neural efficiency may enhance technical performance and skills learning.

CONCLUSION

Imaging surgeons' brain function has identified neural signatures of expertise that might help inform objective assessment and selection processes. Interventions that improve neural efficiency may target skill-specific brain regions and augment surgical performance.

Reliable Detection of Implicit Waveform-Specific Learning in Continuous Tracking Task Paradigm

Implicit waveform-specific (IWS) learning during a typical continuous tracking task paradigm has been reported for decades, as evidenced by better tracking improvement on the repeated segment of a specific target waveform than random segments. However, the occurrence of the IWS learning in such a task paradigm has been challenged by several unsuccessful results in recent literature. This research concerns reliable detection of the induced IWS learning and to this end, proposes to use the similarity between the cursor and the target along the direction corresponding to the waveform pattern as the performance measure. A 3-day experiment designed with full examination on IWS learning including a practice phase, an immediate test phase and a consolidation test phase after 24 hours was conducted to validate the feasibility and sensitivity of the Pearson's correlation coefficient on the vertical movement r _v in this study. Experiment results indicate that r _v is more sensitive in detecting the IWS learning in all phases compared to the conventional root mean square error (RMSE) performance measure. The findings confirm the importance of the performance measure in implicit learning research and the similarity measure in accordance with the waveform could be promising for waveform-specific learning detection in this paradigm.

Time course of EEG activities in continuous tracking task: a pilot study

Motor learning is crucial to surgical skills enhancement, but its neural mechanism has been investigated only using some simple tasks with limited motor involvement. This study aimed to gain more understanding of the neural dynamics during motor learning by investigating the time course of electroencephalogram (EEG) activities in the continuous tracking task that involves more motor components. One participant performed 16 trials of the continuous tracking task on Day1 and Day2 respectively. The 16-channel EEG signals were recorded and analyzed in both the resting and active states. Results showed that the tracking performance improved from Day1 to Day2. Regarding the EEG, it was found that the relative amplitude in the individual alpha band (IAB) decreased locally over primary motor cortex from the resting state to the active state on both days, and this reduction was more focused on the left primary motor cortex on Day2 compared to Day1. Moreover, in the active state the alpha coherence between central and frontal areas also significantly increased from Day1 to Day2. Time course of alpha activities may explain the tracking performance enhancement from Day1 to Day2. Future work will include more participants to extend the validity of current results.

Conscious Control Is Associated With Freezing of Mechanical Degrees of Freedom During Motor Learning

This study investigated whether conscious control is associated with freezing of mechanical degrees of freedom during motor learning. Participants practiced a throwing task using either error-strewn or error-reduced practice protocols, which encourage high or low levels of conscious control, respectively. After 24 hr, participants engaged in a series of delayed retention and transfer tests. Furthermore, propensity for conscious control was assessed using participants' ratings and freezing was gauged through movement variability of the throwing arm. Performance was defined by mean radial error. In the error-strewn group, propensity for conscious control was positively associated with both freezing and performance. In the error-reduced group, propensity for conscious control was negatively associated with performance, but not with freezing. These results suggest that conscious control is associated with freezing of mechanical degrees of freedom during motor learning.

Electroencephalography Pattern Variations During Motor Skill Acquisition

The present study examined how motor skill acquisition affects electroencephalography patterns and compared short- and long-term electroencephalography variations. For this purpose, 17 volunteers with no history of disease, aged 18 to 22 years, attended seven training sessions every other day to practice a pursuit tracking motor skill. Electroencephalography brainwaves were recorded and analyzed on the first and last days within pre- and post-training intervals. The results showed a significant decrease in performance error and variability with practice over time. This progress slowed at the end of training, and there was no significant improvement in individual performance at the last session. In accordance with performance variations, some changes occurred in brainwaves. Specifically, θ power at Fz and α power at Cz increased on the last test day, compared with the first, while the coherence of α at Fz-T3 and Fz-Cz decreased. β Coherence between Fz-Cz was significantly reduced from pre- to posttest. Based on these results, power changes seem to be more affected by long-term training, whereas coherence changes are sensitive to both short- and long-term training. Specifically, β coherence at Fz-Cz was more influenced by short-term effects of training, whereas θ power at Fz, α power at Cz, and α coherence at Fz-T3 and Fz-Cz were affected by longer training.

Neurocognitive mechanisms of the flow state

While the experience of flow is often described in attentional terms-focused concentration or task absorption-specific cognitive mechanisms have received limited interest. We propose that an attentional explanation provides the best way to advance theoretical models and produce practical applications, as well as providing potential solutions to core issues such as how an objectively difficult task can be subjectively effortless. Recent research has begun to utilize brain-imaging techniques to investigate neurocognitive changes during flow, which enables attentional mechanisms to be understood in greater detail. Some tensions within flow research are discussed; including the dissociation between psychophysiological and experiential measures, and the equivocal neuroimaging findings supporting prominent accounts of hypofrontality. While flow has received only preliminary investigation from a neuroscientific perspective, findings already provide important insights into the crucial role played by higher-order attentional networks, and clear indications of reduced activity in brain regions linked to self-referential processing. The manner in which these processes may benefit sporting performance are discussed.

Automated Task Load Detection with Electroencephalography: Towards Passive Brain–Computer Interfacing in Robotic Surgery

Automatic detection of the current task load of a surgeon in the theatre in real time could provide helpful information, to be used in supportive systems. For example, such information may enable the system to automatically support the surgeon when critical or stressful periods are detected, or to communicate to others when a surgeon is engaged in a complex maneuver and should not be disturbed. Passive brain–computer interfaces (BCI) infer changes in cognitive and affective state by monitoring and interpreting ongoing brain activity recorded via an electroencephalogram. The resulting information can then be used to automatically adapt a technological system to the human user. So far, passive BCI have mostly been investigated in laboratory settings, even though they are intended to be applied in real-world settings. In this study, a passive BCI was used to assess changes in task load of skilled surgeons performing both simple and complex surgical training tasks. Results indicate that the introduced methodology can reliably and continuously detect changes in task load in this realistic environment.

Time course of EEG activities in continuous tracking task: A pilot study

BACKGROUND

Motor learning is important in daily activities and rehabilitation, but its neural mechanism has been only investigated using some simple tasks with limited motor involvement.

OBJECTIVE

This study aimed to gain better understanding of the neural dynamics during motor learning by investigating the time course of electroencephalogram (EEG) activities in the continuous tracking task with more motor components.

METHODS

One participant performed 16 trials of the continuous tracking task on Day1 and Day2 respectively. The 16-channel EEG signals were recorded and analyzed in both the resting and active states.

RESULTS

The tracking performance improved from Day1 to Day2. Regarding the EEG, it was found that the relative amplitude in the individual alpha band (IAB) decreased locally over primary motor cortex from the resting state to the active state on both days, and this reduction was more focused on the left primary motor cortex on Day2 compared to Day1. Moreover, in the active state the alpha coherence between central and frontal areas also significantly increased from Day1 to Day2.

CONCLUSION

Time course of alpha activities may explain the tracking performance enhancement from Day1 to Day2. Future work will include more participants to extend the validity of current results.

Disparity in Frontal Lobe Connectivity on a Complex Bimanual Motor Task Aids in Classification of Operator Skill Level

Objective metrics of technical performance (e.g., dexterity, time, and path length) are insufficient to fully characterize operator skill level, which may be encoded deep within neural function. Unlike reports that capture plasticity across days or weeks, this articles studies long-term plasticity in functional connectivity that occurs over years of professional task practice. Optical neuroimaging data are acquired from professional surgeons of varying experience on a complex bimanual coordination task with the aim of investigating learning-related disparity in frontal lobe functional connectivity that arises as a consequence of motor skill level. The results suggest that prefrontal and premotor seed connectivity is more critical during naïve versus expert performance. Given learning-related differences in connectivity, a least-squares support vector machine with a radial basis function kernel is employed to evaluate skill level using connectivity data. The results demonstrate discrimination of operator skill level with accuracy ≥0.82 and Multiclass Matthew's Correlation Coefficient ≥0.70. Furthermore, these indices are improved when local (i.e., within-region) rather than inter-regional (i.e., between-region) frontal connectivity is considered (p = 0.002). The results suggest that it is possible to classify operator skill level with good accuracy from functional connectivity data, upon which objective assessment and neurofeedback may be used to improve operator performance during technical skill training.

Multitask training promotes automaticity of a fundamental laparoscopic skill without compromising the rate of skill learning

Background

A defining characteristic of expertise is automated performance of skills, which frees attentional capacity to better cope with some common intraoperative stressors. There is a paucity of research on how best to foster automated performance by surgical trainees. This study examined the use of a multitask training approach to promote automated, robust laparoscopic skills.

Methods

Eighty-one medical students completed training of a fundamental laparoscopic task in either a traditional single-task training condition or a novel multitask training condition. Following training, participants’ laparoscopic performance was tested in a retention test, two stress transfer tests (distraction and time pressure) and a secondary task test, which was included to evaluate automaticity of performance. The laparoscopic task was also performed as part of a formal clinical examination (OSCE).

Results

The training groups did not differ in the number of trials required to reach task proficiency (p = .72), retention of skill (ps > .45), or performance in the clinical examination (p = .14); however, the groups did differ with respect to the secondary task (p = .016). The movement efficiency (number of hand movements) of single-task trainees, but not multitask trainees, was negatively affected during the secondary task test. The two stress transfer tests had no discernable impact on the performance of either training group.

Conclusion

Multitask training was not detrimental to the rate of learning of a fundamental laparoscopic skill and added value by providing resilience in the face of a secondary task load, indicative of skill automaticity. Further work is needed to determine the extent of the clinical utility afforded by multitask training.

The impact of expert visual guidance on trainee visual search strategy, visual attention and motor skills

Minimally invasive and robotic surgery changes the capacity for surgical mentors to guide their trainees with the control customary to open surgery. This neuroergonomic study aims to assess a "Collaborative Gaze Channel" (CGC); which detects trainer gaze-behavior and displays the point of regard to the trainee. A randomized crossover study was conducted in which twenty subjects performed a simulated robotic surgical task necessitating collaboration either with verbal (control condition) or visual guidance with CGC (study condition). Trainee occipito-parietal (O-P) cortical function was assessed with optical topography (OT) and gaze-behavior was evaluated using video-oculography. Performance during gaze-assistance was significantly superior [biopsy number: (mean ± SD): control = 5.6 ± 1.8 vs. CGC = 6.6 ± 2.0; p < 0.05] and was associated with significantly lower O-P cortical activity [ΔHbO2 mMol × cm [median (IQR)] control = 2.5 (12.0) vs. CGC 0.63 (11.2), p < 0.001]. A random effect model (REM) confirmed the association between guidance mode and O-P excitation. Network cost and global efficiency were not significantly influenced by guidance mode. A gaze channel enhances performance, modulates visual search, and alleviates the burden in brain centers subserving visual attention and does not induce changes in the trainee's O-P functional network observable with the current OT technique. The results imply that through visual guidance, attentional resources may be liberated, potentially improving the capability of trainees to attend to other safety critical events during the procedure.

Understanding Cognitive Performance During Robot-Assisted Surgery

OBJECTIVE

To understand cognitive function of an expert surgeon in various surgical scenarios while performing robot-assisted surgery.

MATERIALS AND METHODS

In an Internal Review Board approved study, National Aeronautics and Space Administration-Task Load Index (NASA-TLX) questionnaire with surgical field notes were simultaneously completed. A wireless electroencephalography (EEG) headset was used to monitor brain activity during all procedures. Three key portions were evaluated: lysis of adhesions, extended lymph node dissection, and urethro-vesical anastomosis (UVA). Cognitive metrics extracted were distraction, mental workload, and mental state.

RESULTS

In evaluating lysis of adhesions, mental state (EEG) was associated with better performance (NASA-TLX). Utilizing more mental resources resulted in better performance as self-reported. Outcomes of lysis were highly dependent on cognitive function and decision-making skills. In evaluating extended lymph node dissection, there was a negative correlation between distraction level (EEG) and mental demand, physical demand and effort (NASA-TLX). Similar to lysis of adhesion, utilizing more mental resources resulted in better performance (NASA-TLX). Lastly, with UVA, workload (EEG) negatively correlated with mental and temporal demand and was associated with better performance (NASA-TLX). The EEG recorded workload as seen here was a combination of both cognitive performance (finding solution) and motor workload (execution). Majority of workload was contributed by motor workload of an expert surgeon. During UVA, muscle memory and motor skills of expert are keys to completing the UVA.

CONCLUSION

Cognitive analysis shows that expert surgeons utilized different mental resources based on their need.

Peyton's four-step approach: differential effects of single instructional steps on procedural and memory performance - a clarification study

BACKGROUND

Although Peyton's four-step approach is a widely used method for skills-lab training in undergraduate medical education and has been shown to be more effective than standard instruction, it is unclear whether its superiority can be attributed to a specific single step.

PURPOSE

We conducted a randomized controlled trial to investigate the differential learning outcomes of the separate steps of Peyton's four-step approach.

METHODS

Volunteer medical students were randomly assigned to four different groups. Step-1 group received Peyton's Step 1, Step-2 group received Peyton's Steps 1 and 2, Step-3 group received Peyton's Steps 1, 2, and 3, and Step-3mod group received Peyton's Steps 1 and 2, followed by a repetition of Step 2. Following the training, the first independent performance of a central venous catheter (CVC) insertion using a manikin was video-recorded and scored by independent video assessors using binary checklists. The day after the training, memory performance during delayed recall was assessed with an incidental free recall test.

RESULTS

A total of 97 participants agreed to participate in the trial. There were no statistically significant group differences with regard to age, sex, completed education in a medical profession, completed medical clerkships, preliminary memory tests, or self-efficacy ratings. Regarding checklist ratings, Step-2 group showed a superior first independent performance of CVC placement compared to Step-1 group (P<0.001), and Step-3 group showed a superior performance to Step-2 group (P<0.009), while Step-2 group and Step-3mod group did not differ (P=0.055). The findings were similar in the incidental free recall test.

CONCLUSION

Our study identified Peyton's Step 3 as being the most crucial part within Peyton's four-step approach, contributing significantly more to learning success than the previous steps and reaching beyond the benefit of a mere repetition of skills demonstration.

Cognitive skills assessment during robot-assisted surgery: separating the wheat from the chaff

OBJECTIVE

To investigate the utility of cognitive assessment during robot-assisted surgery (RAS) to define skills in terms of cognitive engagement, mental workload, and mental state; while objectively differentiating between novice and expert surgeons.

SUBJECTS AND METHODS

In all, 10 surgeons with varying operative experience were assigned to beginner (BG), combined competent and proficient (CPG), and expert (EG) groups based on the Dreyfus model. The participants performed tasks for basic, intermediate and advanced skills on the da Vinci Surgical System. Participant performance was assessed using both tool-based and cognitive metrics.

RESULTS

Tool-based metrics showed significant differences between the BG vs CPG and the BG vs EG, in basic skills. While performing intermediate skills, there were significant differences only on the instrument-to-instrument collisions between the BG vs CPG (2.0 vs 0.2, P = 0.028), and the BG vs EG (2.0 vs 0.1, P = 0.018). There were no significant differences between the CPG and EG for both basic and intermediate skills. However, using cognitive metrics, there were significant differences between all groups for the basic and intermediate skills. In advanced skills, there were no significant differences between the CPG and the EG except time (1116 vs 599.6 s), using tool-based metrics. However, cognitive metrics revealed significant differences between both groups.

CONCLUSION

Cognitive assessment of surgeons may aid in defining levels of expertise performing complex surgical tasks once competence is achieved. Cognitive assessment may be used as an adjunct to the traditional methods for skill assessment during RAS.

Effects of error experience when learning to simulate hypernasality

PURPOSE

The purpose of this study was to evaluate the effects of error experience on the acquisition of hypernasal speech.

METHOD

Twenty-eight healthy participants were asked to simulate hypernasality in either an errorless learning condition (in which the possibility for errors was limited) or an errorful learning condition (in which the possibility for errors was not limited). The nasality level of the participants' speech was measured with a nasometer and reflected by nasalance scores (in percentages). Errorless learners practiced producing hypernasal speech with a threshold nasalance score of 10% at the beginning, gradually increasing to a threshold of 50% at the end. The same set of threshold targets were presented to errorful learners but in a reversed order. Errors were defined by the proportion of speech with a nasalance score below the threshold. A retention test and a transfer test were administered.

RESULTS

Relative to errorful learners, errorless learners displayed fewer errors and a higher mean nasalance score during acquisition. Furthermore, errorless learners outperformed errorful learners in both retention and transfer tests.

CONCLUSION

The results suggest that errorless learning is more effective than errorful learning in acquiring a novel speech motor task that involves manipulation of the nasality level of speech.

Refining the continuous tracking paradigm to investigate implicit motor learning

In two experiments we investigated factors that undermine conclusions about implicit motor learning in the continuous tracking paradigm. In Experiment 1, we constructed a practice phase in which all three segments of the waveform pattern were random, in order to examine whether tracking performance decreased as a consequence of time spent on task. Tracking error was lower in the first segment than in the middle segment and lower in the middle segment than in the final segment, indicating that tracking performance decreased as a function of increasing time-on-task. In Experiment 2, the waveform pattern presented in the middle segment was identical in each trial of practice. In a retention test, tracking performance on the repeated segment was superior to tracking performance on the random segments of the waveform. Furthermore, substitution of the repeated pattern with a random pattern (in a transfer test) resulted in a significantly increased tracking error. These findings imply that characteristics of the repeated pattern were learned. Crucially, tests of pattern recognition implied that participants were not explicitly aware of the presence of a recurring segment of waveform. Recommendations for refining the continuous tracking paradigm for implicit learning research are proposed.

Spectral modulation of frontal EEG during motor skill acquisition: a mobile EEG study

This study investigates the modulation of frontal EEG dynamics with respect to progress in motor skill acquisition using a wireless EEG system with a single dry sensor. Participants were required to complete repeated trials of a computerized visual-motor task similar to mirror drawing while the EEG was collected. In each trial, task performance of the participants was summarized with a familiarity index which took into account the performance accuracy, completion rate and time. Our findings demonstrated that certain EEG power spectra decreased with an increase in motor task familiarity. In particular, frontal EEG activities in delta and theta bands of the whole trial and in gamma band in the middle of the trial are having a significant negative relationship with the overall familiarity level of the task. The findings suggest that frontal EEG spectra are significantly modulated during motor skill acquisition. Results of this study shed light on the possibility of simultaneous monitoring of brain activity during an unconstrained natural task with a single dry sensor mobile EEG in an everyday environment.

External attentional focus enhances movement automatization: a comprehensive test of the constrained action hypothesis

An external focus of attention has been shown to result in superior motor performance compared to an internal focus of attention. This study investigated whether this is due to enhanced levels of movement automatization, as predicted by the constrained action hypothesis (McNevin, Shea, & Wulf, 2003). Thirty healthy participants performed a cyclic one-leg extension-flexion task with both the dominant and non-dominant leg. Focus of attention was manipulated via instructions. The degree of automatization of movement was assessed by measuring dual task costs as well as movement execution parameters (i.e., EMG activity, movement fluency, and movement regularity). Results revealed that an external focus of attention led to significantly better motor performance (i.e., shorter movement duration) than an internal focus. Although dual task costs of the motor task did not differ as a function of attentional focus, cognitive dual task costs were significantly higher when attention was directed internally. An external focus of attention resulted in more fluent and more regular movement execution than an internal focus, whereas no differences were found concerning muscular activity. These results indicate that an external focus of attention results in more automatized movements than an internal focus and, therefore, provide support for the constrained action hypothesis.

Technical competence in surgeons

In this paper, we review the literature to date on technical competence in surgeons; how it can be defined, taught to trainees and assessed. We also examine how we can predict which candidates for surgical training will most likely develop technical competence. While technical competency is just one aspect of what makes a good surgeon, we have recognized a need to review the literature in this area and to combine this with broader definitions of competency. Our review found that several methods are available to objectively measure, assess and predict technical competence and should be used in surgical training.

Enhanced frontoparietal network architectures following "gaze-contingent" versus "free-hand" motor learning

Longitudinal changes in cortical function are known to accompany motor skills learning, and can be detected as an evolution in the activation map. These changes include attenuation in activation in the prefrontal cortex and increased activation in primary and secondary motor regions, the cerebellum and posterior parietal cortex. Despite this, comparatively little is known regarding the impact of the mode or type of training on the speed of activation map plasticity and on longitudinal variation in network architectures. To address this, we randomised twenty-one subjects to learn a complex motor tracking task delivered across six practice sessions in either "free-hand" or "gaze-contingent motor control" mode, during which frontoparietal cortical function was evaluated using functional near infrared spectroscopy. Results demonstrate that upon practice termination, gaze-assisted learners had achieved superior technical performance compared to free-hand learners. Furthermore, evolution in frontoparietal activation foci indicative of expertise was achieved at an earlier stage in practice amongst gaze-assisted learners. Both groups exhibited economical small world topology; however, networks in learners randomised to gaze-assistance were less costly and showed higher values of local efficiency suggesting improved frontoparietal communication in this group. We conclude that the benefits of gaze-assisted motor learning are evidenced by improved technical accuracy, more rapid task internalisation and greater neuronal efficiency. This form of assisted motor learning may have occupational relevance for high precision control such as in surgery or following re-learning as part of stroke rehabilitation.

Cheating experience: Guiding novices to adopt the gaze strategies of experts expedites the learning of technical laparoscopic skills

BACKGROUND

Previous research has demonstrated that trainees can be taught (via explicit verbal instruction) to adopt the gaze strategies of expert laparoscopic surgeons. The current study examined a software template designed to guide trainees to adopt expert gaze control strategies passively, without being provided with explicit instructions.

METHODS

We examined 27 novices (who had no laparoscopic training) performing 50 learning trials of a laparoscopic training task in either a discovery-learning (DL) group or a gaze-training (GT) group while wearing an eye tracker to assess gaze control. The GT group performed trials using a surgery-training template (STT); software that is designed to guide expert-like gaze strategies by highlighting the key locations on the monitor screen. The DL group had a normal, unrestricted view of the scene on the monitor screen. Both groups then took part in a nondelayed retention test (to assess learning) and a stress test (under social evaluative threat) with a normal view of the scene.

RESULTS

The STT was successful in guiding the GT group to adopt an expert-like gaze strategy (displaying more target-locking fixations). Adopting expert gaze strategies led to an improvement in performance for the GT group, which outperformed the DL group in both retention and stress tests (faster completion time and fewer errors).

CONCLUSION

The STT is a practical and cost-effective training interface that automatically promotes an optimal gaze strategy. Trainees who are trained to adopt the efficient target-locking gaze strategy of experts gain a performance advantage over trainees left to discover their own strategies for task completion.

Conscious monitoring and control (reinvestment) in surgical performance under pressure

Background

Research on intraoperative stressors has focused on external factors without considering individual differences in the ability to cope with stress. One individual difference that is implicated in adverse effects of stress on performance is “reinvestment,” the propensity for conscious monitoring and control of movements. The aim of this study was to examine the impact of reinvestment on laparoscopic performance under time pressure.

Methods

Thirty-one medical students (surgery rotation) were divided into high- and low-reinvestment groups. Participants were first trained to proficiency on a peg transfer task and then tested on the same task in a control and time pressure condition. Outcome measures included generic performance and process measures. Stress levels were assessed using heart rate and the State Trait Anxiety Inventory (STAI).

Results

High and low reinvestors demonstrated increased anxiety levels from control to time pressure conditions as indicated by their STAI scores, although no differences in heart rate were found. Low reinvestors performed significantly faster when under time pressure, whereas high reinvestors showed no change in performance times. Low reinvestors tended to display greater performance efficiency (shorter path lengths, fewer hand movements) than high reinvestors.

Conclusion

Trained medical students with a high individual propensity to consciously monitor and control their movements (high reinvestors) displayed less capability (than low reinvestors) to meet the demands imposed by time pressure during a laparoscopic task. The finding implies that the propensity for reinvestment may have a moderating effect on laparoscopic performance under time pressure.

Gaze training enhances laparoscopic technical skill acquisition and multi-tasking performance: a randomized, controlled study

Background

The operating room environment is replete with stressors and distractions that increase the attention demands of what are already complex psychomotor procedures. Contemporary research in other fields (e.g., sport) has revealed that gaze training interventions may support the development of robust movement skills. This current study was designed to examine the utility of gaze training for technical laparoscopic skills and to test performance under multitasking conditions.

Methods

Thirty medical trainees with no laparoscopic experience were divided randomly into one of three treatment groups: gaze trained (GAZE), movement trained (MOVE), and discovery learning/control (DISCOVERY). Participants were fitted with a Mobile Eye gaze registration system, which measures eye-line of gaze at 25 Hz. Training consisted of ten repetitions of the “eye-hand coordination” task from the LAP Mentor VR laparoscopic surgical simulator while receiving instruction and video feedback (specific to each treatment condition). After training, all participants completed a control test (designed to assess learning) and a multitasking transfer test, in which they completed the procedure while performing a concurrent tone counting task.

Results

Not only did the GAZE group learn more quickly than the MOVE and DISCOVERY groups (faster completion times in the control test), but the performance difference was even more pronounced when multitasking. Differences in gaze control (target locking fixations), rather than tool movement measures (tool path length), underpinned this performance advantage for GAZE training.

Conclusions

These results suggest that although the GAZE intervention focused on training gaze behavior only, there were indirect benefits for movement behaviors and performance efficiency. Additionally, focusing on a single external target when learning, rather than on complex movement patterns, may have freed-up attentional resources that could be applied to concurrent cognitive tasks.