Motor Learning

Extrinsic (Augmented) Feedback

• augments feedback occurring intrinsically

• includes any feedback which comes from external source

• can be positive or negative

• can come before, during, or after the trial

• used when introducing a task or new learning

• patients can become reliant on feedback

• best option for those with sensory deficits

• need language comprehension/attention

• enhances performance (not learning)

Intrinsic Feedback

• information about feel of the movement from self

• from internal sensory sources (vision, somatosensory, proprioception, kinesthesia, etc.)

• skill judged against desired performance

• modifications occur intra and inter trial without need for feedback from therapist

• initial performance might suffer

• must know intended movement

• improves generalizability of movement

• enhances selection of strategies for success

• transfer to novel situations is high

• enhances learning (permanent changes)

• error recognition

Frequency of Feedback

• constant feedback

• fading feedback

• intermittent feedback

Constant Feedback

• continuous feedback, most every repetition, little to no time without feedback

• best for immediate, fast, temporary skill acquisition

Fading Feedback

• beginning with constant feedback then giving less and less over time

• allows the learner to own more of the task

• shift toward intrinsic feedback

Intermittent Feedback

• feedback that is not given every repetition but instead occasionally provided and not necessarily on regular intervals

• better than giving feedback after every attempt for long-term retention

Timing of Feedback

• concurrent feedback

• terminal feedback

• summary feedback

Concurrent Feedback

• continuous delivery of information regarding task performance given during the session

• increases dependency on feedback and impairs learning

• good for fast skill acquisition but not learning

Terminal Feedback

• the delivery of information at the conclusion of each repetition of a task

• with visual aids enhances balance

• enhances learning and transfer of task better than concurrent

Summary Feedback

• occurs after the patient has performed a set of repetitions of block of practice

• enhances learning and transfer of task better than concurrent

Type of Feedback

• knowledge of performance

• knowledge of results

Knowledge of Performance

• information provided to the patient regarding achievement or failure of achieving specific key elements of the task

• can be verbal (“a little more weight on the left side”)

• video replay is an option

• good for skills with specific steps embedded in them (i.e. STS)

Knowledge of Results

• information provided to the patient regarding the performance outcome

• tells them if they achieved the goal (“yes”, “no”, “almost”)

• aligns with intrinsic feedback for improved learning

• closes the loop for the learner as to whether or not they met the goal

• can be motivating

Focus of Feedback

• internal focus

• external focus

Internal Focus

• providing cues to the patient about what parts of the body need to be moved to achieve the task

• “place the heel down first when the foot hits the ground”

• causes a reduction in automaticity and hinders learning and retention

External Focus

• providing cues for the patient that are only related to the environment and movement related to things outside of the body

• “take the longest step possible each time”

• can improve balance and posture and should be used after initial introduction of skills

Feedback for the beginning of level of a task

• concurrent

• constant

• knowledge of performance

• internal focus

• extrinsic

Feedback for the goal performance of a task

• summary

• terminal

• intermittent

• knowledge of results

• external focus

• intrinsic

Schedule of Practice

• massed practice

• distributed (spaced) practice

Massed Practice

• work sessions occur with little to no rest periods

• fatigue can be a limiting issue and not recommended for those with fatigue issues

• less effective for motor performance

• better for rapid skill acquisition

Distributed Practice

• the amount of rest from execution of a particular skill/task is equal to or greater than the work time for that same skill/task

• increasing time between practice sessions (but not too much) increases performance on final testing

• better for long term retention

Constant/Blocked Practice

• same task repeated over and over, the same way (same attributes)

• good for first time doing task or first time since injury/surgery

• good for those not able to select strategies for situation due to cognitive/memory deficit

• preferred way if task is always done one way (i.e. balance beam)

• better choice if safety is a major factor

Variable Practice

• same task performed with varying conditions

• STS with UE, STS no UE, STS from chair, STS from low couch

• enhances transfer (generalizability), especially in novel situations

• after initial introduction, shift toward this strategy in practice to secure retention over time

Random Practice

• different tasks performed in succession

• STS, stairs, bed mobility, floor transfer

• simulates how we do tasks in life

• offers contextual interference (good for transfer of tasks)

• after initial introduction, shift toward this strategy in practice to secure retention over time

Continuous Skills

• i.e. walking

• improve with distributed practice schedules

Discrete Skills

• i.e. STS

• improve with massed practice schedule

Closed Environment

• limited to no distractions

• challenges to sensory systems

• safe and predictable

• low cognitive load

Open Environment

• real and unpredictable

• includes variations in sensory challenges

• participant must alter strategies

• high cognitive load

Practice at the beginning level of a task

• constant

• massed

• closed environment

Practice at the goal performance of a task

• variable

• distributed

• random

• open environment

What does OPTIMAL theory of motor learning stand for?

O: optimizing

P: performance

T: through

I: intrinsic

M: motivation

A: (and) attention

L: (for) learning

Optimal Theory of Motor Learning

• complementary (not alternative) theory of motor learning that aims to add to Schmidt’s Schema Theory and Dynamic Systems Theory

• provides additional considerations for the following in regard to motor learning:

  • role of external focus of attention on the intended movement effect

  • variables that influence a learner’s autonomy

  • conditions that enhance expectancies for future performance

• motivation and attentional influences matter

What are the 3 parts of Optimal Theory of Motor Learning

• enhanced expectations (set the bar high)

• autonomy (let them pick)

• external focus (think outside the body)

How to enhance expectations for Optimal Theory of Motor Learning

• more positive feedback after “good” trials enhances motivation, learning, confidence, and self-efficacy

• more concepts of ability to facilitate a growth mindset and decrease threat of task (“walking after an ACL injury takes time, let’s see where you are” … “great start!”)

• more social comparative feedback (“you are doing better than most people at this stage of recovery”)

• more self-modeling (use video of patient doing it well)

• adjust perceived task difficulty (more language promoting success “active people like you typically do it well!” and more of making the goal of the task more achievable “near the hole” versus “in the hole”)

How to enhance autonomy for Optimal Theory of Motor Learning

• more control over practice conditions (“let me know if you want my help”, “if you think a demonstration might help, tell me”, “how many reps do you think you can do?”

• more instructional language that facilitates owning it so they can see their role in their success (“see if you can…”, “do you think you can…”)

• provide more choices within the care plan and incidental choices that make it appear that they have a choice in things but things that do not actually matter as much (“would you like to start with squats, lunges, or step-ups?”, “pick a treatment table, I’ll meet you there”)

How to enhance external focus of attention for Optimal Theory of Motor Learning

• focus directed toward the environment and elements outside of the body

• use of a BP cuff for neutral stability control in dynamic supine core execise

• use laser and a target “do you think you can keep the laser targeted on that line/spot?”