What skills should simulation training in arthroscopy teach residents? A focus on resident input.

PURPOSE:    Our purpose was to identify what surgical skills trainees consider important to possess before performing in the operating room and the components of an optimal simulator. METHODS:    An online survey composed of 35 questions was completed by 67 orthopedic residents from across Canada. The questions examined the opinions of residents for their perspective on what constitutes an optimal design of an arthroscopic simulator. RESULTS:    The average year of residency of the respondents was 3.2, and the average number of arthroscopies assisted on was 66.1 with a range of 0-300. Identification of structures and navigation of the arthroscope were ranked highly in terms of importance for trainee surgeons to possess before performing in the operating room. Higher fidelity simulation models such as cadaveric specimens or the use of synthetic knees were preferred over lower fidelity simulation models such as virtual reality simulators or bench top models. CONCLUSION:    The information from trainees can be used in the development of a simulator for medical education as well as program and curriculum design. The report also highlights the importance of the pre-RCT phases leading to the development of the most effective simulation programs.

Application of motor learning principles to complex surgical tasks: searching for the optimal practice schedule.

Practice of complex tasks can be scheduled in several ways: as whole-task practice or as practice of the individual skills composing the task in either a blocked or a random order. The authors used those 3 schedules to study 18 participants' learning of an orthopedic surgical task. They assessed learning by obtaining expert evaluation of performance and objective kinematic measures before, immediately after, and 1 week after practice (transfer test). During acquisition, the blocked group showed superior performance for simple skills but not for more complex skills. For the expert-based measures of performance, all groups improved from pretest to posttest and remained constant from posttest to transfer. Measures of the final product showed that the whole-practice group's outcomes were significantly better than those of the random group on transfer. All groups showed better efficiency of motions in the posttest than in the pretest. Those measures were also poorer on the transfer test than on the posttest. The present evidence does not support the contextual interference effect--hypothetically, because of the inherent cognitive effort effect associated with some of the component skills. The authors recommend that surgical tasks composed of several discrete skills be practiced as a whole. The results of this study demonstrate the importance of critically appraising basic theories in applied environments.

Quantification of process measures in laparoscopic suturing.

BACKGROUND: Process measures describing the generation of movement are useful for evaluation and performance feedback purposes. This study aimed to identify process measures that differ between novice and advanced laparoscopists while completing a suturing skill. METHODS: A group of junior and a group of senior residents and fellows in surgery (n = 6) placed 10 laparoscopic sutures in a synthetic model. Process measures were quantified using an opto-electric motion/force sensor assembly that recorded: instrument rotation, applied forces, time, and time delays between force application and instrument rotation. RESULTS: Advanced trainees showed increased instrument rotation, higher peak applied force, and faster performance compared to novices (alll p < .01). However, over trials, only novices showed adaptations for instrument rotation and total time (interactions at p < .01) with no adaptation for the force application. The difference between the moments of force application and instrument rotation was not sensitive to participant training. CONCLUSIONS: Movement process measures can enhance our understanding of early adaptation processes and how such factors might be used as feedback to facilitate skill acquisition.

Structural flexibility of laparoscopic instruments: implication for the design of virtual reality simulators.

Laparoscopic training, under simulated settings, benefits from high fidelity models of the actual environment. This study was aimed at reducing uncertainty in the displacement and loads experienced by a laparoscopic instrument during surgical training. Infrared tracking of laparoscopic instruments is ineffective when real tissues attenuate the infrared signals. Incorporating the use of strain gauges for tip deflection measurements allows for online motion and load tracking during a procedure. Strain gauge voltages and infrared markers indicating displacement were both linear with respect to loads up to 700 grams. The resultant strain gauge voltage was equated to deflection values with a calibration constant. The results serve two purposes. First, it may enable the tracking and analysis of the skill level of novice surgeons using bench models. Second, the mechanical model of each instrument can be quantified and incorporated into virtual simulations, thus increasing model fidelity, effectively leading to better learning.

Surface exploration using laparoscopic surgical instruments: the perception of surface roughness.

During laparoscopic surgery video images are used to guide the movements of the hand and instruments, and objects in the operating field often obscure these images. Thus, surgeons often rely heavily on tactile information (sense of touch) to help guide their movements. It is important to understand how tactile perception is affected when using laparoscopic instruments, since many surgical judgements are based on how a tissue 'feels' to the surgeon, particularly in situations where visual inputs are degraded. Twelve naïve participants used either their index finger or a laparoscopic instrument to explore sandpaper surfaces of various grits (60, 100, 150 and 220). These movements were generated with either vision or no vision. Participants were asked to estimate the roughness of the surfaces they explored. The normal and tangential forces of either the finger or instrument on the sandpaper surfaces were measured. Results showed that participants were able to judge the roughness of the sandpaper surfaces when using both the finger and the instrument. However, post hoc comparisons showed that perceptual judgements of surface texture were altered in the no vision condition compared to the vision condition. This was also the case when using the instrument, compared to the judgements provided when exploring with the finger. This highlights the importance of the completeness of the video images during laparoscopic surgery. More normal and tangential force was used when exploring the surfaces with the finger as opposed to the instrument. This was probably an attempt to increase the contact area of the fingertip to maximize tactile input. With the instrument, texture was probably sensed through vibrations of the instrument in the hand. Applications of the findings lie in the field of laparoscopic surgery simulation techniques and tactile perception.

The coordination of hand transport and grasp formation during single- and double-perturbed human prehension movements.

We investigated the mechanisms underlying human prehension movements, by perturbing the size and position of virtual targets. Subjects grasped virtual target discs with thumb and index finger. In 25% of trials, target size or position (single perturbation), or both (double perturbation) were changed 300 ms after target appearance. The experiments were designed such that the kinematic profiles of grasp formation and hand transport had a similar shape, and were analysed by the same algorithm. We found that grasp kinematics were influenced by changes of target position, and transport kinematics by changes of target size; we also found that the kinematics of double-perturbation trials could not be explained as a linear combination of single-perturbation effects. These findings confirm and expand previous evidence against the view that grasp and transport are controlled by fully independent channels. Most importantly, we found that the time of correction onset was not the same for grasp and transport, neither in single- nor in double-perturbation trials. This outcome argues against a holistic (single-channel) model of prehension; instead, our data are consistent with the notion of two mutually coupled channels.

What causes specificity of practice in a manual aiming movement: vision dominance or transformation errors?

The withdrawal of vision of the arm during a manual aiming task has been found to result in a large increase in aiming error, regardless of the amount of practice in normal vision before its withdrawal. In the present study, the authors investigated whether the increase in error reflects the domination of visual afferent information over the movement representation developed during practice to the detriment of other sources of afferent information or whether it reflects only transformation errors of the location of the target from an allocentric to an egocentric frame of reference. Participants (N = 40) performed aiming movements with their dominant or nondominant arm in a full-vision or target- only condition. The results of the present experiment supported both of those hypotheses. The data indicated that practice does not eliminate the need for visual information for optimizing movement accuracy and that learning is specific to the source or sources of afferent information more likely to ensure optimal accuracy during practice. In addition, the results indicated that movement planning in an allocentric frame of reference might require simultaneous vision of the arm and the target. Finally, practice in a target-only condition, with knowledge of results, was found to improve recoding of the target in an egocentric frame of reference.

Control strategies when intercepting slowly moving targets.

In 3 experiments, the authors investigated and described how individuals control manual interceptive movements to slowly moving targets. Participants (N = 8 in each experiment) used a computer mouse and a graphics tablet assembly to manually intercept targets moving across a computer screen toward a marked target zone. They moved the cursor so that it would arrive in the target zone simultaneously with the target. In Experiment 1, there was a range of target velocities, including some very slow targets. In Experiment 2, there were 2 movement distance conditions. Participants moved the cursor either the same distance as the target or twice as far. For both experiments, hand speed was found to be related to target speed, even for the very slowly moving targets and when the target-to-cursor distance ratios were altered, suggesting that participants may have used a strategy similar to tracking. To test that notion, in Experiment 3, the authors added a tracking task in which the participants tracked the target cursor into the target zone. Longer time was spent planning the interception movements; however, there was a longer time in deceleration for the tracking movements, suggesting that more visually guided trajectory updates were made in that condition. Thus, although participants scaled their interception movements to the cursor speed, they were using a different strategy than they used in tracking. It is proposed that during target interception, anticipatory mechanisms are used rather than the visual feedback mechanism used when tracking and when pointing to stationary targets.

The visuomotor system resists the horizontal-vertical illusion.

The effect of the horizontal-vertical illusion on the visual and visuomotor systems was investigated. Participants (N = 8) viewed horizontal and vertical lines in an inverted-T stimulus and judged whether the two line segments were the same or different lengths. Participants also reached out and grasped either the vertical or the horizontal line segment of the stimulus. Perceptually, participants succumbed to the illusion; that is, they judged Ts of equal horizontal and vertical line lengths to be different and Ts of unequal line lengths to be the same. When reaching toward the same stimuli, however, the size of their grip aperture was scaled appropriately for the various line lengths. Thus, whereas the perceptual system succumbed to the illusion, the visuomotor system did not. Those results support a model proposed by M. A. Goodale and A. D. Milner (1992), who posited separate cortical pathways for visual perception and visually guided action.

Motor skill learning of concentric and eccentric isokinetic movements in older adults.

Neuromuscular adaptation at the onset of resisted exercise can be observed as increases in torque and surface electromyography. The effect of learning the motor task has been hypothesized to contribute to these early increases, especially for older people. Thus, the purpose of this study was to investigate the facilitatory effects of practice on motor performance in older adults during short-term isokinetic training of the ankle dorsiflexors (DF). Twenty-eight men and women (M = 76.3 +/- 4.6 years) volunteered for a 2-week, 3-days/week strength training program. They were tested in a sitting position on a KinCom isokinetic dynamometer at 30, 90, and 180 degrees s-1 through 40 degrees of DF movement (concentric and eccentric contractions). Criterion curves of lever arm angle patterns were cross-correlated with subject-generated angle patterns, showing significantly better correlations on posttest versus baseline. Smoothness and proficiency of muscle contraction improved with practice by fewer hesitations in movement and increased ability to change between concentric and eccentric muscle contractions. Increased agonist electromyography and torque were hypothesized to be secondary to greater neural drive and/or synchronization of motor unit firing rate and/or recruitment during maximal voluntary contraction, improved coordination, and adapted neural control of concentric and eccentric muscle contraction.

Task dependent processing of visual information about target acceleration.

The objective of this study was to investigate the sensitivity of the perceptual and motor systems to target acceleration information using verbal magnitude estimations of target acceleration and manual interception of these targets. The results showed that in the perceptual task the participants were responding mainly to acceleration threshold values, which is acceleration as a function of initial, final, and average velocities, rather then to the absolute accelerations. When manually intercepting the targets the participants responded mainly to the absolute acceleration value and target initial velocity. Thus, these results suggest that target motion can be processed in the ventral (perception) and dorsal (action) visual streams however different motion characteristics are processed in these streams depending on the required output.

Target velocity effects on manual interception kinematics.

Participants generated manual interception movements toward a target cursor that moved across a computer screen. The target reached its peak velocity either during the first third, at the midpoint, or during the last third of the movement. In Experiment 1 the view of the target was available for either the first 316, 633, 950, or 1267 ms, after which it disappeared. Results showed that for all viewing conditions, the timing of the interception velocity was related to the temporal properties of the target's trajectory. In Experiment 2, when the portion of the target trajectory that was viewed was reversed (such that participants did not see the first 316, 633, 950, or 1267 ms of the trajectory, but instead saw only the later portions of the trajectory), there was no clear relationship between the target trajectory and the timing of the aiming trajectory. These results suggest that participants use visual information early in the target's trajectory to form a representation of the target motion that is used to facilitate manual interception.

The effect of illusory size on force production when grasping objects.

Milner and Goodale (1995) have proposed that visuomotor and perceptual processes are mediated by discrete visual systems that reflect the functional independence of action and perception. The visuomotor system is proposed to be insensitive to pictorial illusions of object size, whereas the perceptual system is reliably "tricked" by such figures. Brenner and Smeets (1996) and Jackson and Shaw (2000) demonstrated that grasp preshaping, but not grasping force, is immune to the Ponzo visual illusion, suggesting that not all visuomotor processes operate independently of the perceptual system. The present study investigated the effect of illusory object size on prehension kinematics and grasping dynamics (i.e., grip force and load force) as well as perceptual judgements of object size. Unlike previous investigations, object mass was held constant independent of changes in size. The Ponzo figure reliably affected perceptual estimates of object size, but this effect was restricted to one form of the illusion. Some aspects of the prehension movement were sensitive to veridical but not illusory object size (peak grip aperture, peak grip force, peak vertical wrist acceleration), whereas other movement parameters demonstrated illusory size effects (movement time, peak wrist velocity). Still other movement parameters were not sensitive to veridical or illusory object size (peak load force). Together the data suggest that certain prehension components are immune to pictorial illusions of object size, whereas others are not. Complex interactions between the perceptual and visuomotor systems appear to underlie the anticipatory scaling of grasping forces in prehension.

Target viewing time and velocity effects on prehension.

The goal of the present study was to understand which characteristics (movement time or velocity) of target motion are important in the control and coordination of the transport and grasp-preshape components of prehensile movements during an interception task. Subjects were required to reach toward, grasp and lift an object as it entered a target area. Targets approached along a track at four velocities (500, 750, 1000 and 1250 mm/s) which were presented in two conditions. In the distance-controlled condition, targets moving at all velocities traveled the same distance. In the viewing-time-controlled condition, combinations of velocity and starting distances were performed such that the moving target was visible for 1000 ms for all trials. Analyses of kinematic data revealed that when, target distance was controlled, velocity affected all transport-dependent measures; however, when viewing time was controlled, these dependent measures were no longer affected by target velocity. Thus, the use of velocity information was limited in the viewing-time-controlled condition, and subjects used other information, such as target movement time, when generating the transport component of the prehensile movement. For the grasp-preshape component, both peak aperture and peak-aperture velocity increased as target velocity increased, regardless of condition, indicating that target velocity was used to control the spatial aspects of aperture formation. However, the timing of peak aperture was affected by target velocity in the distance-controlled condition, but not in the viewing-time-controlled condition. These results provide evidence for the autonomous generation of the spatial and temporal aspects of grasp preshape. Thus, an independence between the transport and grasp-preshape phases was found, whereby the use of target velocity as a source of information for generating the transport component was limited; however, target velocity was an important source of information in the grasp-preshape phase.

Manual asymmetries in response to rapid target movement.

Two studies are reported that examine reaching responses of the two hands to unexpectedly displaced targets, located along the midline and to the left and right. In the first study, subjects used the index finger to point to the targets. The left hand movement time and time to peak velocity were longer than for the right hand. For both hands, performance was superior when reaching into ipsilateral space. No evidence was found for early (before peak velocity) trajectory corrections in response to perturbations. In the second study, subjects reached and grasped dowels which appeared to move unexpectedly. Again, movement times were smaller when reaching with the right hand when compared to the left, but only on trials when the dowel was located on the subject's right. When subjects reached to the left, the left hand had shorter movement times. Early trajectory corrections were observed in the velocity profiles; the pattern was similar for both hands. These data are discussed in terms of visual processing abilities of the left and right cerebral hemispheres, and visual processing abilities when pointing and grasping.

The influence of aging and target motion on the control of prehension.

The purpose of this study was to examine age-related differences in reaching behavior when younger (mean age = 26.0 years) and older (mean age = 70.1 years) individuals were required to reach toward and grasp both small and large targets that were either stationary or moving. The older subjects had shorter movement times, and smaller within-subject movement time variability than younger subjects. Also, the deceleration of the reach was shorter for older subjects, indicating that they were not making extensive use of on-line feedback, and were instead utilizing anticipatory control strategies. There were no age differences in the size of the maximum grasp around the target, but the timing of the grasp was influenced by target motion for the younger subjects, suggesting on-line control for the younger subjects only.

Anticipatory locomotor adjustments for accommodating versus avoiding level changes in humans.

The control of locomotion has been studied from various perspectives related to the tasks of pattern generation, equilibrium control or adaptation to the environment. The last of these locomotor components has received comparably less attention, specifically pertaining to anticipatory adjustments. Continuing the work which has been conducted on both humans and cats, the present paper explores the nature of the differences in anticipatory locomotor adjustments for obstacle avoidance versus the accommodation to level changes. Six subjects walked in six different environments including no obstructions, a simple obstacle, two different level changes (a platform and stairs), and a combination of an obstacle with each respective level change. Full dynamic analyses allowed comparison of muscle torques as well as muscle power generated and absorbed at the lower limb joints across conditions. It was found that the previously shown robust lower limb reorganization characterized by a knee flexor generation strategy was upheld in all conditions when the obstacle was present. Pure level changes involved an augmentation of the ongoing hip strategy inherent in normal level walking. In the compound environment of obstructed level changes, subjects chose to combine an augmentation of hip flexor power with a reorganization to active knee flexion. The results are discussed from the point of view of general principles of mechanical coordination and the exploitation of intersegmental dynamics for foot transport.

An investigation into movement planning and execution deficits in individuals with schizophrenia.

The purpose of this study was to examine whether individuals with schizophrenia demonstrate slowing in movement planning (reaction time), or in movement execution (movement time and velocity), in comparison to normals. Twelve schizophrenic and 12 control right-handed males performed aiming movements with a mouse (controlled by either the left or right hand) on a graphics tablet towards targets of differing sizes and distances appearing on a computer screen. Results showed that, for reaction time, the controls were faster than the schizophrenics and the latter had a left hand advantage for movement preparation while the controls showed no such differences. For movement time, no group differences were found. However, as expected, movement times were shorter (i.e., movements were faster) to the large, and near targets. These results support Fitts' law (Fitts, 1954) which describes a relationship where aiming movement time decreases as target distance decreases, and target size increases. We provide evidence here for a movement planning deficit in schizophrenic patients with no decrement in movement execution compared to controls.

Delayed visual feedback while learning to track a moving target.

Two studies investigated the effects of delayed visual feedback on manual tracking. In Experiment 1, individuals practiced with visual feedback provided either immediately (0 delay) or with a 333-ms delay. During acquisition, the 0 delay group performed with less error than the 333-ms delay group. A retention test with 0 delay feedback was performed with the least error by the 0 delay group. A transfer test using a different 0 delay tracking pattern, was performed with the least error by the 333-ms delay group. In Experiment 2, individuals practiced at six different delays. Error increased as training feedback delay increased. For retention there were no differences between the delay groups during the 0 delay retention. At a 417-ms retention, test error decreased as training feedback delay increased. Results indicate that error during acquisition does not necessarily impair learning and that feedback delays can be beneficial for learning.