Background: Practicing arm and gait movements with robotic assistance after neurologic injury can help patients improve their mo- vement ability, but patients sometimes reduce their effort during training in response to the assistance. Reduced effort has been hypothesized to diminish clinical outcomes of robotic training. To better understand patient slacking, we studied the role of visu-al distraction and auditory feedback in modulating patient effort during a common robot-assisted tracking task. Methods: Fourteen participants with chronic left hemiparesis from stroke, five control participants with chronic right hemiparesis and fourteen non-impaired healthy control participants, tracked a visual target with their arms while receiving adaptive assistance from a robotic arm exoskeleton. We compared four practice conditions: the baseline tracking task alone; tracking while also performing a visual distracter task; tracking with the visual distracter and sound feedback; and tracking with sound feedback. For the distracter task, symbols were randomly displayed in the corners of the computer screen, and the participants were instructed to click a mouse button when a target symbol appeared. The sound feedback consisted of a repeating beep, with the frequency of repetition made to increase with increasing tracking error. Results: Participants with stroke halved their effort and doubled their tracking error when per-forming the visual distracter task with their left hemiparetic arm. With sound feedback, however, these participants increased their effort and decreased their tracking error close to their baseline levels, while also performing the distracter task suc-cessfully. These effects were significantly smaller for the participants who used their non-paretic arm and for the participants without stroke. Conclusions: Visual distraction decreased participants effort during a standard robot-assisted movement training task. This effect was greater for the hemiparetic arm, suggesting that the increased demands associated with controlling an af-fected arm make the motor system more prone to slack when distracted. Providing an alternate sensory channel for feedback, i.e., auditory feedback of tracking error, enabled the participants to simultaneously perform the tracking task and distracter task effec-tively. Thus, incorporating real-time auditory feedback of performance errors might improve clinical outcomes of robotic therapy systems.

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