Motor Adaptation Deficits in Ideomotor Apraxia

Limb-related sensory prediction errors and task-related performance errors facilitate human sensorimotor learning through separate mechanisms

The unpredictable nature of our world can introduce a variety of errors in our actions, including sensory prediction errors (SPEs) and task performance errors (TPEs). SPEs arise when our existing internal models of limb-environment properties and interactions become miscalibrated due to changes in the environment, while TPEs occur when environmental perturbations hinder achievement of task goals. The precise mechanisms employed by the sensorimotor system to learn from such limb- and task-related errors and improve future performance are not comprehensively understood. To gain insight into these mechanisms, we performed a series of learning experiments wherein the location and size of a reach target were varied, the visual feedback of the motion was perturbed in different ways, and instructions were carefully manipulated. Our findings indicate that the mechanisms employed to compensate SPEs and TPEs are dissociable. Specifically, our results fail to support theories that suggest that TPEs trigger implicit refinement of reach plans or that their occurrence automatically modulates SPE-mediated learning. Rather, TPEs drive improved action selection, that is, the selection of verbally sensitive, volitional strategies that reduce future errors. Moreover, we find that exposure to SPEs is necessary and sufficient to trigger implicit recalibration. When SPE-mediated implicit learning and TPE-driven improved action selection combine, performance gains are larger. However, when actions are always successful and strategies are not employed, refinement in behavior is smaller. Flexibly weighting strategic action selection and implicit recalibration could thus be a way of controlling how much, and how quickly, we learn from errors.

The independence of impairments in proprioception and visuomotor adaptation after stroke

BACKGROUND

Proprioceptive impairments are common after stroke and are associated with worse motor recovery and poor rehabilitation outcomes. Motor learning may also be an important factor in motor recovery, and some evidence in healthy adults suggests that reduced proprioceptive function is associated with reductions in motor learning. It is unclear how impairments in proprioception and motor learning relate after stroke. Here we used robotics and a traditional clinical assessment to examine the link between impairments in proprioception after stroke and a type of motor learning known as visuomotor adaptation.

METHODS

We recruited participants with first-time unilateral stroke and controls matched for overall age and sex. Proprioceptive impairments in the more affected arm were assessed using robotic arm position- (APM) and movement-matching (AMM) tasks. We also assessed proprioceptive impairments using a clinical scale (Thumb Localization Test; TLT). Visuomotor adaptation was assessed using a task that systematically rotated hand cursor feedback during reaching movements (VMR). We quantified how much participants adapted to the disturbance and how many trials they took to adapt to the same levels as controls. Spearman's rho was used to examine the relationship between proprioception, assessed using robotics and the TLT, and visuomotor adaptation. Data from healthy adults were used to identify participants with stroke who were impaired in proprioception and visuomotor adaptation. The independence of impairments in proprioception and adaptation were examined using Fisher's exact tests.

RESULTS

Impairments in proprioception (58.3%) and adaptation (52.1%) were common in participants with stroke (n = 48; 2.10% acute, 70.8% subacute, 27.1% chronic stroke). Performance on the APM task, AMM task, and TLT scores correlated weakly with measures of visuomotor adaptation. Fisher's exact tests demonstrated that impairments in proprioception, assessed using robotics and the TLT, were independent from impairments in visuomotor adaptation in our sample.

CONCLUSION

Our results suggest impairments in proprioception may be independent from impairments in visuomotor adaptation after stroke. Further studies are needed to understand factors that influence the relationship between motor learning, proprioception and other rehabilitation outcomes throughout stroke recovery.

Feasibility and Validation of a Robotic-Based Multisensory Integration Assessment in Healthy Controls and a Stroke Patient

After experiencing brain damage, stroke patients commonly suffer from motor and sensory impairments that impact their ability to perform volitional movements. Visuo-proprioceptive integration is a critical component of voluntary movement, allowing for accurate movements and a sense of ownership over one's body. While recent studies have increased our understanding of the balance between visual compensation and proprioceptive deficits in stroke patients, quantitative methods for studying multisensory integration are still lacking. This study aimed to evaluate the feasibility of adapting a 3D visuo-proprioceptive disparity (VPD) task into a 2D setting using an upper-limb robotic platform for moderate to severe chronic stroke patients. To assess the implementation of the 2D task, a cohort of unimpaired healthy participants performed the VPD task in both a 3D and 2D environment. We used a computational Bayesian model to predict errors in visuo-proprioceptive integration and compared the model's predictions to real behavioral data. Our findings indicated that the behavioral trends observed in the 2D and 3D tasks were similar, and the model accurately predicted behavior. We then evaluated the feasibility of our task to assess post-stroke deficits in a patient with severe motor and sensory deficits. Ultimately, this work may help to improve our understanding of the significance of visuo-proprioceptive integration and aid in the development of better rehabilitation therapies for improving sensorimotor outcomes in stroke patients.

Bimanual coordination during reach-to-grasp actions is sensitive to task goal with distinctions between left- and right-hemispheric stroke

The perceptual feature of a task such as how a task goal is perceived influences performance and coordination of bimanual actions in neurotypical adults. To assess how bimanual task goal modifies paretic and non-paretic arm performance and bimanual coordination in individuals with stroke affecting left and right hemispheres, 30 participants with hemispheric stroke (15 right-hemisphere damage-RHD); 15 left-hemisphere damage-LHD) and 10 age-matched controls performed reach-to-grasp and pick-up actions under bimanual common-goal (i.e., two physically coupled dowels), bimanual independent-goal (two physically uncoupled dowels), and unimanual conditions. Reach-to-grasp time and peak grasp aperture indexed motor performance, while time lags between peak reach velocities, peak grasp apertures, and peak pick-up velocities of the two hands characterized reach, grasp, and pick-up coordination, respectively. Compared to unimanual actions, bimanual actions significantly slowed non-paretic arm speed to match paretic arm speed, thus affording no benefit to paretic arm performance. Detriments in non-paretic arm performance during bimanual actions was more pronounced in the RHD group. Under common-goal conditions, movements were faster with smaller peak grasp apertures compared to independent-goal conditions for all groups. Compared to controls, individuals with stroke demonstrated poor grasp and pick-up coordination. Of the patient groups, patients with LHD showed more pronounced deficits in grasp coordination between hands. Finally, grasp coordination deficits related to paretic arm motor deficits (upper extremity Fugl-Meyer score) for LHD group, and to Trail-Making Test performance for RHD group. Findings suggest that task goal and distinct clinical deficits influence bimanual performance and coordination in patients with left- and right-hemispheric stroke.

Assessing Impairments in Visuomotor Adaptation After Stroke

Background:

Motor impairment in the arms is common after stroke and many individuals participate in therapy to improve function. It is assumed that individuals with stroke can adapt and improve their movements using feedback that arises from movement or is provided by a therapist. Here we investigated visuomotor adaptation in individuals with sub-acute and chronic stroke.

Objective:

We examined the impact of the stroke-affected arm (dominant or non-dominant), time post-stroke, and relationships with clinical measures of motor impairment and functional independence.

Methods:

Participants performed reaching movements with their arm supported in a robotic exoskeleton. We rotated the relationship between the motion of the participant’s hand and a feedback cursor displayed in their workspace. Outcome measures included the amount that participants adapted their arm movements and the number of trials they required to adapt.

Results:

Participants with stroke (n = 36) adapted less and required more trials to adapt than controls (n = 29). Stroke affecting the dominant arm impaired the amount of adaptation more than stroke affecting the non-dominant arm. Overall, 53% of participants with stroke were impaired in one or more measures of visuomotor adaptation. Initial adaptation was weakly correlated with time post-stroke, and the amount of adaptation correlated moderately with clinical measures of motor impairment and functional independence.

Conclusion:

Our findings reveal impairments in visuomotor adaptation that are associated with motor impairment and function after stroke. Longitudinal studies are needed to understand the relationship between adaptation and recovery attained in a therapy setting.

Symmetric interlimb transfer of newly acquired skilled movements

In this study, we aimed to examine features of interlimb generalization or "transfer" of newly acquired motor skills, with a broader goal of better understanding the mechanisms mediating skill learning. Right-handed participants (n = 36) learned a motor task that required them to make very rapid but accurate reaches to one of eight randomly presented targets, thus bettering the typical speed-accuracy tradeoff. Subjects were divided into an "RL" group that first trained with the right arm and was then tested on the left and an "LR" group that trained with the left arm and was subsequently tested on the right. We found significant interlimb transfer in both groups. Remarkably, we also observed that participants learned faster with their left arm compared with the right. We hypothesized that this could be due to a previously suggested left arm/right hemisphere advantage for movements under variable task conditions. To corroborate this, we recruited two additional groups of participants (n = 22) that practiced the same task under a single target condition. This removal of task level variability eliminated learning rate differences between the arms, yet interlimb transfer remained robust and symmetric, as in the first experiment. Additionally, the strategy used to reduce errors during learning, albeit heterogeneous across subjects particularly in our second experiment, was adopted by the untrained arm. These findings may be best explained as the outcome of the operation of cognitive strategies during the early stages of motor skill learning.NEW & NOTEWORTHY How newly acquired motor skills generalize across effectors is not well understood. Here, we show that newly learned skilled actions transfer symmetrically across the arms and that task-level variability influences learning rate but not transfer magnitude or direction. Interestingly, strategies developed during learning with one arm transfer to the untrained arm. This likely reflects the outcome of learning driven by cognitive mechanisms during the initial stages of motor skill acquisition.

Mechanistic determinants of effector-independent motor memory encoding

Coordinated, purposeful movements learned with one effector generalize to another effector, a finding that has important implications for tool use, sports, performing arts, and rehabilitation. This occurs because the motor memory acquired through learning comprises representations that are effector-independent. Despite knowing this for decades, the neural mechanisms and substrates that are causally associated with the encoding of effector-independent motor memories remain poorly understood. Here we exploit intereffector generalization, the behavioral signature of effector-independent representations, to address this crucial gap. We first show in healthy human participants that postlearning generalization across effectors is principally predicted by the level of an implicit mechanism that evolves gradually during learning to produce a temporally stable memory. We then demonstrate that interfering with left but not right posterior parietal cortex (PPC) using high-definition cathodal transcranial direct current stimulation impedes learning mediated by this mechanism, thus potentially preventing the encoding of effector-independent memory components. We confirm this in our final experiment in which we show that disrupting left PPC but not primary motor cortex after learning has been allowed to occur blocks intereffector generalization. Collectively, our results reveal the key mechanism that encodes an effector-independent memory trace and uncover a central role for the PPC in its representation. The encoding of such motor memory components outside primary sensorimotor regions likely underlies a parsimonious neural organization that enables more efficient movement planning in the brain, independent of the effector used to act.

Deep Cerebellar Transcranial Direct Current Stimulation of the Dentate Nucleus to Facilitate Standing Balance in Chronic Stroke Survivors-A Pilot Study

Objective: Cerebrovascular accidents are the second leading cause of death and the third leading cause of disability worldwide. We hypothesized that cerebellar transcranial direct current stimulation (ctDCS) of the dentate nuclei and the lower-limb representations in the cerebellum can improve functional reach during standing balance in chronic (>6 months’ post-stroke) stroke survivors. Materials and Methods: Magnetic resonance imaging (MRI) based subject-specific electric field was computed across a convenience sample of 10 male chronic (>6 months) stroke survivors and one healthy MRI template to find an optimal bipolar bilateral ctDCS montage to target dentate nuclei and lower-limb representations (lobules VII–IX). Then, in a repeated-measure crossover study on a subset of 5 stroke survivors, we compared 15 min of 2 mA ctDCS based on the effects on successful functional reach (%) during standing balance task. Three-way ANOVA investigated the factors of interest– brain regions, montages, stroke participants, and their interactions. Results: “One-size-fits-all” bipolar ctDCS montage for the clinical study was found to be PO9h–PO10h for dentate nuclei and Exx7–Exx8 for lobules VII–IX with the contralesional anode. PO9h–PO10h ctDCS performed significantly (alpha = 0.05) better in facilitating successful functional reach (%) when compared to Exx7–Exx8 ctDCS. Furthermore, a linear relationship between successful functional reach (%) and electric field strength was found where PO9h–PO10h montage resulted in a significantly (alpha = 0.05) higher electric field strength when compared to Exx7–Exx8 montage for the same 2 mA current. Conclusion: We presented a rational neuroimaging based approach to optimize deep ctDCS of the dentate nuclei and lower limb representations in the cerebellum for post-stroke balance rehabilitation. However, this promising pilot study was limited by “one-size-fits-all” bipolar ctDCS montage as well as a small sample size.

Action Observation for Neurorehabilitation in Apraxia

Neurorehabilitation and brain stimulation studies of post-stroke patients suggest that action-observation effects can lead to rapid improvements in the recovery of motor functions and long-term motor cortical reorganization. Apraxia is a clinically important disorder characterized by marked impairment in representing and performing skillful movements [gestures], which limits many daily activities and impedes independent functioning. Recent clinical research has revealed errors of visuo-motor integration in patients with apraxia. This paper presents a rehabilitative perspective focusing on the possibility of action observation as a therapeutic treatment for patients with apraxia. This perspective also outlines impacts on neurorehabilitation and brain repair following the reinforcement of the perceptual-motor coupling. To date, interventions based primarily on action observation in apraxia have not been undertaken.

Distortion of Visuo-Motor Temporal Integration in Apraxia: Evidence From Delayed Visual Feedback Detection Tasks and Voxel-Based Lesion-Symptom Mapping

Limb apraxia is a higher brain dysfunction that typically occurs after left hemispheric stroke and its cause cannot be explained by sensory disturbance or motor paralysis. The comparison of motor signals and visual feedback to generate errors, i.e., visuo-motor integration, is important in motor control and motor learning, which may be impaired in apraxia. However, in apraxia after stroke, it is unknown whether there is a specific deficit in visuo-motor temporal integration compared to visuo-tactile and visuo-proprioceptive temporal integration. We examined the precision of visuo-motor temporal integration and sensory-sensory (visuo-tactile and visuo-proprioception) temporal integration in apraxia after stroke by using a delayed visual feedback detection task with three different conditions (tactile, passive movement, and active movement). The delay detection threshold and the probability curve for delay detection obtained in this task were quantitative indicators of the respective temporal integration functions. In addition, we performed subtraction and voxel-based lesion-symptom mapping to identify the brain lesions responsible for apraxia and deficits in visuo-motor temporal integration. The behavioral experiments showed that the delay detection threshold was extended and that the probability curve for delay detection was less steep in apraxic patients compared to controls (pseudo-apraxic patients and unaffected patients), only for the active movement condition, and not for the tactile and passive movement conditions. Furthermore, the severity of apraxia was significantly correlated with the delay detection threshold and the steepness of the probability curve in the active movement condition. These results indicated that multisensory (i.e., visual, tactile, and proprioception) feedback was normally temporally integrated, but motor prediction and visual feedback were not correctly temporally integrated in apraxic patients. That is, apraxic patients had difficulties with visuo-motor temporal integration. Lesion analyses revealed that both apraxia and the distortion of visuo-motor temporal integration were associated with lesions in the fronto-parietal motor network, including the left inferior parietal lobule and left inferior frontal gyrus. We suppose that damage to the left inferior fronto-parietal network could cause deficits in motor prediction for visuo-motor temporal integration, but not for sensory-sensory (visuo-tactile and visuo-proprioception) temporal integration, leading to the distortion of visuo-motor temporal integration in patients with apraxia.

Interference between competing motor memories developed through learning with different limbs

Learning from motor errors that occur across different limbs is essential for effective tool use, sports training, and rehabilitation. To probe the neural organization of error-driven learning across limbs, we asked whether learning opposing visuomotor mappings with the two arms would interfere. Young right-handers first adapted to opposite visuomotor rotations A and B with different arms and were then reexposed to A 24 h later. We observed that relearning of A was never faster nor were initial errors smaller than prior A learning, which would be expected if there was no interference from B. Rather, errors were greater than or similar to, and learning rate was slower than or comparable to, previous A learning depending on the order in which the arms learned. This indicated robust interference between the motor memories of A and B when they were learned with different arms in close succession. We then proceeded to uncover that the order-dependent asymmetry in performance upon reexposure resulted from asymmetric transfer of learning from the left arm to the right but not vice versa and that the observed interference was retrograde in nature. Such retrograde interference likely occurs because the two arms require the same neural resources for learning, a suggestion consistent with that of our past work showing impaired learning following left inferior parietal damage regardless of the arm used. These results thus point to a common neural basis for formation of new motor memories with different limbs and hold significant implications for how newly formed motor memories interact. NEW & NOTEWORTHY In a series of experiments, we demonstrate robust retrograde interference between competing motor memories developed through error-based learning with different arms. These results provide evidence for shared neural resources for the acquisition of motor memories across different limbs and also suggest that practice with two effectors in close succession may not be a sound approach in either sports or rehabilitation. Such training may not allow newly acquired motor memories to be stabilized.

The Neuropsychology of Movement and Movement Disorders: Neuroanatomical and Cognitive Considerations

This paper highlights major developments over the past two to three decades in the neuropsychology of movement and its disorders. We focus on studies in healthy individuals and patients, which have identified cognitive contributions to movement control and animal work that has delineated the neural circuitry that makes these interactions possible. We cover advances in three major areas: (1) the neuroanatomical aspects of the "motor" system with an emphasis on multiple parallel circuits that include cortical, corticostriate, and corticocerebellar connections; (2) behavioral paradigms that have enabled an appreciation of the cognitive influences on the preparation and execution of movement; and (3) hemispheric differences (exemplified by limb praxis, motor sequencing, and motor learning). Finally, we discuss the clinical implications of this work, and make suggestions for future research in this area. (JINS, 2017, 23, 768-777).