Motor Learning: Optimizing Conditions for Teaching and Learning Movement

8


Motor Learning


Optimizing Conditions for Teaching and Learning Movement


Joyce R. Maring, PT, DPT, EdD and Susan Joy Leach, PT, PhD, NCS, CEEAA


CHAPTER OBJECTIVES


After reading this chapter, the reader will be prepared to:



  • Describe the influence of motor control theories on the application of teaching and learning motor skills.
  • Identify the stages of motor learning and the focus of each stage of learning in skill development.
  • Analyze the role of attention in learning a new motor skill.
  • Classify motor skills according to existing taxonomies.
  • Describe the conditions and variables that influence how motor tasks are processed.
  • Relate the conditions of prepractice and practice to outcomes in motor performance and motor learning.
  • Consider the role of providing feedback in effectively teaching motor skill acquisition.
  • Apply the principles of motor learning to clinical case scenarios to enhance teaching and learning effectiveness and patient/client performance.

In this chapter, we transition to the role of the therapist as a specialist in the movement system and therefore as movement educator. Therapists teach patients and others how to best acquire or regain motor skills required for maximal participation in all aspects of life. Similar to education in the classroom, teaching motor skills requires the therapist to design environments and conditions that encourage learning through active engagement and practice. In this chapter, we explore our role as movement educators. We describe how theories of motor control and motor learning inform practice. We examine various types of movement, task characteristics, and movement taxonomies. Humans as information processors is discussed and linked to concepts such as attention, interference, response alternatives, and accuracy demands, all essential to teaching and learning about movement. We examine conditions of practice, types of practice, and practice schedules, and how each can be used to optimize learning given the individual, the task, and the environment. Various forms of feedback are introduced and linked to effective learning. Finally, the chapter ends with a discussion of differences across the lifespan.


ROLE OF THEORY IN PRACTICE


Physical therapists are considered movement specialists. We analyze movement and movement dysfunction and then work with individuals to establish or re-establish optimal movements that lead to improved function and quality of life. Therefore, we serve as movement educators and need to effectively apply to clinical practice all of the principles of teaching-learning discussed in this book. We need to know what strategies, patterns, and types of practice will lead to the most effective motor learning in the populations we serve. What are those internal and external processes associated with practice and experience that contribute to motor learning or the acquisition of a motor skill?


Motor learning is usually inferred by changes in motor performance. Throughout this chapter, we distinguish between learning and performance because they are not the same. For example, it is possible for someone to demonstrate an improvement in motor performance for a short period without demonstrating learning.



CRITICAL THINKING CLINICAL SCENARIO


You are working with a patient, practicing mat to wheelchair transfers. The session is 30 minutes long. By the end of the session, he is performing the skill independently (eg, without verbal or physical cues).


Reflective Questions



  1. Has this patient learned the motor skill?
  2. How would you be test to determine whether learning occurred?

Even though the patient described above in the Critical Thinking Clinical Scenario performed the movement fairly well at the end of the session, he may not have learned the new motor skill. For us to assess whether the patient has really learned the transfer, we would have to evaluate whether he could demonstrate the skill several weeks in the future or apply what he has learned about transfers to a new situation in which he was required to perform a transfer (eg, between a bed and commode). We call the ability to perform a movement over time retention of movement and the ability to use that movement in a new situation, the transfer of learning. Both retention and transfer are evidence of learning.


Questions surrounding motor learning cannot be separated from questions of motor control; the study of the nature of movement and how it is regulated. Understanding the neural, physical, and behavioral aspects that control movement provides the background from which to establish effective motor learning strategies. That is why we spend so much time in school studying the basic sciences, and it explains why we must become lifelong learners of the factors that contribute to the successful production of functional movement. It is up to us to remain informed about and participate in updating motor control theory to help us make sense of what we see.


Theories are sets of assumptions that we use to explain and predict behaviors. They provide frameworks for our intervention strategies and therapeutic approaches. Theories drive practice. Theoretical assumptions should not be randomly selected, but rather should be chosen as a result of careful and systematic testing and observations. As the systematic testing of assumptions in motor control and learning progressed, theories also evolved; this evolution has had a tremendous impact on the way we practice physical therapy. Just as your assumptions about culture influence your practice, the conjectures that you have about how we control movement influence how you intervene when working with an individual with movement dysfunction. Physical and occupational therapists have been referred to as applied motor control physiologists.1 That is why we need to include a brief discussion to meet the objectives related to motor learning or teaching patients new motor skills (an in-depth discussion of current motor control theories is beyond the objectives of this chapter).


Motor Control Theories


Historical motor control theories were based on assumptions of hierarchical and stimulus-response control of movement.2 Sensory input dictates motor output. According to this theory of how we control our movements, if we are trying to improve the way someone walks, our best treatment strategy is to provide him or her with optimal sensory feedback that will, in turn, result in a better walking pattern. So, for example, if we are working with a child with cerebral palsy who uses excessive hip adduction and internal rotation and who is having difficulty getting full hip extension when walking, we might facilitate the child’s movements by giving tactile and proprioceptive input (ie, placing your hands on) to the gluteus medius and gluteus maximus muscles to facilitate hip extension and inhibit the adduction. Through the lens of these historical theories, therapists viewed movement dysfunction secondary to a neurologic lesion as an interruption of the ability of the higher levels to inhibit or control the lower-level primitive reflexes. In this context, our primary role as therapists was to use sensory feedback, such as facilitation and inhibition, to help the higher centers of the nervous system recover control over the lower centers.


Systems Theory and Beyond


Today, we have moved beyond stimulus-response and hierarchical control theories of movement control. Current motor control theories suggest that there are many complex factors that may influence the control and learning or relearning of movements. Russian scientist Bernstein described much of the early work in this area. He hypothesized that movement control was distributed among interacting systems and that all of these interactions must be considered in accounting for the control of movement. This is referred to as a distributed model of motor control.3 Today, that model continues to evolve and expand to take into account the many parameters of movement that must be considered. For example, motor control theories must explain factors such as initiation of movement, the pattern and timing of muscle recruitment, and the influence of environmental variations and task requirements on movement production. That is a lot to consider!



STOP AND REFLECT


You are working with a patient who recently sprained his ankle, and you want to teach him how to walk up the stairs using crutches. Think about all of the factors that must be considered in trying to teach a patient how to walk up the stairs using crutches. Consider the following:



  • Task factors (eg, handling the crutches, maintaining the leg in a non–weight-bearing position)
  • Individual factors (eg, muscle strength, range of motion)
  • Environmental factors (eg, depth of step, presence of a handrail)

Shumway-Cook and Woollacott4 and others describe the dynamic systems model, in which movement emerges from the interaction of the following 3 primary factors: the environment, the task, and the individual. Each of these factors has the ability to both constrain and enable movement possibilities. Focusing on only one factor, such as the processes within an individual, excludes the contribution of the demands of the task and environment to the control and production of movement. As physical therapists, we are well trained to identify the movements that we want to facilitate and we can describe in detail the musculoskeletal components required to produce those movements. But that is only one piece of the puzzle, and, to be effective teachers of movement and motor skill, we need to pay attention to the attributes of the tasks that we are asking the individual to learn and the environmental contexts in which those tasks will be performed. Movements that may serve an individual well in one environment may need to shift in response to a change in a key parameter. For example, imagine that you were walking on a treadmill. As the velocity increased, your gait pattern would dramatically change as you were transitioning from a walk to a run to meet the increasing velocity demands.



CRITICAL THINKING CLINICAL SCENARIO


A child is able to climb the stairs independently in the therapy gym.


Reflective Questions



  1. How does the task change if the child is climbing stairs in between scheduled classes with the rest of his or her classmates?
  2. What are some individual and environmental attributes that will come into play in this new scenario that were not as important in the therapy gym?

This evolving motor control theory impacts how we, as therapists, examine and intervene with patients who are learning or relearning how to accomplish functional skills. Theory impacts practice! Current theories of motor control and learning stress the organization of practice and movements around a behavioral goal so that retraining becomes task-oriented.4 All practice sessions should be centered on an established goal or task that is valued by the participant.5 As you know by now, this is a concept that is important to all teaching-learning strategies. The added purpose of a goal-directed task enhances motor learning in all contexts.6


Given the earlier example, evolving theories require the therapist to consider the goal of the task (eg, independent and safe ambulation in a specific environment) in addition to the process of ambulating. Potentially, the therapist can think of ways to change the task or to modify the environment to improve the pattern of movement and, therefore, the outcome. This allows the therapist and patient to focus not only on individual factors, such as strength and range of motion, but also on task and environmental factors when designing an intervention intended to achieve movement goals.



CRITICAL THINKING CLINICAL SCENARIO


A physical therapist is working with a patient who had a stroke. The patient is unable to initiate any movement at all with her right arm. The goal of the session is to improve the patient’s ability to perform bed mobility (especially rolling onto the uninvolved side).


Reflective Question



  1. How might the therapist’s approach differ if the therapist primarily used a reflex or hierarchical control of movement to influence therapy vs a system’s approach that considers factors related to the environment, task, and individual?


KEY POINTS TO REMEMBER



  • Taking into account how movement is controlled is important in considering how movement is learned.
  • Theory drives practice!
  • Motor control theory continues to evolve.
  • Dynamic systems theory considers the influence of the environment and the task in addition to individual factors in movement control.
  • Movement is increasingly viewed as goal-oriented rather than process-oriented.

TYPES OF MOVEMENT AND MOTOR LEARNING


Although knowing about motor control is important to understanding how our patients learn new movements, this chapter focuses on motor learning and the therapist’s role in teaching movement. Motor learning refers to the acquisition of skilled movement. We all produce predictable reflexive movements with the right stimulus; these movements do not require any experience. For example, withdrawing from a painful stimulus and scratching an itch are movements that occur without practice and learning. Our discussion focuses on the types of movements that occur only as learning occurs and that can be consistently reproduced as a result of practice and experience. For example, a tennis serve, a corner kick in soccer, and the use of a 4-point gait pattern with crutches are learned movements that require practice.


Although we measure learning by measuring performance, learning and performance may not be the same thing, as noted previously. Performance is the actual demonstration of skill, and its parameters can be clearly described and measured. Accuracy, velocity, range, and power are all attributes of motor performance that are relatively easy to quantify. While improved performance is likely associated with learning, it is possible to perform well without learning and learn without performing well! Consider the athlete who learned a task well but is fatigued, stressed, or nervous. Although the task is well learned, it may be poorly performed under those conditions.


Do you remember the first time you had to take a practical examination? Perhaps you learned how to perform a manual muscle test with a laboratory partner and felt that you were quite proficient. Yet, when it came time to perform the test on the practical examination, you may not have performed it as well as you had previously thanks to the added stress of your instructor watching. Someone may also practice a skill several times in a row in a single session and perform it well on the last trial. Yet, 1 week later, the performance may be back to the baseline level because the improvement was temporary and motor learning did not occur. Remember the distinction between learning and performance because we will come back to it later in this chapter. As a teacher of movement, you will need to distinguish between strategies that will enhance someone’s performance vs approaches to improve motor learning.


Stages of Motor Learning


Through practice, the acquisition of skilled behavior moves through the following stages of learning: cognitive, associative, and autonomous (Table 8-1). Fitts and Posner7 described these 3 stages of learning quite some time ago, and they still provide a useful framework today.


Cognitive Stage


At this stage of learning, the individual is seeking to understand what it takes to perform the skill and to develop a cognitive map. The learner will perform a series of trials and discard the strategies that are not successful. He or she usually relies heavily on feedback (especially visual cues) and practices best in a stable or closed environment. A stable or closed environment is defined as a predictable environment in which everything is the same each and every time a person does the task.


For example, you may be working with a patient who had a recent amputation and has a new prosthetic limb. Initially, he or she may want to practice walking in the parallel bars (a stable and closed environment) and receive a lot of feedback. The patient may experiment with shifting his or her weight in different directions over the prosthetic limb and moving the prosthetic limb in all planes of motion. A mirror could be set up to provide visual input.


As a therapist working with a patient in the cognitive stage of motor learning you may want to provide the following:



  • A safe closed environment
  • Opportunities for trial-and-error practice of the movement
  • Opportunities for feedback (particularly visual cues)

Associative Stage


This is the middle stage of learning a new motor task. The movement begins to look more organized and coordinated than it did during the cognitive stage, and there is greater consistency, fewer errors, and fewer extra movements except when the patient is distracted or asked to perform more than one task at a time. At this stage of practice, he or she is able to successfully walk with the prosthetic limb in a closed environment (ie, within the parallel bars). The individual reliably moves in all directions as long as he or she is able to concentrate on what he or she is doing. The patient tells you that he or she is beginning to get the feel of it. Errors in gait pattern and problems with balancing with the new limb emerge when he or she is unexpectedly distracted or if he or she has to do too many things at once, such as answer a question and turn a corner at the same time. As a therapist working with a patient/client in the associative stage of learning, you may do the following:



  • Add complexity and decrease the predictability of the environment
  • Use open and authentic environments
  • Provide feedback but focus on proprioceptive feedback and decrease manual cues


Autonomous Stage


This final stage generally happens after much practice and the task requires little cognitive effort at this point. The individual can now concentrate on other demands at the same time as performing the task and can readily perform the skill or task in a predictable or a dynamic and changing environment. Research in cognitive neuroscience supports that performing a skill in the autonomous stage is associated with less cortical effort, especially for the parts of the brain that have to make decisions.8


Again, building on the previous example, now the patient is able to walk successfully using his or her prosthetic limb in most environments. The individual is able to shift directions and maintain conversation simultaneously. Moving from linoleum to carpet is not a problem. He or she tells you that he or she sometimes forgets that he or she is even wearing a prosthetic limb. At this point, your patient may be able to perform a certain task independently without thinking. As a therapist, you may begin to introduce new tasks to your patient so that he or she can begin to manage more than one task at a time (ie, dual-tasking), which is consistent with the demands of day-to-day life.


As a therapist working with a patient in the autonomous stage of motor learning, you may do the following:



  • Continue to provide opportunities for practice in increasingly more complex and challenging environments.
  • Provide challenges and distracters within the environment to increase the demand.


CRITICAL THINKING CLINICAL SCENARIO


You are working with an 8-year-old girl with cerebral palsy and spastic diplegia who is learning to negotiate the stairs independently. One of the classes she attends during the school day requires her to ascend/descend the stairs one time each day with her class.


Reflective Question



  1. Can you apply the framework of learning to teaching a patient/client a new skill? Consider the type of practice, environment, and feedback that you would provide during learning in the following stages:

    • Cognitive stage
    • Associative stage
    • Autonomous stage

Types of Movement


Given the interaction we described between an individual, a task, and the environment, it likely comes as no surprise that tasks and movements can be classified and that each type of movement may be controlled and learned differently. This is an important point. As therapists, we are required to analyze the task that the individual is trying to learn so that we can help him or her to select a strategy with the best chance of success. Tasks can be classified in many different ways. Movement scientists have created groupings and taxonomies based on a variety of organizing principles. Some of the ways in which tasks can be classified include the following:



Movement Taxonomy


Gentile9 created a taxonomy that looked at movement along 3 continua simultaneously:



  1. Stationary vs variable environment
  2. Stable vs dynamic body
  3. No manipulation vs maximum manipulation demands.

Figure 8-1 illustrates Gentile’s Taxonomy of Tasks.10



CRITICAL THINKING CLINICAL SCENARIO


You are working with a patient/client who has had a stroke affecting the cerebellar region and has impaired balance in all positions.


Reflective Questions



  1. Apply the taxonomy of movements. Plan a progression of activities that move the patient from learning to stand without support to managing activities of daily living (eg, eating, brushing teeth) while in the upright position. Set up a progression of activities that considers the following:

    a. Moving the demands from a stable to a dynamic body position and from a stable or closed environment to a variable environment. How can you vary the position and environment so that the task becomes more demanding?


    b. Moving the demands from no manipulation to reasonably complex manipulation. How can you progress the patient in terms of holding an eating utensil or comb to use for eating or grooming, all while maintaining balance?


Open vs Closed Tasks or Skills


This classification considers the interaction of the task and the environment. Closed skills or tasks are characterized by fixed environmental demands and can be produced with minimal variations each time. Open tasks occur under variable conditions, requiring instantaneous adaptation. Most tasks fall along a continuum of open or closed, depending on the role of the environment. Sometimes, we use the terms open and closed to refer to the environment itself. As noted earlier, the closed environment is stable and predictable, and the open environment is constantly changing. Table 8-2 describes the characteristics of open vs closed tasks or skills and provides examples of each.



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Figure 8-1. Gentile’s taxonomy of tasks. (Reprinted from Campbell SK, Palisano RJ, Vander Linden DW. Physical Therapy for Children. 3rd ed. Philadelphia, PA: WB Saunders; 2006.)



CRITICAL THINKING CLINICAL SCENARIO


You are working with a patient/client who has had a stroke and is planning to transition back to a community-dwelling situation. The patient is working toward independence in bed mobility, household transfers (toilet, tub, bed, chairs, floor), and ambulation on level and uneven surfaces.


Reflective Questions



  1. The patient’s room would typically be considered a closed environment. The community would most likely represent an open environment. How would you use the therapy gym to progress the level of challenge in preparation for the demands of an open environment?
  2. How would factors such as levels of noise, physical barriers, distractors, and time allotted affect the patient’s ability to complete the task?

Discrete vs Continuous Tasks or Skills


Intuitively, you know the type of skills required to perform a specific skill; for example, picking something up from the floor from a standing position is very different than the type of skill required to go for a walk. Tasks can be classified as discrete tasks, which have a recognizable beginning or end, vs a continuous skill, which does not have an inherent beginning and end. Table 8-2 describes the characteristics of discrete vs continuous tasks or skills and provides examples of each. Sometimes, a series of discrete movements can be performed in a sequence. We refer to these as serial movements, and they are composed of discrete movements strung together. Many activities of daily living are serial movements. For example, dressing in the morning requires a series of discrete tasks performed together.



CRITICAL THINKING CLINICAL SCENARIO


A therapist is working with a 6-year-old child on stair climbing in a school setting. Often, the child has to carry items such as a snack or books up the stairs. The child may also be required to ascend and descend the steps at various times of the day. Other children simultaneously presenting on the stairs may represent a whole new environment to master!


Using the taxonomies presented earlier, do the following:




Stability vs Mobility Tasks or Skills


As previously described in Gentile’s9 Taxonomy (stable vs dynamic body), movement requirements can vary depending on whether the base of support is in motion. Table 8-2 describes the characteristics of stability vs mobility tasks or skills and provides examples of each.


It Matters!


We have talked about how therapists need to consider the taxonomy of tasks and environments so that they can intentionally increase the complexity and demands of the task. This building process helps our patients to perform necessary skills at an autonomous level. Performing necessary skills autonomously means that they can be performed safely in real-life scenarios. The individual cannot only walk independently, but can also cross a street while monitoring other pedestrians and the color of the traffic light. Setting clinical goals in collaboration with the patient/client that adequately incorporate the practical realities of living and working in the community is a critical skill required of all therapists.



STOP, DO, AND REFLECT


List one task that you have completed today that was the following:



  • Continuous
  • Discrete
  • Serial

Label each of the following tasks that your patient/client likely has to perform every day as continuous, discrete, or serial:



  • Walking
  • Brushing his or her teeth
  • Eating a meal
  • Turning on a light switch
  • Combing his or her hair
  • Transferring from the bed to the toilet

Which of the above tasks would you consider open? Why?


Which of the above tasks would you consider mobile? Why?


We have now described several characteristics intrinsic to a task. We will soon tie those characteristics into ways in which the tasks should be practiced to maximize successful learning. For now, file that information into your memory bank and move on!



KEY POINTS TO REMEMBER



  • Motor learning should be distinguished from motor performance.
  • Motor learning occurs in stages, and therapists should adjust the type and environment of practice to reflect the patient’s stage of learning.
  • There are several ways to classify movement. This is useful to know because of the following:

    • Therapists should consider the type of functional task that the patient needs to perform to design the best practice.
    • The classification may be viewed as a way to progress the complexity and demands of a task.

FACTORS THAT INFLUENCE HOW WE PROCESS MOTOR TASKS


Historical concepts of motor control emphasized human beings as reflexive. In a reflexive model, sensory input drives the motor output. In a similar fashion, educational psychologists and behaviorists described associative learning and operant conditioning as primary principles governing how we learn and what behaviors to expect based on the stimulus received. Through experience, we associate 2 stimuli, and it is theoretically possible to predict an individual’s behavior based on the stimulus that he or she has received. We do not need to know much about the inner workings of the individual’s mind; only the stimulus received and its associated behavioral output.


Humans Are Information Processors


There is a significant body of evidence that we exert far more control over our responses than such a perspective would indicate. We are much more than a “black box” that receives input, which subsequently drives the output. There are a number of factors that influence what stimuli we attend to, how quickly we can filter the stimuli and select possible response options, and then how we implement the output we selected. Schmidt and Lee11 describe human beings as complex information processors. After the stimulus is received from the environment, we process it in a number of ways before acting upon it. As information processors, we do the following:



  • Identify stimuli that we receive: As part of the identification process, we detect and recognize familiar patterns. Most responses require us to pick out meaningful patterns of features in the stimuli presented (eg,, how fast is that car travelling toward me?).
  • Select a number of stimulus-response alternatives: We decide upon the possible options.
  • Program a response based on the selection: This involves organizing and initiating a reaction.
  • Produce a response at the level of the effector.

The point is, as an information processor, we have a lot of control over the stimuli we attend to and the subsequent responses we select. Those processes are influenced, however, by a number of factors. Understanding those factors assists us in being aware of their impact on the patients/clients we treat and, therefore, we can better assist them in selecting a response that leads to improved function.


Attention and Information Processing


We all have a limited potential for attention at any given moment. We may be bombarded by stimuli and sensory input, but it is not possible to attend to all of the input we receive. We do not, however, cut off the sensory input at the level of the receptors. Our nervous systems are picking up all of the sounds, sensations, visual inputs, and stimuli that surround us. The stimuli pass through some sort of attention filter and we decide which ones require our response.


What factors impact the filter? Have you ever attended a loud and noisy party? You probably conducted conversations with friends and acquaintances around you while tuning out, to the best of your ability, those sounds that interfered with your attention to the conversation. In fact, you were probably minimally aware of other conversations around you. If, however, you suddenly heard your name mentioned in a conversation nearby or shouted across the room, you would likely switch attention to the individual(s) who voiced your name. This example demonstrates that you do not cut off the stimuli at the level of your sensory receptors or you would not have heard your name in the first place.


Stimuli that are somehow meaningful to us based on our experiences and emotions make it through the filter and command our attention. You may not have noticed a particular model and make of a car until you purchased one yourself. Then, suddenly, the road appears to be full of that particular vehicle. It likely was not the number of cars that changed, but the filter of your attention was adjusted by your recent car purchase. Intense stimuli also have a tendency to make it through the filter. Loud noises, bright lights, and intense sensations generally make us sit up and take notice.


As stated previously, we all have a limited capacity for attention. It requires effort to direct our attention. Probably all of us have read a page or paragraph without effort and attention, and, when we came to the last sentence, we had no clue what we just finished reading! Our capacity to attend improves with practice, and we can learn how to expend the required effort. Nevertheless, we can only attend to one task at a single point in time. We are single-channel operators with limited capacity. This is true for motor tasks and mental skills.



STOP AND REFLECT


Have you ever tried to listen to 2 people talking at the same time?



  • How successfully and accurately could you recount both conversations?
  • What strategies did you use to try and listen to both conversations simultaneously?
  • If you opted to attend to one conversation vs the other, what prompted you to attend to the selected conversation?

Is multitasking possible? Can you attend to 2 tasks simultaneously? The answer is both yes and no! It is possible to perform 2 tasks simultaneously if one of the tasks does not require attention. If a task is so well learned or so simple that it can be performed automatically, it does not use up the limited capacity for attention and the individual can perform that task while performing the more attention-requiring task. Most of us can walk and talk simultaneously. The limited capacity we have for processing 2 tasks simultaneously, however, is one of the arguments against permitting the use of cell phones while driving. Although driving is a well-rehearsed skill that often does not require much mental effort, unexpected shifts in traffic, velocity, and flow do require our full attention, making any attention diverted to the cell phone hazardous. Remember the example of the patient/client learning to walk with a prosthetic? Initially, all of his or her attention must be directed toward the task of walking. Only when walking becomes automatic can the patient/client direct attention to other tasks, such as talking simultaneously.


Dividing Attention


One way to determine how much attention is being used is to calculate dual-task cost. Consider 2 tasks that you can measure separately, such as gait speed and a cognitive task such as saying the alphabet out loud and skipping every other letter. Both of these skills can be performed separately and then performed together. Any drop in performance in the dual-task condition over the single-task condition would be considered the dual-task cost. A drop in performance may be noted in either one or both of the tasks. A common test to determine someone’s risk for falls is the Timed Up and Go (TUG) test that simply measures the amount of time that it takes someone to transfer to a stand-up position, walk a short distance, turn, and sit back down again.12 It turns out that if you add a manual component such as carrying a cup of water (TUG manual) or a cognitive component such as counting backward by 3 (TUG cognitive), the amount of increased time required to complete the TUG task is a good measure of the cost of dividing one’s attention to perform dual tasks.13 The clinical implications of this finding are enormous, both for testing whether a person can safely navigate open environments where attention must be divided to maintain safety and in planning therapeutic interventions where distractors and additional tasks can be added incrementally. Think back again to the person with the prosthetic. How might you incrementally move from a closed and single-task environment to the demands of an open environment where attention has to be divided?



CRITICAL THINKING CLINICAL SCENARIO


Interferences to Attention


There are 2 types of interferences to attention when performing a motor task: capacity and physical.


Using cell phones while driving is a great example of both types.



  • If you are driving while talking on a hands-free headset, your phone conversation may interfere with your capacity to respond to traffic and changing conditions.
  • If you are holding a cell phone to your ear, you may experience both a physical and a capacity interference in responding to the demands of driving.

Reflective Questions



  1. If a patient is relearning independent ambulation while walking in a busy room, what examples of physical and capacity interference is this patient likely to encounter?
  2. How would you train the patient to be able to effectively divide attention to perform safely when the interference is present?
  3. Think back to the patient with a prosthetic who may first learn to walk in a set of parallel bars. How can that task become incrementally more complex with multiple demands on the patient’s attention?

Focus of Attention


Given that attention plays such an important role in movement, can a therapist influence what the patient pays attention to and does focus of attention influence a patient’s performance? The focus of attention literature resoundingly says yes. In the focus of attention paradigm, the instructions or feedback provided to learners can have a significant impact on motor skill learning.14 An internal focus occurs when learners are directed to pay attention to their body movements, whereas an external focus occurs when learners are directed to pay attention to the effects of their movements on the environment or the outcome of their movements.15 Using a very simple example, a therapist may direct the patient’s focus of attention while moving from sit to stand by asking a patient to “push up with your hands” (internal focus) vs “push up from the armrests” (external focus). The point of the instruction is to focus the learner’s attention on the outcome of the movement rather than the movement itself.


Studies consistently demonstrate that an external focus of attention helps the participant to reliably learn the skill with more efficiency and effectiveness over less time. This is true whether the person is learning to stand on a stable or unstable surface15,16 or learning a complex sport such as a slalom ski simulator task,17 pitching a golf ball at a target,18 hitting tennis strokes,1820 volleyball tennis serve,21 and a soccer pass.21 The results consistently show that an external focus is superior to an internal focus in terms of effective learning and performance. So, for ball games, it is usually better to focus the learner’s attention on the direction of a ball toward a target than to analyze how the arm or leg moved to contact the ball.


The effect of an external focus has also been studied in some patient populations. For example, an external focus of attention was shown to improve postural stability in a group of patients who had a stroke and experienced problems with balance.22 Participants who were instructed to shift their weight toward an external target next to their hip performed much better than those who were instructed on the weight-shifting movement itself. Using an external focus of attention during practice led to increased efficiency of movements and likely indicated decreased attention requirements, meaning that more automatic strategies were used during the task. (Remember the importance of getting to the automatic stage of learning!) Although findings related to the superiority of an external focus of attention are robust, physical therapists typically use instructions and feedback that are internally focused during stroke rehabilitation.23,24 Researchers recorded and analyzed several gait training sessions and noticed that therapists asked the patient to pay attention to an internal process, such as pushing off with a leg or lifting a foot, in 67% of the directions. For patients having difficulty clearing a foot during gait or on the stairs, rather than asking the patient to lift his or her foot (internal focus), an external focus could be created by asking the patient to touch your hand with his or her knee or to touch a target on a step. Movement educators must consider the potential impact of our directions related to the person’s focus of attention while remembering that an external focus will generally help the person to learn faster and more efficiently; in other words, allow the movement to become more automatic.



STOP AND REFLECT


Essentially, an external focus of attention requires the person to pay attention to the goal of the movement vs the movement itself. What have you already learned about the importance of goal-directed learning? It turns out that learning a motor skill follows the same principles that can be applied to other types of learning.


Examples have been provided for how a therapist can provide instructions or feedback that influence movement at the individual, task, and environment levels. It was seen at the individual level when a patient who was having difficulty standing with equal weight distribution was asked by the therapist to shift her weight to the right (internal focus) vs try to touch the rail with her right hip (external focus). It was illustrated at the task level when the patient was asked to push up with his hands from sit to stand (internal focus) vs push up from the armrests (external focus). Finally, it was highlighted at the environmental level when the therapist asked the patient to lift his feet up (internal focus) vs touch his target on the step (external focus).


Consider the following:



  • You are working with a patient who has Parkinson’s disease. He walks with a shuffling gait (decreased range of motion of the hip and knee during swing and no heel-toe progression). You want him to take larger steps and to pick up his feet while swinging each leg forward. One method would be to instruct the patient to do that while paying attention to the movements. If you want, instead, to focus the person’s attention externally, how might you set up the session and the activity differently?
  • You are working with a patient with multiple sclerosis who demonstrates insufficient foot clearance during gait with occasional toe drag bilaterally. The patient is unable to walk along a straight path and frequently deviates from the line of progression. You want him to take larger steps and to pick up his feet while swinging each leg forward. One method would be to instruct the patient to do that while paying attention to the movements. If you want, instead, to focus the person’s attention externally, how might you set up the session and the activity differently?
  • You are working with a patient who has had a stroke and has a weak right arm. The patient wants to learn to reuse the arm to perform household tasks, such as folding laundry and doing dishes. Contrast what a session using an external vs internal focus of control would look like as you work to assist your patient achieve the goal.

May 30, 2017 | Posted by in NURSING | Comments Off on Motor Learning: Optimizing Conditions for Teaching and Learning Movement
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