Training-based interventions in motor rehabilitation after stroke: theoretical and clinical considerations

Basic neuroscience research on brain plasticity, motor learning and recovery has stimulated new concepts in neurological rehabilitation. Combined with the development of set methodological standards in clinical outcome research, these findings have led to a double-paradigm shift in motor rehabilitation: (a) the move towards evidence-based procedures for the assessment of clinical outcome & the employment of disablement models to anchor outcome parameters, and (b) the introduction of practice-based concepts that are derived from testable models that specify treatment mechanisms. In this context, constraint-induced movement therapy (CIT) has played a catalytic role in taking motor rehabilitation forward into the scientific arena. As a theoretically founded and hypothesis-driven intervention, CIT research focuses on two main issues. The first issue is the assessment of long-term clinical benefits in an increasing range of patient groups, and the second issue is the investigation of neuronal and behavioural treatment mechanisms and their interactive contribution to treatment success. These studies are mainly conducted in the research environment and will eventually lead to increased treatment benefits for patients in standard health care. However, gradual but presumably more immediate benefits for patients may be achieved by introducing and testing derivates of the CIT concept that are more compatible with current clinical practice. Here, we summarize the theoretical and empirical issues related to the translation of research-based CIT work into the clinical context of standard health care.     

The force of symmetry revisited: symmetry-to-noise ratios regulate (a)symmetry effects

Freyd and Tversky's [Am. J. Psychol. 97 (1984) 109] data suggested that human observers tend to overestimate relatively high levels of symmetry (symmetry effect), and tend to underestimate relatively low levels of symmetry (asymmetry effect). However, on the basis of their holographic approach to visual regularity, van der Helm and Leeuwenberg [Psychol. Rev. 103(3) (1996) 429] predicted that, at any level of symmetry, both symmetry and asymmetry effects may occur as a consequence of correct estimates of symmetry-to-noise ratios. This prediction was tested in two experiments, with tasks and stimuli similar to those in Freyd and Tversky's study. First, subjects had to judge whether a noisy symmetry is more similar to a slightly more symmetrical variant or to a slightly less symmetrical variant. Second, for every pair of stimuli in such a triadic comparison, subjects had to judge which stimulus is the more symmetrical one. The results from both experiments show that the occurrence of (a)symmetry effects indeed depends on symmetry-to-noise ratios.     

Mental rotation depends on the number of objects rather than on the number of image fragments

It is often intuitively assumed that disconnected image fragments result in a representation of separate objects. When objects are partly occluded, disconnected image fragments can still result in a representation of a single object, based on visual completion. In a simultaneous matching task, displays showing one object, partly occluded objects, or two objects were compared with each other. When only a translation was required to match pairs of displays, one-object displays were matched faster than both occluded-object and two-object displays, which did not differ significantly from each other. When mental rotation and translation were required, the one-object displays were again matched the fastest. In addition, an advantage for occluded-object displays compared with two-object displays was found. We conclude that when the generation of a mental representation is likely, object-based connectedness determines object matching. Mental rotation then seems to depend on the number of objects rather than on the number of image fragments.     

Central inhibition ability modulates attention-induced motion blindness

Impaired motion perception can be induced in normal observers in a rapid serial visual presentation task. Essential for this effect is the presence of motion distractors prior to the motion target, and we proposed that this attention-induced motion blindness results from high-level inhibition produced by the distractors. To investigate this, we compared the extent of the attention-induced motion blindness effect with performance on central inhibition tasks: Stroop colour naming and negative priming. A negative correlation between Stroop interference and motion performance reflected that low Stroop scores, indicative of strong inhibition ability, was associated with more severe impairments in motion perception. This association could not be explained by individual differences in fluid intelligence, task switching or response speed. Negative priming was not specifically associated with attention-induced motion blindness. The results confirm that attention can modulate motion perception and suggest that the processes involved may be shared with high-level cognitive abilities.     

Grammatical language impairment and the specificity of cognitive domains: relations between auditory and language abilities

Grammatical-specific language impairment (G-SLI) in children, arguably, provides evidence for the existence of a specialised grammatical sub-system in the brain, necessary for normal language development. Some researchers challenge this, claiming that domain-general, low-level auditory deficits, particular to rapid processing, cause phonological deficits and thereby SLI. We investigate this possibility by testing the auditory discrimination abilities of G-SLI children for speech and non-speech sounds, at varying presentation rates, and controlling for the effects of age and language on performance. For non-speech formant transitions, 69% of the G-SLI children showed normal auditory processing, whereas for the same acoustic information in speech, only 31% did so. For rapidly presented tones, 46% of the G-SLI children performed normally. Auditory performance with speech and non-speech sounds differentiated the G-SLI children from their age-matched controls, whereas speed of processing did not. The G-SLI children evinced no relationship between their auditory and phonological/grammatical abilities. We found no consistent evidence that a deficit in processing rapid acoustic information causes or maintains G-SLI. The findings, from at least those G-SLI children who do not exhibit any auditory deficits, provide further evidence supporting the existence of a primary domain-specific deficit underlying G-SLI.     

Beliefs in personality disorders: a test with the personality disorder belief questionnaire

The hypothesis that each personality disorder (PD) is characterized by a specific set of beliefs was tested in a sample of 643 subjects, including non-patient controls, axis-I and axis-II patients, diagnosed with SCID-I and -II interviews. Beliefs of six PDs (avoidant, dependent, obsessive-compulsive, paranoid, histrionic, borderline) were assessed with the Personality Disorder Belief Questionnaire (PDBQ). Factor analyses supported the existence of six hypothesized sets of beliefs. Structural equation modeling (SEM) supported the hypothesis that each PD is characterized by a specific set of beliefs. Path coefficients were however in the medium range, suggesting that PDs are not solely determined by beliefs. Nevertheless, empirically derived cutoff scores of the six belief subscales were reasonably successful in classifying subjects, percentages ranging form 51% to 83%. It appeared that there was a monotonical increase in scores on each belief subscale from non-patient controls, to patients without any PD, to patients with PDs (other than the pertinent PD), to patients with the pertinent PD. This suggests that PD-related beliefs are at least partly associated with (personality) psychopathology in general. Another explanation is that many patients' position on the underlying dimensions is not high enough to lead to a DSM PD diagnosis, but high enough to lead to an elevated belief score.     

Effects of suppressing neutral and obsession-like thoughts in normal subjects: beyond frequency

Recent cognitive-behavioral theories on obsessive-compulsive disorder (OCD) show that deliberate attempts to suppress intrusive and undesirable thoughts lie at the genesis of clinical obsessions. In this paper the results of an experimental study on the suppression of neutral and obsession-like thoughts in normal subjects are presented. Eighty-seven university students performed in three experimental periods: (1) base-line monitoring, (2) experimental instruction, and (3) monitoring. For each of these periods, the frequency of the occurrence of a "white bear" thought or a personally relevant intrusive thought was registered. Half of the subjects received instructions to suppress the target-thought in period 2, and the other half were instructed to only monitor the target-thought in each of the experimental periods. Several measures were also obtained before and after the experiment: annoyance caused by the intrusion, suppression effort, subjective success, and evaluative appraisals of the target-thought. The results showed neither immediate nor delayed frequency increases of the target thought. However, evidence was found that deliberate thought suppression efforts, regardless of their content, had greater negative consequences than did non suppression. These results are discussed in relation to the recent cognitive proposals about OCD.     

Prepared movements are elicited early by startle

A startle stimulus has been shown to elicit a ballistic response in a reaction time (RT) task at very short latencies without involvement of the cerebral cortex (J. Valls-Sole, J. C. Rothwell, F. Gooulard, G. Cossu, & E. Munoz, 1999). The present authors examined the nature of the startle response. A simple RT task was used in which 8 participants performed arm extension movements to 3 target distances (20 degrees, 40 degrees, and 60 degrees ) in a blocked design. An unpredictable startling acoustic stimulus (124 dB) replaced the imperative stimulus in certain trials. The authors verified the presence of a startle response independent from the prepared response by observing electromyographic (EMG) activity in sternocleidomastoid and orbicularis oculi muscles. Findings indicated that when the participant was startled, the intended voluntary response was produced at significantly shorter response latencies. Furthermore, the kinematic variables of the observed response during startle trials for all 3 target distances were mostly unchanged. The EMG characteristics of the responses were not modified, indicating that the response produced was indeed the prepared and intended response.     

The role of knowledge of results frequency in learning through observation

The authors examined whether reduced knowledge of results (KR) frequency during observation of a model's performance enhances learning. As they viewed a timing task, observers (n = 54) received KR about the model's performance on each trial (100% KR) or on 1 out of 3 trials (33% KR). Controls (n = 18) received only physical practice; they did not take part in the observation session. The authors also wanted to dissociate the guidance effect of KR during physical practice from the guidance role played by the representation acquired during observation. Therefore, following the observation phase, participants physically performed the task with either the same or a different KR frequency than that experienced during observation. The effects of observation and physical practice on learning were assessed in delayed retention tests. The beneficial effect of reduced KR frequency during observation continued for the following physical practice phases. Possible explanations as to why KR influences observational learning are discussed.     

Braking reaching movements: a test of the constant tau-dot strategy under different viewing conditions

Following F. Zaal and R. J. Bootsma (1995), the authors studied whether the decelerative phase of a reaching movement could be modeled as a constant tau-dot strategy resulting in a soft collision with the object. Specifically, they investigated whether that strategy is sustained over different viewing conditions. Participants (N = 11) were required to reach for 15- and 50-mm objects at 2 different distances under 3 conditions in which visual availability of the immediate environment and of the reaching hand were varied. Tau-dot estimates and goodness-of-fit were highly similar across the 3 conditions. Only within-participant variability of tau-dot estimates was increased when environmental cues were removed. That finding suggests that the motor system uses a tau-dot strategy involving the intermodal (i.e., visual, proprioceptive, or both) specification of information to regulate the decelerative phase of reaching under restricted viewing conditions. The authors provide recommendations for improving the derivation of tau;(x) estimates and stress the need for further research on how time-to-contact information is used in the regulation of the dynamics of actions such as reaching.