Interaction of hand orientations during familiarization of a goal-directed aiming task.

The purpose of the present study was to examine errors for an isometric goal-directed aiming task during familiarization at different hand orientation. Interaction between neutral and pronated hand orientations with and without directional feedback would provide insights into short-term adaptations and the nature of control. In this study, 30 healthy right-handed adults (age, 22.7 ± 3.1 years; weight, 69.4 ± 16.6 kg; height, 166.7 ± 7.9 cm) were randomly assigned to neutral or pronated hand orientation conditions. To assess familiarization, participants performed ten sets (16 targets/set) of goal-directed aiming task with continuous visual feedback towards targets symmetrically distributed about the origin. Following familiarization, participants then completed eight sets; four sets with and four sets without directional feedback, in an alternated order. For both hand orientations, directional errors were reduced in the first two sets (p < 0.05), suggesting only three sets were required for familiarization. Additionally, the learning rate was also similar for both hand orientations. Following familiarization, aiming errors without feedback were significantly higher than with feedback while no change between sets was observed, regardless of hand orientation. Aiming errors were reduced in the early phase with and without visual feedback, however, in the late phase, errors were corrected when visual feedback was provided. It suggests that hand orientation does not affect familiarization, and mechanisms similar to rapid learning may be involved. It is probable that learning is consolidated during familiarization along with feedforward input to maintain performance. In addition, proprioceptive feedback plays a role in reducing errors early, while the online visual feedback plays a role in reducing errors later, independent of hand orientation.

Acoustic stimulation increases implicit adaptation in sensorimotor adaptation.

Sensorimotor adaptation is an important part of our ability to perform novel motor tasks (i.e., learning of motor skills). Efforts to improve adaptation in healthy and clinical patients using non-invasive brain stimulation methods have been hindered by inter-individual and intra-individual variability in brain susceptibility to stimulation. Here, we explore unpredictable loud acoustic stimulation as an alternative method of modulating brain excitability to improve sensorimotor adaptation. In two experiments, participants moved a cursor towards targets, and adapted to a 30º rotation of cursor feedback, either with or without unpredictable acoustic stimulation. Acoustic stimulation improved initial adaptation to sensory prediction errors in Study 1, and improved overnight retention of adaptation in Study 2. Unpredictable loud acoustic stimulation might thus be a potent method of modulating sensorimotor adaptation in healthy adults.

Cumulative distribution functions: An alternative approach to examine the triggering of prepared motor actions in the StartReact effect.

There has been much debate concerning whether startling sensory stimuli can activate a fast-neural pathway for movement triggering (StartReact) which is different from that of voluntary movements. Activity in sternocleidomastoid (SCM) electromyogram is suggested to indicate activation of this pathway. We evaluated whether SCM activity can accurately identify trials which may differ in their neurophysiological triggering and assessed the use of cumulative distribution functions (CDFs) of reaction time (RT) data to identify trials with the shortest RTs for analysis. Using recent data sets from the StartReact literature, we examined the relationship between RT and SCM activity. We categorised data into short/longer RT bins using CDFs and used linear mixed-effects models to compare potential conclusions that can be drawn when categorising data on the basis of RT versus on the basis of SCM activity. The capacity of SCM to predict RT is task-specific, making it an unreliable indicator of distinct neurophysiological mechanisms. Classification of trials using CDFs is capable of capturing potential task- or muscle-related differences in triggering whilst avoiding the pitfalls of the traditional SCM activity-based classification method. We conclude that SCM activity is not always evident on trials that show the early triggering of movements seen in the StartReact phenomenon. We further propose that a more comprehensive analysis of data may be achieved through the inclusion of CDF analyses. These findings have implications for future research investigating movement triggering as well as for potential therapeutic applications of StartReact.

Pushing attention to one side: Force field adaptation alters neural correlates of orienting and disengagement of spatial attention.

Sensorimotor adaptation to wedge prisms can alter the balance of attention between left and right space in healthy adults, and improve symptoms of spatial neglect after stroke. Here we asked whether the orienting of spatial attention to visual stimuli is affected by a different form of sensorimotor adaptation that involves physical perturbations of arm movement, rather than distortion of visual feedback. Healthy participants performed a cued discrimination task before and after they made reaching movements to a central target. A velocity-dependent force field pushed the hand aside during each reach, and required participants to apply compensatory forces toward the opposite side. We used event-related potentials (ERPs) to determine whether electroencephalography (EEG) responses reflecting orienting (cue-locked N1) and disengagement (target-locked P1) of spatial attention are affected by adaptation to force fields. After adaptation, the cue-locked N1 was relatively larger for stimuli presented in the hemispace corresponding to the direction of compensatory hand force. P1 amplitudes evoked by invalidly cued targets presented on the opposite side were reduced. This suggests that force field adaptation boosted attentional orienting responses toward the side of hand forces, and impeded attentional disengagement from that side, mimicking previously reported effects of prism adaptation. Thus, remapping between motor commands and intended movement direction is sufficient to bias ERPs, reflecting changes in the orienting of spatial attention in the absence of visuo-spatial distortion or visuo-proprioceptive mismatch. Findings are relevant to theories of how sensorimotor adaptation can modulate attention, and may open new avenues for treatment of spatial neglect.

Triggering Mechanisms for Motor Actions: The Effects of Expectation on Reaction Times to Intense Acoustic Stimuli.

Motor actions can be released much sooner than normal when the go-signal is of very high intensity (>100 dBa). Although statistical evidence from individual studies has been mixed, it has been assumed that sternocleidomastoid (SCM) muscle activity could be used to distinguish between two neural circuits involved in movement triggering. We summarized meta-analytically the available evidence for this hypothesis, comparing the difference in premotor reaction time (RT) of actions where SCM activity was elicited (SCM+ trials) by loud acoustic stimuli against trials in which it was absent (SCM- trials). We found ten studies, all reporting comparisons between SCM+ and SCM- trials. Our mini meta-analysis showed that premotor RTs are faster in SCM+ than in SCM- trials, but the effect can be confounded by the variability of the foreperiods employed. We present experimental data showing that foreperiod predictability can induce differences in RT that would be of similar size to those attributed to the activation of different neurophysiological pathways to trigger prepared actions. We discuss plausible physiological mechanisms that would explain differences in premotor RTs between SCM+ and SCM- trials.

Do we know what we need? Preference for feedback about accurate performances does not benefit sensorimotor learning.

Previous research on skill acquisition has shown that learners seem to prefer receiving knowledge of results (KR) about those trials in which they have performed more accurately. In the present study, we assessed whether this preference leads to an advantage in terms of skill acquisition, transfer, and retention of their capacity to extrapolate the motion of decelerating objects during periods of visual occlusion. Instead of questionnaires, we adopted a more direct approach to investigate learners' preferences for KR. Participants performed 90 trials of a motion extrapolation task (acquisition phase) in which, every three trials, they could decide between receiving KR about their best or worst performance. Retention and transfer tests were carried out 24 hr after the acquisition phase, without KR, to examine the effects of the self-selected KR on sensorimotor learning. Consistent with the current literature, a preference for receiving KR about the most accurate performance was observed. However, participants' preferences were not consistent throughout the experiment as less than 10% (N = 40) selected the same type of KR in all their choices. Importantly, although preferred by most participants, KR about accurate performances had detrimental effects on skill acquisition, suggesting that learners may not always choose the KR that will maximize their learning experiences and skill retention. (PsycINFO Database Record

Unilateral movement preparation causes task-specific modulation of TMS responses in the passive, opposite limb.

KEY POINTS: Activity in the primary motor cortices of both hemispheres increases during unilateral movement preparation, but the functional role of ipsilateral motor cortex activity is unknown. Ipsilateral motor cortical activity could represent subliminal 'motor planning' for the passive limb. Alternatively, it could represent the state of the active limb, to support coordination between the limbs should a bimanual movement be required. Here we assessed how preparation of forces toward different directions, with the left wrist, alters evoked responses to transcranial magnetic stimulation of left motor cortex. Preparation of a unilateral movement caused excitability increases in ipsilateral motor cortex that reflected forces produced with the active limb in an intrinsic (body-centred), rather than an extrinsic (world-centred), coordinate system. These results suggest that ipsilateral motor cortical activity prior to unilateral action reflects the state of the active limb, rather than subliminal motor planning for the passive limb. ABSTRACT: Corticospinal excitability is modulated for muscles on both sides of the body during unilateral movement preparation. For the effector, there is a progressive increase in excitability, and a shift in direction of muscle twitches evoked by transcranial magnetic stimulation (TMS) toward the impending movement. By contrast, the directional characteristics of excitability changes in the opposite (passive) limb have not been fully characterized. Here we assessed how preparation of voluntary forces towards four spatially distinct visual targets with the left wrist alters muscle twitches and motor-evoked potentials (MEPs) elicited by TMS of left motor cortex. MEPs were facilitated significantly more in muscles homologous to agonist rather than antagonist muscles in the active limb, from 120 ms prior to voluntary EMG onset. Thus, unilateral motor preparation has a directionally specific influence on pathways projecting to the opposite limb that corresponds to the active muscles rather than the direction of movement in space. The directions of TMS-evoked twitches also deviated toward the impending force direction of the active limb, according to muscle-based coordinates, following the onset of voluntary EMG. The data indicate that preparation of a unilateral movement increases task-dependent excitability in ipsilateral motor cortex, or its downstream projections, that reflects the forces applied by the active limb in an intrinsic (body-centred), rather than an extrinsic (world-centred), coordinate system. The results suggest that ipsilateral motor cortical activity prior to unilateral action reflects the state of the active limb, rather than subliminal motor planning for the passive limb.

Cerebellar anodal tDCS increases implicit learning when strategic re-aiming is suppressed in sensorimotor adaptation.

Neurophysiological and neuroimaging work suggests that the cerebellum is critically involved in sensorimotor adaptation. Changes in cerebellar function alter behaviour when compensating for sensorimotor perturbations, as shown by non-invasive stimulation of the cerebellum and studies involving patients with cerebellar degeneration. It is known, however, that behavioural responses to sensorimotor perturbations reflect both explicit processes (such as volitional aiming to one side of a target to counteract a rotation of visual feedback) and implicit, error-driven updating of sensorimotor maps. The contribution of the cerebellum to these explicit and implicit processes remains unclear. Here, we examined the role of the cerebellum in sensorimotor adaptation to a 30° rotation of visual feedback of hand position during target-reaching, when the capacity to use explicit processes was manipulated by controlling movement preparation times. Explicit re-aiming was suppressed in one condition by requiring subjects to initiate their movements within 300ms of target presentation, and permitted in another condition by requiring subjects to wait approximately 1050ms after target presentation before movement initiation. Similar to previous work, applying anodal transcranial direct current stimulation (tDCS; 1.5mA) to the right cerebellum during adaptation resulted in faster compensation for errors imposed by the rotation. After exposure to the rotation, we evaluated implicit remapping in no-feedback trials after providing participants with explicit knowledge that the rotation had been removed. Crucially, movements were more adapted in these no-feedback trials following cerebellar anodal tDCS than after sham stimulation in both long and short preparation groups. Thus, cerebellar anodal tDCS increased implicit remapping during sensorimotor adaptation, irrespective of preparation time constraints. The results are consistent with the possibility that the cerebellum contributes to the formation of new visuomotor maps that correct perturbations in sensory feedback, even when explicit processes are suppressed during sensorimotor adaptation.

Assessing colonoscopic inspection skill using a virtual withdrawal simulation: a preliminary validation of performance metrics.

BACKGROUND: The effectiveness of colonoscopy for diagnosing and preventing colon cancer is largely dependent on the ability of endoscopists to fully inspect the colonic mucosa, which they achieve primarily through skilled manipulation of the colonoscope during withdrawal. Performance assessment during live procedures is problematic. However, a virtual withdrawal simulation can help identify and parameterise actions linked to successful inspection, and offer standardised assessments for trainees. METHODS: Eleven experienced endoscopists and 18 endoscopy novices (medical students) completed a mucosal inspection task during three simulated colonoscopic withdrawals. The two groups were compared on 10 performance metrics to preliminarily assess the validity of these measures to describe inspection quality. Four metrics were related to aspects of polyp detection: percentage of polyp markers found; number of polyp markers found per minute; percentage of the mucosal surface illuminated by the colonoscope (≥0.5 s); and percentage of polyp markers illuminated (≥2.5 s) but not identified. A further six metrics described the movement of the colonoscope: withdrawal time; linear distance travelled by the colonoscope tip; total distance travelled by the colonoscope tip; and distance travelled by the colonoscope tip due to movement of the up/down angulation control, movement of the left/right angulation control, and axial shaft rotation. RESULTS: Statistically significant experienced-novice differences were found for 8 of the 10 performance metrics (p's < .005). Compared with novices, experienced endoscopists inspected more of the mucosa and detected more polyp markers, at a faster rate. Despite completing the withdrawals more quickly than the novices, the experienced endoscopists also moved the colonoscope more in terms of linear distance travelled and overall tip movement, with greater use of both the up/down angulation control and axial shaft rotation. However, the groups did not differ in the number of polyp markers visible on the monitor but not identified, or movement of the left/right angulation control. All metrics that yielded significant group differences had adequate to excellent internal consistency reliability (α = .79 to .90). CONCLUSIONS: These systematic differences confirm the potential of the simulated withdrawal task for evaluating inspection skills and strategies. It may be useful for training, and assessment of trainee competence.

A novel training device for tip control in colonoscopy: preliminary validation and efficacy as a training tool.

BACKGROUND: Effective control of the colonoscope tip is one of the most fundamental components of colonoscopy skill. Mastering fine tip control can be problematic for novice trainees, yet no validated training regimes exist for developing this specific skill component in isolation. We aimed to conduct a preliminary validation of a novel training device for colonoscopic tip control, and to assess its efficacy as a training tool. METHODS: In study 1 (validation), 13 experienced colonoscopists and 16 novices used a colonoscope to accurately track 28 targets on each of four concave "training surfaces" as quickly as possible, and we compared their performance. In study 2 (pre-post-training study), another 16 novices were tested before and after a six-session training program. In both studies, the main outcome measurements were completion time (measured automatically by the device) and variability of individual performance (the SD of each individual's completion times across trials). RESULTS: Compared with novices, experienced colonoscopists were faster (P < 0.0001) and their performances less variable (P < 0.0001). With training, novices became faster (P < 0.0001) and more consistent (P = 0.003), and these improvements also generalized to novel training surfaces (P's < 0.01). After training, the novices' tip control performance was indistinguishable from that of the experienced colonoscopists (P's > 0.05). The composite measures of completion time used in both studies all had acceptable to excellent internal consistency reliability (α's ranged from 0.72 to 0.93). CONCLUSIONS: We found that performance measures derived from using the device to assess skill can discriminate between experienced colonoscopists and novices in terms of their ability to control and guide the colonoscope tip precisely, providing preliminary evidence to support the construct validity of the metrics. The device is also an effective training tool for this fundamental component of colonoscopy skill.

Unexpected acoustic stimulation during action preparation reveals gradual re-specification of movement direction.

A loud acoustic stimulus (LAS) is often used as a tool to investigate motor preparation in simple reaction time (RT) tasks, where all movement parameters are known in advance. In this report, we used a LAS to examine direction specification in simple and choice RT tasks. This allowed us to investigate how the specification of movement direction unfolds during the preparation period. In two experiments, participants responded to the appearance of an imperative stimulus (IS) with a ballistic wrist force directed toward one of two targets. In probe trials, a LAS (120dBa) was delivered around the time of IS presentation. In Experiment 1, RTs in the simple RT task were faster when the LAS was presented, but the effect on the movement kinematics was negligible. In the Choice RT task, however, movement direction variability increased when the LAS was presented. In Experiment 2, when we primed movements toward one direction, our analyses revealed that the longer participants took to start a movement, the more accurate their responses became. Our results show not only that movement direction reprogramming occurs quickly and continuously, but also that LAS can be a valuable tool to obtain meaningful readouts of the motor system's preparatory state.

Assessment of colorectal polyp recognition skill: development and validation of an objective test.

BACKGROUND: The quality of colonoscopy is known to vary. The extent to which colonoscopists can recognize the presence of subtle colorectal lesions by visually distinguishing them from the surrounding mucosa (i.e., polyp recognition skill) may be one of several attributes that influence polyp detection rates. The aim of the present study was to develop and validate the first objective test of polyp recognition skill. METHODS: Validation study. Twenty-eight experienced colonoscopists and eighty novices took a preliminary 280-item computer-based polyp recognition test. Items were genuine endoscopic images which participants assessed for the presence of "likely polyps." Half included clinically identified polyps. Participants clicked on a suspected lesion or a button marked "no likely polyp", and the main outcome measures were accuracy and response latency. The best items were selected for the final 50-item test. RESULTS: In the preliminary test, experienced colonoscopists correctly identified more polyps than novices (P < .0001) and better discriminated between clinically identified polyps and non-polyp features (as measured by d', P < .0001). For polyp items, the experienced group also responded faster (P < .01). Effect sizes were large for accuracy (Cohen's d = 3.22) and d' (Cohen's d = 3.22). The 50 final test items produced comparable results for accuracy, d', and response latency. For both versions of the test, score scale reliability was high for both polyp and non-polyp items (α = .82 to .97). CONCLUSIONS: The observed experienced-novice differences support the construct validity of the performance measures derived from the tests, indicating that polyp recognition skill can be quantified objectively. The final test may potentially be used to assess trainees, but test sensitivity may be insufficient to make fine-grained distinctions between different skill levels among experienced colonoscopists. More sensitive future tests may provide a valuable supplement to clinical detection rates, allowing objective comparisons between skilled colonoscopists.

The efficacy of training insertion skill on a physical model colonoscopy simulator.

Background and study aims: Prior research supports the validity of performance measures derived from the use of a physical model colonoscopy simulator - the Kyoto Kagaku Colonoscope Training Model (Kyoto Kagaku Co. Ltd., Kyoto, Japan) - for assessing insertion skill. However, its use as a training tool has received little research attention. We assessed the efficacy of a brief structured program to develop basic colonoscope insertion skill through unsupervised practice on the model. Participants and methods: This was a training study with pretesting and post-testing. Thirty-two colonoscopy novices completed an 11-hour training regime in which they practiced cases on the model in a colonoscopy simulation research laboratory. They also attempted a series of test cases before and after training. For each outcome measure (completion rates, time to cecum and peak force applied to the model), we compared trainees' post-test performance with the untrained novices and experienced colonoscopists from a previously-reported validation study. Results: Compared with untrained novices, trained novices had higher completion rates and shorter times to cecum overall (Ps < .001), but were out-performed by the experienced colono-scopists on these metrics (Ps < .001). Nevertheless, their performance was generally closer to that of the experienced group. Overall, trained novices did not differ from either experience-level comparison group in the peak forces they applied (P > .05). We also present the results broken down by case. Conclusions: The program can be used to teach trainees basic insertion skill in a more or less self-directed way. Individuals who have completed the program (or similar training on the model) are better prepared to progress to supervised live cases.

Feedforward compensation for novel dynamics depends on force field orientation but is similar for the left and right arms.

There are well-documented differences in the way that people typically perform identical motor tasks with their dominant and the nondominant arms. According to Yadav and Sainburg's (Neuroscience 196: 153-167, 2011) hybrid-control model, this is because the two arms rely to different degrees on impedance control versus predictive control processes. Here, we assessed whether differences in limb control mechanisms influence the rate of feedforward compensation to a novel dynamic environment. Seventy-five healthy, right-handed participants, divided into four subsamples depending on the arm (left, right) and direction of the force field (ipsilateral, contralateral), reached to central targets in velocity-dependent curl force fields. We assessed the rate at which participants developed predictive compensation for the force field using intermittent error-clamp trials and assessed both kinematic errors and initial aiming angles in the field trials. Participants who were exposed to fields that pushed the limb toward ipsilateral space reduced kinematic errors more slowly, built up less predictive field compensation, and relied more on strategic reaiming than those exposed to contralateral fields. However, there were no significant differences in predictive field compensation or kinematic errors between limbs, suggesting that participants using either the left or the right arm could adapt equally well to novel dynamics. It therefore appears that the distinct preferences in control mechanisms typically observed for the dominant and nondominant arms reflect a default mode that is based on habitual functional requirements rather than an absolute limit in capacity to access the controller specialized for the opposite limb.

Savings for visuomotor adaptation require prior history of error, not prior repetition of successful actions.

When we move, perturbations to our body or the environment can elicit discrepancies between predicted and actual outcomes. We readily adapt movements to compensate for such discrepancies, and the retention of this learning is evident as savings, or faster readaptation to a previously encountered perturbation. The mechanistic processes contributing to savings, or even the necessary conditions for savings, are not fully understood. One theory suggests that savings requires increased sensitivity to previously experienced errors: when perturbations evoke a sequence of correlated errors, we increase our sensitivity to the errors experienced, which subsequently improves error correction (Herzfeld et al. 2014). An alternative theory suggests that a memory of actions is necessary for savings: when an action becomes associated with successful target acquisition through repetition, that action is more rapidly retrieved at subsequent learning (Huang et al. 2011). In the present study, to better understand the necessary conditions for savings, we tested how savings is affected by prior experience of similar errors and prior repetition of the action required to eliminate errors using a factorial design. Prior experience of errors induced by a visuomotor rotation in the savings block was either prevented at initial learning by gradually removing an oppositely signed perturbation or enforced by abruptly removing the perturbation. Prior repetition of the action required to eliminate errors in the savings block was either deprived or enforced by manipulating target location in preceding trials. The data suggest that prior experience of errors is both necessary and sufficient for savings, whereas prior repetition of a successful action is neither necessary nor sufficient for savings.

Strength Training Biases Goal-Directed Aiming.

PURPOSE: Goal-directed movements tend to resemble the characteristics of previously executed actions. Here we investigated whether a single bout of strength training, which typically involves stereotyped actions requiring strong neural drive, can bias subsequent aiming behavior toward the direction of trained forces. METHODS: In experiment 1 (n = 10), we tested the direction of force exerted in an isometric aiming task before and after 40 repetitions of 2-s maximal-force ballistic contractions toward a single directional target. In experiment 2 (n = 12), each participant completed three training conditions in a counterbalanced crossover design. In two conditions, both the aiming task and the training were conducted in the same (neutral) forearm posture. In one of these conditions, the training involved weak forces to determine whether the level of neural drive during training influences the degree of bias. In the third condition, high-force training contractions were performed in a 90° pronated forearm posture, whereas the low-force aiming task was performed in a neutral forearm posture. This dissociated the extrinsic training direction from the pulling direction of the trained muscles during the aiming task. RESULTS: In experiment 1, we found that aiming direction was biased toward the training direction across a large area of the work space (approximately ±135°; tested for 16 targets spaced 22.5° apart), whereas in experiment 2, we found systematic bias in aiming toward the training direction defined in extrinsic space, but only immediately after high-force contractions. CONCLUSION: Our findings suggest that bias effects of training involving strong neural drive generalize broadly to untrained movement directions and are expressed according to extrinsic rather than muscle-based coordinates.

Electric and acoustic stimulation during movement preparation can facilitate movement execution in healthy participants and stroke survivors.

There has been increasing interest in the use of loud acoustic stimulation (LAS) to gain insight into the preparation and initiation of motor actions. Typically, LAS presented during movement preparation in healthy participants culminates in the earlier than normal initiation of the prepared movement and an increase in the magnitude of the response. Recent reports have shown LAS can also facilitate movement in chronic stroke survivors. This suggests that current therapies for motor recovery after stroke might benefit from employing such alternate methods of triggering movement. In this study we sought to test a new way to facilitate motor actions that could be of relevance in clinical settings. Five individuals with chronic motor impairments due to stroke and eight healthy young adults performed a functional reaching task in response to a visual go-signal. On 30% of the trials, LAS or electric stimuli (collectively, sensory stimuli) were unexpectedly presented in synchrony with the go-signal. Both healthy and stroke participants reacted with shorter latencies and executed faster responses when sensory stimulation was synchronized with the go-signal. We have replicated previous findings showing acoustic stimuli can aid movement execution in chronic stroke survivors and demonstrated the same type of effect can be achieved using electric stimulation. Thus, these two types of sensory stimuli can be easily integrated with current devices available to assist people with stroke to engage in rehabilitation efforts.

A competency framework for colonoscopy training derived from cognitive task analysis techniques and expert review.

BACKGROUND: Colonoscopy is a difficult cognitive-perceptual-motor task. Designing an appropriate instructional program for such a task requires an understanding of the knowledge, skills and attitudes underpinning the competency required to perform the task. Cognitive task analysis techniques provide an empirical means of deriving this information. METHODS: Video recording and a think-aloud protocol were conducted while 20 experienced endoscopists performed colonoscopy procedures. "Cued-recall" interviews were also carried out post-procedure with nine of the endoscopists. Analysis of the resulting transcripts employed the constant comparative coding method within a grounded theory framework. The resulting draft competency framework was modified after review during semi-structured interviews conducted with six expert endoscopists. RESULTS: The proposed colonoscopy competency framework consists of twenty-seven skill, knowledge and attitude components, grouped into six categories (clinical knowledge; colonoscope handling; situation awareness; heuristics and strategies; clinical reasoning; and intra- and inter-personal). CONCLUSIONS: The colonoscopy competency framework provides a principled basis for the design of a training program, and for the design of formative assessment to gauge progress towards attaining the knowledge, skills and attitudes underpinning the achievement of colonoscopy competence.

The facilitation of motor actions by acoustic and electric stimulation.

The presentation of a loud acoustic stimulus during the preparation of motor actions can both speed movement initiation and increase response vigor. Several recent studies have explored this phenomenon as a means to investigate the mechanisms and neural correlates of movement preparation. Here, we sought to determine the generality of this effect across sensory modalities, and in particular whether unexpected somatosensory stimulation can facilitate movements in a manner similar to loud sounds. We show that electric and acoustic stimuli can be similarly effective in inducing the early release of motor actions, in both reaction time and anticipatory timing tasks. Consistent with recent response activation models of motor preparation, we also demonstrate that increasing the intensity of electric stimuli induces both progressive decreases in reaction time and increases in response vigor. Additionally, we show that the early release of motor actions can be induced by electric stimuli targeting predominantly either muscle afferents or skin afferents. Finally, we show that simultaneous acoustic and electric stimulation leads to earlier releases of anticipatory actions than either unimodal stimulus. These findings may lead to new avenues for experimental and clinical exploitation of the effects of accessory sensory information on movement preparation and initiation.

The effects of preparation and acoustic stimulation on contralateral and ipsilateral corticospinal excitability.

A loud auditory stimulus (LAS) presented together with an imperative stimulus during preparation for motor actions can speed their initiation. The effects of LAS on corticospinal excitability (CSE), however, depend on the state of preparation of the motor system for action. CSE also depends on the brain hemisphere controlling the responding limb. Usually, CSE is increased just before movement onset in the hemisphere controlling the movement and inhibited on the other side. This study investigated the impact of LAS on CSE of the contralateral and ipsilateral hemispheres, while participants prepared for a voluntary abduction of the index finger. In Experiment 1, we attempted to identify the pattern of modulation of the ipsilateral cortex (resting side) by determining the time course of corticospinal changes in anticipatory timing actions using transcranial magnetic stimulation. In Experiment 2, we investigated the impact of LAS on the ipsilateral and contralateral CSE during anticipatory preparation. Results found no modulation of ipsilateral CSE during preparation, but indicate an increase in CSE after EMG onset on the acting limb. Moreover, we found that LAS presentation increased CSE on the contralateral side (active side).