Examining Sex Differences in Relationships Between Subjective and Objective Measures of Upper Extremity Motor Impairment in a Sample of Stroke Survivors.

BACKGROUND AND PURPOSE: Rehabilitation professionals use subjective and objective outcome measures to assess stroke-related impact and impairment. Understanding if subjective and objective findings correlate among stroke survivors, especially if these associations differ between females and males, can inform care decisions. METHODS: A retrospective cross-sectional design was used, with data selected from subacute to chronic stroke survivors on age, time since stroke, the hand domain from the Stroke Impact Scale version 3.0 (SIS-H), and the Fugl-Meyer Upper Extremity (FMUE) Assessment. Group differences were assessed for all outcomes based on sex and time poststroke. Separate correlations for females and males were performed between the subjective (SIS-H) and objective measures (FMUE) of upper limb function and impairment. RESULTS: Data from 148 participants (44 females) were included in this study. SIS-H was significantly correlated with FMUE in both females and males ( P s ≤ 0.001). No significant differences were found between the groups' mean SIS-H or FMUE scores based on sex or time poststroke. DISCUSSION AND CONCLUSIONS: Subjective and objective measures of physical functioning were correlated in both females and males. Although we found no sex differences in our primary outcomes, the sample size of females was disproportionately lower than the males. This is consistent with an ongoing problem in the stroke recovery research field, where females are often underrepresented and understudied, and where females who experience higher levels of impairment are less likely to participate in research.

Responsiveness and trajectory of changes in the rating of everyday arm-use in the community and home (REACH) scale over the first-year post-stroke.

OBJECTIVE: To examine the trajectory of the Rating of Everyday Arm-use in the Community and Home (REACH) scores over the first-year post-stroke, determine if REACH scores are modified by baseline impairment level and explore the responsiveness of the REACH scale through hypothesis testing. DESIGN: Consecutive sample longitudinal study. SETTING: Participants were recruited from an acute stroke unit and followed up at three, six, and 12 months post-stroke. PARTICIPANTS: Seventy-three participants with upper limb weakness (Shoulder Abduction and Finger Extension score ≤ 8). MAIN MEASURES: The REACH scale is a six-level self-report classification scale that captures how the affected upper limb is being used in one's own environment. The Fugl-Meyer Upper Limb Assessment (FMA-UL), Stroke Upper Limb Capacity Scale (SULCS), accelerometer-based activity count ratio and Global Rating of Change Scale (GRCS) were used to capture upper limb impairment, capacity, and use. RESULTS: The following proportions of participants improved at least one REACH level: 64% from baseline to three months, 37% from three to six months and 13% from six to 12 months post-stroke. The trajectory of REACH scores over time was associated with baseline impairment. Change in REACH had a moderate correlation to change in SULCS and the GRCS but not FMA-UL or the activity count ratio. CONCLUSIONS: Results of hypothesis testing provide preliminary evidence of the responsiveness of the REACH scale. On average, individuals with severe impairment continued to show improvement in use over the first year, while those with mild/moderate impairment plateaued and a small proportion decreased in the early chronic phase.

Manipulating visual-motor experience to probe for observation-induced after-effects in adaptation learning.

Observers can learn to move in novel, adapted environments after watching a learning or expert model. Although this is an effective practice technique, it is unclear how this learning is achieved and if observers update an internal model of their visual-motor environment, as shown through the presence of after-effects (i.e., negative carry-over effects when aiming in a normal environment following exposure to perturbed conditions). For such updating to occur via observational practice, it has been reasoned that the observer requires the motor capabilities to perform the task they are observing. To test this, we first trained three groups to physically move in clockwise (CW) or counterclockwise (CCW) rotated environments. When immediately returned to a normal environment, after-effects were seen. We then attempted to wash out these effects before allowing two of these groups (CW and CCW), and a naïve observation only group, to watch a video of an actor performing in a CW environment. This observation phase was immediately followed by another test for after-effects and a direct test of learning when aiming in the rotated environment. Consistent with previous data, there were direct learning effects due to observation. Although after-effects increased for the experienced observers, these were small and were not significantly different from a physical practice only group that did not undergo the observation phase. Therefore, even with a motor repertoire for the rotated environment, there was a lack of evidence that observational practice results in implicit (re)updating of an internal model for aiming.

Frontoparietal function and underlying structure reflect capacity for motor skill acquisition during healthy aging.

While capacity for motor skill acquisition changes with healthy aging, there has been little consideration of how age-related changes in brain function or baseline brain structure support motor skill acquisition. We examined: (1) age-dependent changes in functional reorganization related to frontoparietal regions during motor skill acquisition, and (2) whether capacity for motor skill acquisition relates to baseline white matter microstructure in frontoparietal tracts. Healthy older and younger adults engaged in 4 weeks of skilled motor practice. Resting-state functional connectivity (rsFC) assessed functional reorganization before and after practice. Diffusion tensor imaging indexed microstructure of a frontoparietal tract at baseline, generated by rsFC seeds. Motor skill acquisition was associated with decreases in rsFC in healthy older adults and increases in rsFC in healthy younger adults. Frontoparietal tract microstructure was lower in healthy older versus younger adults, yet it was negatively associated with rate of skill acquisition regardless of group. Findings indicate that age-dependent alterations in frontoparietal function and baseline structure of a frontoparietal tract reflect capacity for motor skill acquisition.

Updating of Implicit Adaptation Processes through Erroneous Numeric Feedback.

There is debate about how implicit and explicit processes interact in sensorimotor adaptation, implicating how error signals drive learning. Target error information is thought to primarily influence explicit processes, therefore manipulations to the veracity of this information should impact adaptation but not implicit recalibration (i.e. after-effects). Thirty participants across three groups initially adapted to rotated cursor feedback. Then we manipulated numeric target error through knowledge of results (KR) feedback, where groups practised with correct or incorrect (+/-15°) numeric KR. Participants adapted to erroneous KR, but only the KR + 15 group showed augmented implicit recalibration, evidenced by larger after-effects than before KR exposure. In the presence of sensory prediction errors, target errors modulated after-effects, suggesting an interaction between implicit and explicit processes.

Implicit Adaptation Processes Promoted by Immediate Offline Visual and Numeric Feedback.

In adaptation learning, visual feedback impacts how adaptation proceeds. With concurrent feedback, a more implicit/feedforward process is thought to be engaged, compared to feedback after movement, which promotes more explicit processes. Due to discrepancies across studies, related to timing and type of visual feedback, we isolated these conditions here. Four groups (N = 52) practiced aiming under rotated feedback conditions; feedback was provided concurrently, immediately after movement (visually or numerically), or visually after a 3 s delay. All groups adapted and only delayed feedback attenuated implicit adaptation as evidenced by post-practice after-effects. Contrary to some suggestions, immediately presented offline and numeric feedback resulted in implicit after-effects, potentially due to comparisons between feedforward information and seen or imagined feedback.

Profiling Somatosensory Impairment after Stroke: Characterizing Common "Fingerprints" of Impairment Using Unsupervised Machine Learning-Based Cluster Analysis of Quantitative Measures of the Upper Limb.

Altered somatosensory function is common among stroke survivors, yet is often poorly characterized. Methods of profiling somatosensation that illustrate the variability in impairment within and across different modalities remain limited. We aimed to characterize post-stroke somatosensation profiles ("fingerprints") of the upper limb using an unsupervised machine learning cluster analysis to capture hidden relationships between measures of touch, proprioception, and haptic object recognition. Raw data were pooled from six studies where multiple quantitative measures of upper limb somatosensation were collected from stroke survivors (n = 207) using the Tactile Discrimination Test (TDT), Wrist Position Sense Test (WPST) and functional Tactile Object Recognition Test (fTORT) on the contralesional and ipsilesional upper limbs. The Growing Self Organizing Map (GSOM) unsupervised machine learning algorithm was used to generate a topology-preserving two-dimensional mapping of the pooled data and then separate it into clusters. Signature profiles of somatosensory impairment across two modalities (TDT and WPST; n = 203) and three modalities (TDT, WPST, and fTORT; n = 141) were characterized for both hands. Distinct impairment subgroups were identified. The influence of background and clinical variables was also modelled. The study provided evidence of the utility of unsupervised cluster analysis that can profile stroke survivor signatures of somatosensory impairment, which may inform improved diagnosis and characterization of impairment patterns.

Improved processing speed and decreased functional connectivity in individuals with chronic stroke after paired exercise and motor training.

After stroke, impaired motor performance is linked to an increased demand for cognitive resources. Aerobic exercise improves cognitive function in neurologically intact populations and may be effective in altering cognitive function post-stroke. We sought to determine if high-intensity aerobic exercise paired with motor training in individuals with chronic stroke alters cognitive-motor function and functional connectivity between the dorsolateral prefrontal cortex (DLPFC), a key region for cognitive-motor processes, and the sensorimotor network. Twenty-five participants with chronic stroke were randomly assigned to exercise (n = 14; 66 ± 11 years; 4 females), or control (n = 11; 68 ± 8 years; 2 females) groups. Both groups performed 5-days of paretic upper limb motor training after either high-intensity aerobic exercise (3 intervals of 3 min each, total exercise duration of 23-min) or watching a documentary (control). Resting-state fMRI, and trail making test part A (TMT-A) and B were recorded pre- and post-intervention. Both groups showed implicit motor sequence learning (p < 0.001); there was no added benefit of exercise for implicit motor sequence learning (p = 0.738). The exercise group experienced greater overall cognitive-motor improvements measured with the TMT-A. Regardless of group, the changes in task score, and dwell time during TMT-A were correlated with a decrease in DLPFC-sensorimotor network functional connectivity (task score: p = 0.025; dwell time: p = 0.043), which is thought to reflect a reduction in the cognitive demand and increased automaticity. Aerobic exercise may improve cognitive-motor processing speed post-stroke.

In the absence of physical practice, observation and imagery do not result in updating of internal models for aiming.

The presence of after-effects in adaptation tasks implies that an existing internal model has been updated. Previously, we showed that although observers adapted to a visuomotor perturbation, they did not show after-effects. In this experiment, we tested 2 further observer groups and an actor group. Observers were now actively engaged in watching (encouraged through imagery and movement estimation), with one group physically practising for 25% of the trials (mixed). Participants estimated the hand movements that produced various cursor trajectories and/or their own hand movement from a preceding trial. These trials also allowed us to assess the development of explicit knowledge as a function of the three practice conditions. The pure observation group did not show after-effects, whereas the actor and mixed groups did. The pure observation group improved their ability to estimate hand movement of the video model. Although the actor and mixed groups improved in actual reaching accuracy, they did not improve in explicit estimation. The mixed group was more accurate in reaching during adaptation and showed larger after-effects than the actors. We suggest that observation encourages an explicit mode of learning, enabling performance benefits without corresponding changes to an internal model of the mapping between output and sensory input. However, some physical practice interspersed with observation can change the manner with which learning is achieved, encouraging implicit learning and the updating of an existing internal model.

Combining Observation and Physical Practice: Benefits of an Interleaved Schedule for Visuomotor Adaptation and Motor Memory Consolidation.

Visuomotor adaptation to novel environments can occur via non-physical means, such as observation. Observation does not appear to activate the same implicit learning processes as physical practice, rather it appears to be more strategic in nature. However, there is evidence that interspersing observational practice with physical practice can benefit performance and memory consolidation either through the combined benefits of separate processes or through a change in processes activated during observation trials. To test these ideas, we asked people to practice aiming to targets with visually rotated cursor feedback or engage in a combined practice schedule comprising physical practice and observation of projected videos showing successful aiming. Ninety-three participants were randomly assigned to one of five groups: massed physical practice (Act), distributed physical practice (Act+Rest), or one of 3 types of combined practice: alternating blocks (Obs_During), or all observation before (Obs_Pre) or after (Obs_Post) blocked physical practice. Participants received 100 practice trials (all or half were physical practice). All groups improved in adaptation trials and showed savings across the 24-h retention interval relative to initial practice. There was some forgetting for all groups, but the magnitudes were larger for physical practice groups. The Act and Obs_During groups were most accurate in retention and did not differ, suggesting that observation can serve as a replacement for physical practice if supplied intermittently and offers advantages above just resting. However, after-effects associated with combined practice were smaller than those for physical practice control groups, suggesting that beneficial learning effects as a result of observation were not due to activation of implicit learning processes. Reaction time, variable error, and post-test rotation drawings supported this conclusion that adaptation for observation groups was promoted by explicit/strategic processes.

Now you see me, now you don't: Adapting practice through target exclusion negatively impacts motor learning.

How to optimize practice through scheduling of different task components or skills is a question that has received a lot of attention in motor learning research. Consistently, schedules with high variability in the order that skills are practiced elicit better learning outcomes than schedules with low variability. Another idea is that learners should seek to reduce the uncertainty of practice outcomes, by avoiding well-learned, low error components in acquisition. To test this idea, we used a target exclusion method to prevent learners from returning to task components with low error and studied how individuals given choice over practice choose to allocate time to components of varying difficulty. In a multi-target adaptation paradigm, we compared exclusion with no exclusion methods in random-schedule, self-control and yoked, matched-schedule groups (6 groups total). To manipulate uncertainty, we excluded targets from practice once participants attained a criterion error score (mean < 5o) from the last 5 trials to the same target. Contrary to our predictions, groups that practiced without target exclusion were more accurate in retention compared to exclusion groups; irrespective of practice schedule. Self-control groups adopted uncertainty-based practice, spending more time at difficult targets and less time at easier targets. However, there were no group differences in error, based on schedule-type (random, self-control and yoked). In conclusion, target exclusion was not an effective method for learning and did not support the efficacy of uncertainty-based practice for learning novel skills. There were benefits from keeping easier/low error skills in practice for later retention. These benefits did not appear to be related to the increased switching between skills, but could be related to increased task engagement and more optimal challenge associated with practice on a range of target difficulties, rather than the most difficult.

Watch and learn: seeing is better than doing when acquiring consecutive motor tasks.

During motor adaptation learning, consecutive physical practice of two different tasks compromises the retention of the first. However, there is evidence that observational practice, while still effectively aiding acquisition, will not lead to interference and hence prove to be a better practice method. Observers and Actors practised in a clockwise (Task A) followed by a counterclockwise (Task B) visually rotated environment, and retention was immediately assessed. An Observe-all and Act-all group were compared to two groups who both physically practised Task A, but then only observed (ObsB) or did not see or practice Task B (NoB). The two observer groups and the NoB control group better retained Task A than Actors, although importantly only the observer groups learnt Task B. RT data and explicit awareness of the rotation suggested that the observers had acquired their respective tasks in a more strategic manner than Actor and Control groups. We conclude that observational practice benefits learning of multiple tasks more than physical practice due to the lack of updating of implicit, internal models for aiming in the former.