Use-dependent plasticity explains aftereffects in visually guided locomotor learning of a novel step length asymmetry

Explicit and implicit locomotor learning in individuals with chronic hemiparetic stroke

Motor learning involves both explicit and implicit processes that are fundamental for acquiring and adapting complex motor skills. However, stroke may damage the neural substrates underlying explicit and/or implicit learning, leading to deficits in overall motor performance. While both learning processes are typically used in concert in daily life and rehabilitation, no gait studies have determined how these processes function together after stroke when tested during a task that elicits dissociable contributions from both. Here, we compared explicit and implicit locomotor learning in individuals with chronic stroke to age- and sex-matched neurologically intact controls. We assessed implicit learning using split-belt adaptation (where two treadmill belts move at different speeds). We assessed explicit learning (i.e., strategy-use) using visual feedback during split-belt walking to help individuals explicitly correct for step length errors created by the split-belts. The removal of visual feedback after the first 40 strides of split-belt walking, combined with task instructions, minimized contributions from explicit learning for the remainder of the task. We utilized computational modeling to determine the individual contributions of explicit and implicit processes to overall behavioral change. The computational and behavioral analyses revealed that, compared to controls, individuals with chronic stroke demonstrated deficits in both explicit and implicit contributions to locomotor learning, a result that runs counter to prior work testing each process individually during gait. Since post-stroke locomotor rehabilitation involves interventions that rely on both explicit and implicit motor learning, future work should determine how locomotor rehabilitation interventions can be structured to optimize overall motor learning.

Acute pain impairs retention of locomotor learning

Despite abundant evidence that pain alters movement performance, considerably less is known about the potential effects of pain on motor learning. Some of the brain regions involved in pain processing are also responsible for specific aspects of motor learning, indicating that the two functions have the potential to interact, yet it is unclear if they do. In experiment 1, we compared the acquisition and retention of a novel locomotor pattern in young, healthy individuals randomized to either experience pain via capsaicin and heat applied to the lower leg during learning or no stimulus. On day 1, participants learned a new asymmetric walking pattern using distorted visual feedback, a paradigm known to involve mostly explicit re-aiming processes. Retention was tested 24 h later. Although there were no differences in day 1 acquisition between groups, individuals who experienced pain on day 1 demonstrated reduced retention on day 2. Furthermore, the degree of forgetting between days correlated with pain ratings during learning. In experiment 2, we examined the effects of a heat stimulus alone, which served as a control for (nonpainful) cutaneous stimulation, and found no effects on either acquisition or retention of learning. Thus, pain experienced during explicit, strategic locomotor learning interferes with motor memory consolidation processes and does so most likely through a pain mechanism and not an effect of distraction. These findings have important implications for understanding basic motor learning processes and for clinical rehabilitation, in which painful conditions are often treated through motor learning-based interventions.NEW & NOTEWORTHY Pain is a highly prevalent and burdensome experience that rehabilitation practitioners often treat using motor learning-based interventions. Here, we showed that experimental acute pain, but not a heat stimulus, during locomotor learning impaired 24-h retention of the newly learned walking pattern. The degree of retention loss was related to the perceived pain level during learning. These findings suggest important links between pain and motor learning that have significant implications for clinical rehabilitation.

Reinforcement Learning during Locomotion

When learning a new motor skill, people often must use trial and error to discover which movement is best. In the reinforcement learning framework, this concept is known as exploration and has been linked to increased movement variability in motor tasks. For locomotor tasks, however, increased variability decreases upright stability. As such, exploration during gait may jeopardize balance and safety, making reinforcement learning less effective. Therefore, we set out to determine if humans could acquire and retain a novel locomotor pattern using reinforcement learning alone. Young healthy male and female participants walked on a treadmill and were provided with binary reward feedback (indicated by a green checkmark on the screen) that was tied to a fixed monetary bonus, to learn a novel stepping pattern. We also recruited a comparison group who walked with the same novel stepping pattern but did so by correcting for target error, induced by providing real-time veridical visual feedback of steps and a target. In two experiments, we compared learning, motor variability, and two forms of motor memories between the groups. We found that individuals in the binary reward group did, in fact, acquire the new walking pattern by exploring (increasing motor variability). Additionally, while reinforcement learning did not increase implicit motor memories, it resulted in more accurate explicit motor memories compared with the target error group. Overall, these results demonstrate that humans can acquire new walking patterns with reinforcement learning and retain much of the learning over 24 h.

Effects of an Acute High Intensity Exercise Bout on Retention of Explicit, Strategic Locomotor Learning in Individuals With Chronic Stroke

BACKGROUND

Exercise priming, pairing high intensity exercise with a motor learning task, improves retention of upper extremity tasks in individuals after stroke, but has shown no benefit to locomotor learning. This difference may relate to the type of learning studied. Upper extremity studies used explicit, strategic tasks; locomotor studies used implicit sensorimotor adaptation (split-belt treadmill). Since walking is an important rehabilitation goal, it is crucial to understand under which circumstances exercise priming may improve retention of a newly learned walking pattern.

OBJECTIVE

Determine the impact of exercise priming on explicit, strategic locomotor learning task retention in chronic stroke survivors.

METHODS

Chronic stroke survivors (>6 months) performed 2 treadmill walking sessions. Visual feedback was used to train increased step length. Participants were assigned to control group (no exercise), continuous exercise (5 minutes high intensity), or long-interval exercise (15 minutes high/moderate intervals). After day 1 learning, participants either rested or performed exercise. On day 2, retention of the learned walking pattern was tested.

RESULTS

All groups learned on day 1 (P < .001). The 2 priming groups showed significant changes in blood lactate and heart rate after exercise priming, the resting control group did not (P < .001). On day 2, there was no significant between-group difference in cued or un-cued task retention (P = .963 and .287, respectively).

CONCLUSIONS

Exercise priming did not affect retention of an explicit locomotor task in chronic stroke survivors. Further work should explore subgroups of individuals for whom priming may have selective clinical benefit to locomotor learning.ClinicalTrials.gov Identifier: NCT03726047.

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.

The-state-of-the-art of soft robotics to assist mobility: a review of physiotherapist and patient identified limitations of current lower-limb exoskeletons and the potential soft-robotic solutions

BACKGROUND

Soft, wearable, powered exoskeletons are novel devices that may assist rehabilitation, allowing users to walk further or carry out activities of daily living. However, soft robotic exoskeletons, and the more commonly used rigid exoskeletons, are not widely adopted clinically. The available evidence highlights a disconnect between the needs of exoskeleton users and the engineers designing devices. This review aimed to explore the literature on physiotherapist and patient perspectives of the longer-standing, and therefore greater evidenced, rigid exoskeleton limitations. It then offered potential solutions to these limitations, including soft robotics, from an engineering standpoint.

METHODS

A state-of-the-art review was carried out which included both qualitative and quantitative research papers regarding patient and/or physiotherapist perspectives of rigid exoskeletons. Papers were themed and themes formed the review's framework.

RESULTS

Six main themes regarding the limitations of soft exoskeletons were important to physiotherapists and patients: safety; a one-size-fits approach; ease of device use; weight and placement of device; cost of device; and, specific to patients only, appearance of the device. Potential soft-robotics solutions to address these limitations were offered, including compliant actuators, sensors, suit attachments fitting to user's body, and the use of control algorithms.

CONCLUSIONS

It is evident that current exoskeletons are not meeting the needs of their users. Solutions to the limitations offered may inform device development. However, the solutions are not infallible and thus further research and development is required.

Natural ageing primarily affects the initial response to a sustained walking perturbation but not the ability to adapt over time

The ability to flexibly respond and adapt the walking pattern over time to unexpected gait perturbations is pivotal for safe and efficient locomotion. However, these abilities might be affected by age due to age-related changes in sensorimotor functioning. In this cross-sectional lifespan study, we used a split-belt paradigm to determine how age affects the initial response (i.e., flexibility)-and the ability to adapt after prolonged exposure-to a sustained gait perturbation. Healthy adults (N = 75) of different ages (12-13 per decade) were included and walked on a split-belt treadmill, in which a sustained gait perturbation was imposed by increasing one of the belt speeds. Linear regression models, with the evoked spatiotemporal gait asymmetry during the early perturbation and late adaptation, were performed to determine the effects of age on the flexibility and adaptability to split-belt walking. Results showed that the flexibility to respond to an unexpected perturbation decreased across the lifespan, as evidenced by a greater step length asymmetry (SLA) during the early perturbation phase. Despite this reduced flexibility in step lengths, late adaptation levels in SLA were comparable across different ages. With increasing age, however, subjects needed more steps to reach a stable level in SLA. Finally, when the belts were set to symmetrical speeds again, the magnitude of SLA (i.e., the aftereffects) increased with age. Collectively, these findings suggest that natural ageing comes with a decrease in gait flexibility, while the ability to adapt to split-belt walking was not affected by age-only how adaptation was achieved.

Concurrent locomotor adaptation and retention to visual and split-belt perturbations

Gait asymmetry is a common symptom in groups with neurological disorders and significantly reduces gait efficiency. To develop efficient training for gait rehabilitation, we propose a novel gait rehabilitation paradigm that combines two distinct perturbation strategies: visual feedback distortion (VFD) and split-belt treadmill (SBT) walking. In SBT walking, spatiotemporal gait adaptation can be readily achieved, but it quickly fades after training. Gait adaptation to implicit VFD in an unconscious manner tends to persist longer, potentially due to a greater engagement of implicit learning during training. Thus, we investigated whether the combined strategies would lead to more effective changes in symmetric gait patterns with longer retention periods. We compared the retention of the preserved asymmetric pattern acquired by "implicit VFD+SBT walking" with "SBT-only walking" and with "SBT walking with conscious correction". In the implicit VFD+SBT walking, the speed of the two belts was gradually changed, the visual representation of gait symmetry was implicitly distorted, and no instructions were given to subjects except to watch the visual feedback. In the SBT walking with conscious correction, subjects were instructed to consciously correct their steps with the help of visual feedback while SBT walking. The SBT-only walking consisted of SBT walking with no visual feedback. After the 7-minute adaptation period, we removed the visual feedback and the split-belt perturbations, and we assessed the retention of the preserved asymmetric pattern while subjects continued walking for the 15-minute post-adaptation period. In a group of subjects who spontaneously showed visuomotor adaptation in response to the implicit VFD (16 out of 27 subjects), we found a greater retention rate during the implicit VFD+SBT walking trial than the SBT-only walking or the SBT walking with conscious correction trials. The implicit visual distortion paradigm delivered in an attention-independent (unconscious) manner can be utilized and integrated into SBT walking to improve the efficacy of symmetric gait adaptation by producing longer-lasting effects on the retention of a newly learned motor pattern.

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.

Dissociable use-dependent processes for volitional goal-directed reaching

Repetition of specific movement biases subsequent actions towards the practiced movement, a phenomenon known as use-dependent learning (UDL). Recent experiments that impose strict constraints on planning time have revealed two sources of use-dependent biases, one arising from dynamic changes occurring during motor planning and another reflecting a stable shift in motor execution. Here, we used a distributional analysis to examine the contribution of these biases in reaching. To create the conditions for UDL, the target appeared at a designated 'frequent' location on most trials, and at one of six 'rare' locations on other trials. Strikingly, the heading angles were bimodally distributed, with peaks at both frequent and rare target locations. Despite having no constraints on planning time, participants exhibited a robust bias towards the frequent target when movements were self-initiated quickly, the signature of a planning bias; notably, the peak near the rare target was shifted in the frequently practiced direction, the signature of an execution bias. Furthermore, these execution biases were not only replicated in a delayed-response task but were also insensitive to reward. Taken together, these results extend our understanding of how volitional movements are influenced by recent experience.

Fluid Cognition Relates to Locomotor Switching in Neurotypical Adults, Not Individuals After Stroke

BACKGROUND AND PURPOSE

The ability to switch between walking patterns (ie, locomotor switching) is vital for successful community navigation and may be impacted by poststroke impairments. Thus, the purpose of this work was to examine locomotor switching and the relationship between locomotor switching and fluid cognition in individuals after stroke compared with neurotypical adults.

METHODS

Twenty-nine individuals more than 6 months after stroke and 18 neurotypical adults participated in a 2-day study. On day 1, participants were taught a new walking pattern on the treadmill and then locomotor switching was assessed by instructing participants to switch between the new walking pattern and their usual walking pattern. The change between these 2 patterns was calculated as the switching index. On day 2, the NIH Toolbox Cognition Battery was administered to obtain the Fluid Cognition Composite Score (FCCS), which reflected fluid cognition. The switching index was compared between groups using an analysis of covariance, and the relationship between locomotor switching and fluid cognition was assessed with regression.

RESULTS

Individuals after stroke had significantly lower switching indexes compared with neurotypical adults (P = 0.03). The regression showed a significant interaction between group and FCCS (P = 0.002), with the FCCS predicting the switching index in neurotypical adults but not in individuals after stroke.

DISCUSSION AND CONCLUSIONS

Individuals after stroke appear to have deficits in locomotor switching compared with neurotypical adults. The relationship between fluid cognition and locomotor switching was significant in neurotypical adults but not in individuals after stroke. Future work to understand the relationship between specific cognitive domains and locomotor switching is needed (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A361).

Visuomotor errors drive step length and step time adaptation during 'virtual' split-belt walking: the effects of reinforcement feedback

Precise foot placement is dependent on changes in spatial and temporal coordination between two legs in response to a perturbation during walking. Here, we used a 'virtual' split-belt adaptation task to examine the effects of reinforcement (reward and punishment) feedback about foot placement on the changes in error, step length and step time asymmetry. Twenty-seven healthy adults (20 ± 2.5 years) walked on a treadmill with continuous feedback of the foot position and stepping targets projected on a screen, defined by a visuomotor gain for each leg. The paradigm consisted of a baseline period (same gain on both legs), visuomotor adaptation period (split: one high = 'fast', one low = 'slow' gain) and post-adaptation period (same gain). Participants were divided into 3 groups: control group received no score, reward group received increasing score for each target hit, and punishment group received decreasing score for each target missed. Re-adaptation was assessed 24 ± 2 h later. During early adaptation, the slow foot undershot and fast foot overshot the stepping target. Foot placement errors were gradually reduced by late adaptation, accompanied by increasing step length asymmetry (fast < slow step length) and step time asymmetry (fast > slow step time). Only the punishment group showed greater error reduction and step length re-adaptation on the next day. The results show that (1) explicit feedback of foot placement alone drives adaptation of both step length and step time asymmetry during virtual split-belt walking, and (2) specifically, step length re-adaptation driven by visuomotor errors may be enhanced by punishment feedback.

Fluid Cognitive Abilities Are Important for Learning and Retention of a New, Explicitly Learned Walking Pattern in Individuals After Stroke

BACKGROUND

There is significant variability in poststroke locomotor learning that is poorly understood and affects individual responses to rehabilitation interventions. Cognitive abilities relate to upper extremity motor learning in neurologically intact adults, but have not been studied in poststroke locomotor learning.

OBJECTIVE

To understand the relationship between locomotor learning and retention and cognition after stroke.

METHODS

Participants with chronic (>6 months) stroke participated in 3 testing sessions. During the first session, participants walked on a treadmill and learned a new walking pattern through visual feedback about their step length. During the second session, participants walked on a treadmill and 24-hour retention was assessed. Physical and cognitive tests, including the Fugl-Meyer-Lower Extremity (FM-LE), Fluid Cognition Composite Score (FCCS) from the NIH Toolbox -Cognition Battery, and Spatial Addition from the Wechsler Memory Scale-IV, were completed in the third session. Two sequential regression models were completed: one with learning and one with retention as the dependent variables. Age, physical impairment (ie, FM-LE), and cognitive measures (ie, FCCS and Spatial Addition) were the independent variables.

RESULTS

Forty-nine and 34 participants were included in the learning and retention models, respectively. After accounting for age and FM-LE, cognitive measures explained a significant portion of variability in learning (R² = 0.17, P = .008; overall model R² = 0.31, P = .002) and retention (ΔR² = 0.17, P = .023; overall model R² = 0.44, P = .002).

CONCLUSIONS

Cognitive abilities appear to be an important factor for understanding locomotor learning and retention after stroke. This has significant implications for incorporating locomotor learning principles into the development of personalized rehabilitation interventions after stroke.

Use of explicit processes during a visually guided locomotor learning task predicts 24-h retention after stroke

Implicit and explicit processes can occur within a single locomotor learning task. The combination of these learning processes may impact how individuals acquire/retain the task. Because these learning processes rely on distinct neural pathways, neurological conditions may selectively impact the processes that occur, thus, impacting learning and retention. Thus, our purpose was to examine the contribution of implicit and explicit processes during a visually guided walking task and characterize the relationship between explicit processes and performance/retention in stroke survivors and age-matched healthy adults. Twenty chronic stroke survivors and twenty healthy adults participated in a 2-day treadmill study. Day 1 included baseline, acquisition1, catch, acquisition2, and immediate retention phases, and day 2 included 24-h retention. During acquisition phases, subjects learned to take a longer step with one leg through distorted visual feedback. During catch and retention phases, visual feedback was removed and subjects were instructed to walk normally (catch) or how they walked during the acquisition phases (retention). Change in step length from baseline to catch represented implicit processes. Change in step length from catch to the end of acquisition2 represented explicit processes. A mixed ANOVA found no difference in the type of learning between groups (P = 0.74). There was a significant relationship between explicit processes and 24-h retention in stroke survivors (r = 0.47, P = 0.04) but not in healthy adults (r = 0.34, P = 0.15). These results suggest that stroke may not affect the underlying learning mechanisms used during locomotor learning, but that these mechanisms impact how well stroke survivors retain the new walking pattern.NEW & NOTEWORTHY This study found that stroke survivors used implicit and explicit processes similar to age-matched healthy adults during a visually guided locomotion learning task. The amount of explicit processes was related to how well stroke survivors retained the new walking pattern but not to how well they performed during the task. This work illustrates the importance of understanding the underlying learning mechanisms to maximize retention of a newly learned motor behavior.

Gradually learning to increase gait propulsion in young unimpaired adults

Distorted visual feedback (DVF) may employ both implicit and explicit approaches to enhance motor learning. Our purpose was to test the effect of DVF of gait propulsion on the capacity to alter propulsive forces, and to determine the biomechanical determinants of propulsion. Seventeen young unimpaired individuals walked for three minutes of baseline (no feedback), then completed three randomly ordered, 10-minute Learning conditions: Real, 10DVF, and 20DVF. During the DVF conditions, we gradually decreased the feedback value without the participants' knowledge. For all Learning conditions, participants were instructed to maintain the propulsive force between two targets representing ±1 standard deviation as obtained from baseline. A one-minute retention trial without any feedback was performed immediately after Learning. Participants increased propulsive forces and trailing limb angle in both DVF conditions that persisted through retention; however, no change in ankle plantarflexion moment was noted. These findings offer promise of translation to clinical populations with propulsion deficits and require combined implicit and explicit learning components.