How to help cerebellar patients make the most of their remaining learning capacities

The P3 event-related potential increases when humans learn a strategy for motor adaptation

Human motor learning involves cognitive strategies in addition to implicit adaptation. Differences in systems-level neurophysiology between strategy-based and implicit learning remain poorly understood. We asked how the P3 event-related potential, an electroencephalography signal known to increase during early motor learning, relates to strategy-based learning and implicit adaptation. We re-analysed data from two experiments, in which participants (n = 64) reached towards a visual target, with online visual feedback replacing vision of their moving hand. We induced learning by rotating the visual feedback. In the first experiment, feedback rotations were turned on during pairs of two consecutive trials, interspersed between non-rotated trials. In one condition, feedback was rotated relative to the actual movement, allowing participants to develop a re-aiming strategy on the second trial of each pair, while it was rotated relative to the target in the other condition, rendering re-aiming futile. P3 amplitude increased in the first rotated trial in both conditions, but this increase was more pronounced in the re-aiming condition. In the second experiment, a constant visuomotor rotation was turned on for many consecutive trials. We instructed one group beforehand how to re-aim successfully, while the other group had to develop a strategy by themselves. P3 amplitude increased during early adaptation only in the latter group. These findings collectively suggest that in the context of motor learning, the P3 ERP is associated with a need to develop, or adjust, a cognitive strategy.

Effectiveness of rehabilitation intervention in persons with Friedreich ataxia

Introduction

The relevance of rehabilitation in progressive neurological disorders, such as Friedreich's Ataxia (FRDA), has yet to be convincingly proven. FRDA is characterized by ataxia, loss of gait, scoliosis, cardiomyopathy, dysarthria and dysphagia, with reduced life expectancy. The disease onset is usually in adolescence, leading to progressive disability. Omaveloxolone has been recently approved as the first pharmacological treatment for FRDA in adults and adolescents aged 16 years and older. Regarding non-pharmacological therapies, neurorehabilitation is a valuable aid in addressing the symptoms and in maintaining the residual functioning. We performed a prospective observational cohort study to evaluate the efficacy of inpatient rehabilitation (IR) for people with FRDA.

Methods

A total of 42 individuals (29 adults and 13 children) with FRDA were recruited. There were 27 ambulant and 15 non-ambulant participants. The patients underwent IR of 3 and 4 weeks in children and adults, respectively. The IR treatment was designed to be applied within a multidisciplinary setting, so FRDA patients underwent, in addition to physiotherapy, also occupational therapy, practical manual activities and psychological support aiming to enhance transferable skills useful in the activities of daily living. The primary outcome was the Scale for the Assessment and Rating of Ataxia (SARA). Other measures were: Friedreich Ataxia Rating Scale (FARS) and Nine Hole Peg Test (NHPT). Furthermore, we used the 6 Minute Walk Test (6MWT), the Timed Up and Go (TUG) and the Berg Balance Scale (BBS) only on ambulant subjects. Outcomes were evaluated at baseline and at the end of the treatment.

Results

We report that the IR significantly improves motor performance and ataxia symptoms in patients with FRDA. Our study shows significant functional improvement in all the outcome measures used, except for NHPT bilaterally. FARS and SARA scores post-IR are significatively reduced when compared (p < 0.001).

Discussion

We demonstrate that IR programs in FRDA can provide a meaningful clinical improvement in terms of outcome measures. These findings could be useful when approaching progressive neurological disorders.

Strategy-based motor learning decreases the post-movement β power

Motor learning depends on the joint contribution of several processes including cognitive strategies aiming at goal achievement and prediction error-driven implicit adaptation. Understanding this functional interplay and its clinical implications requires insight into the individual learning processes, including at a neural level. Here, we set out to examine the impact of learning a cognitive strategy, over and above implicit adaptation, on the oscillatory post-movement β rebound (PMBR), which typically decreases in power following (visuo)motor perturbations. Healthy participants performed reaching movements towards a target, with online visual feedback replacing the view of their moving hand. The feedback was sometimes rotated, either relative to their movements (visuomotor rotation) or invariant to their movements (and relative to the target; clamped feedback), always for two consecutive trials interspersed between non-rotated trials. In both conditions, the first trial with a rotation was unpredictable. On the second trial, the task was either to re-aim, and thereby compensate for the rotation experienced in the first trial (visuomotor rotation; Compensate condition), or to ignore the rotation and keep on aiming at the target (clamped feedback; Ignore condition). After-effects did not differ between conditions, indicating that the amount of implicit learning was similar, while large differences in movement direction in the second rotated trial between conditions indicated that participants successfully acquired re-aiming strategies. Importantly, PMBR power following the first rotated trial was modulated differently in the two conditions. Specifically, it decreased in both conditions, but this effect was larger when participants had to acquire a cognitive strategy and prepare to re-aim. Our results therefore suggest that the PMBR is modulated by cognitive demands of motor learning, possibly reflecting the evaluation of a behaviourally significant goal achievement error.

Excessive excitability of inhibitory cortical circuit and disturbance of ballistic targeting movement in degenerative cerebellar ataxia

This study aimed to investigate abnormalities in inhibitory cortical excitability and motor control during ballistic-targeting movements in individuals with degenerative cerebellar ataxia (DCA). Sixteen participants took part in the study (DCA group [n = 8] and healthy group [n = 8]). The resting motor-threshold and cortical silent period (cSP) were measured in the right-hand muscle using transcranial magnetic stimulation over the left primary motor cortex. Moreover, the performance of the ballistic-targeting task with right wrist movements was measured. The Scale for the Assessment and Rating of Ataxia was used to evaluate the severity of ataxia. The results indicated that the cSP was significantly longer in participants with DCA compared to that in healthy controls. However, there was no correlation between cSP and severity of ataxia. Furthermore, cSP was linked to the ballistic-targeting task performance in healthy participants but not in participants with DCA. These findings suggest that there is excessive activity in the gamma-aminobutyric acid-mediated cortical inhibitory circuit in individuals with DCA. However, this increase in inhibitory activity not only fails to contribute to the control of ballistic-targeting movement but also shows no correlation with the severity of ataxia. These imply that increased excitability in inhibitory cortical circuits in the DCA may not contribute the motor control as much as it does in healthy older adults under limitations associated with a small sample size. The study's results contribute to our understanding of motor control abnormalities in people with DCA and provide potential evidence for further research in this area.

Mini-review: The Role of the Cerebellum in Visuomotor Adaptation

The incredible capability of the brain to quickly alter performance in response to ever-changing environment is rooted in the process of adaptation. The core aspect of adaptation is to fit an existing motor program to altered conditions. Adaptation to a visuomotor rotation or an external force has been well established as tools to study the mechanisms underlying sensorimotor adaptation. In this mini-review, we summarize recent findings from the field of visuomotor adaptation. We focus on the idea that the cerebellum plays a central role in the process of visuomotor adaptation and that interactions with cortical structures, in particular, the premotor cortex and the parietal cortex, may be crucial for this process. To this end, we cover a range of methodologies used in the literature that link cerebellar functions and visuomotor adaptation; behavioral studies in cerebellar lesion patients, neuroimaging and non-invasive stimulation approaches. The mini-review is organized as follows: first, we provide evidence that sensory prediction errors (SPE) in visuomotor adaptation rely on the cerebellum based on behavioral studies in cerebellar patients. Second, we summarize structural and functional imaging studies that provide insight into spatial localization as well as visuomotor adaptation dynamics in the cerebellum. Third, we discuss premotor — cerebellar interactions and how these may underlie visuomotor adaptation. And finally, we provide evidence from transcranial direct current and magnetic stimulation studies that link cerebellar activity, beyond correlational relationships, to visuomotor adaptation .

Predictive coding and adaptive behavior in patients with genetically determined cerebellar ataxia--A neurophysiology study

Genetically determined cerebellar ataxias (CA) are a heterogeneous group of disorders with progressive decline of cerebellar functions. The cerebellum influences internal forward models that play a role in cognitive control, but whether these processes are dysfunctional in CA is unclear. Here, we examined sensory predictive coding processes and response adaptation in CA and healthy controls (HC) using behavioral tests with concomitant EEG recordings. N = 23 patients and N = 29 age- and sex-matched HC were studied. Sensory prediction coding was tested with an auditory distraction paradigm and error-related behavioral adaptation with a visual flanker task. As neurophysiological markers we studied different event-related potentials: the P3a for orientation of attention; the N2 and the error-related negativity (ERN) for cognitive adaptation processes/consequences of response errors; error-related positivity (Pe) for error-awareness; the mismatch negativity (MMN) for sensory predictive coding; and reorientation negativity (RON) for reorientation after unexpected events. Overall reaction times were slower in patients compared to HC, but error rates did not differ. Both in patients and HC, P3a amplitudes were larger in distraction trials, but the P3a amplitude was smaller in patients compared to HC. The MMN as well as behavioral and EEG-correlates of response adaptation (ERN/N2) did not differ between groups, while the Pe was attenuated in patients. During sensory predictive coding, RON amplitudes were significantly larger in HC compared to patients. In HC, but not in patients, RON amplitudes were also larger in deviant compared to frequent trials. Processes generating internal forward models are largely intact in genetically determined CA, whereas updating of mental models and error awareness are disturbed in these patients.