Evidence Based Applications of Motor Learning to Everyday Patient/Client Care

Transcription

1 Evidence Based Applications of Motor Learning to Everyday Patient/Client Care Michael J. Majsak, PT, EdD Associate Professor and Chair, Department of Physical Therapy, School of Health Sciences and Practice, New York Medical College, Valhalla, New York Description: The goal of patient/client care is optimal functional competence; that is, the ability of patients/clients to perform daily activities in a variety of environments, under different conditions, with a minimal cost of physical and cognitive demand. This often requires patients/clients to change their motor behavior. Motor learning is a set of processes through which changes in motor behavior can be promoted, retained, and generalized. Several of these processes may be disrupted following a pathology. Physical therapists can promote motor learning by manipulating task conditions, providing external feedback and physical assistance, and structuring the manner and schedules of practice. To provide the most effective learning conditions therapists must always consider the cognitive and physical resources of patients, the complexity of the tasks to be learned, and the amount of practice that is possible. The purpose of this session is to illustrate how physical therapists can use judicious delivery of external feedback, and structure practice conditions to optimally engage clients with different neurologic pathologies in the processes that underlie the learning of functional motor tasks. Objectives: Upon completion of this course, you will be able to: 1) Describe three major components of motor learning, and how these components may be disrupted in clients with various types of neurologic pathologies, 2) Compare and contrast how the delivery of external feedback and structuring of practice conditions can be manipulated to optimally engage clients in the processes underlying motor learning, 3) Provide judicious external feedback and create and modify practice conditions to optimally engage clients in the processes underlying motor learning. I. The Goal of Clients: Functional Competence A. Definition: The ability of patients to perform daily activities in a variety of environments, under different conditions, with a minimal cost of physical and cognitive demand (Majsak, in press) B. How do clients get there? 1. Utilization of available resources (previously referred to as compensation ) 2. Recovery of damaged systems 3. Neuroplasticity (Kleim and Jones, 2010) II. Changes in motor behavior involve some manner of motor learning: A. Definition of motor learning: A set of processes associated with practice or experience leading to relatively permanent changes in the capability for responding. (Schmidt, 1988) B. What do we know about predicting the motor learning capacity of clients? 1. Actually, very little - Clients: CVA, PD, TBI, CP - Tasks: - Practice conditions:

2 C. How do we assess learning clinically? 1. Observation vs. Probing - Explicit and Implicit learning 2. Motor performance vs. Capacity for responding 3. Acquisition/Habit formation vs. Retention and Generalization of motor skills III. A Contemporary Model of Motor learning (Majsak, in press): Perception of Self and Environment Developing a Motor Plan KP Performing, Information Processing, and Practicing KR Transitional Information Motor Learning Three Major Components of Motor Learning A. Perception of Self and Environment 1. Personal Constraints: Contributing subsystems - Biomechanical - Neuromuscular - Psychological * Dynamic Systems Model (Thelan and Ulrich, 1991) 2. External Constraints: Spatial and Temporal - Taxonomy of Tasks (Gentile, 1987) 3. Perception/Action Coupling (Gibson, 1966) - How do I fit (spatial/temporal) in my world? - Affordances (Gibson, 1977) B. Developing a Motor Plan: What Needs to be Planned? 1. The relationship and possibilities between the intrinsic constraints of the client and the external constraints of the real world 2. The Rules for successful task performance - Finding the 10s (Majsak, in press)

3 3. Appropriate diversity of movement patterns within a coordination mode of task performance (Latash et al., 2002; Newell et al., 1991) 4. The processes for motor planning: Perception, action, and assessment: - Picking-up information - Creating or using previously learned movement strategies to accomplish tasks - Selecting appropriate movement patterns to carry out movement strategies - Analyzing results of actions - Assessing the plan and the execution of the motor plan - Making appropriate corrections to the plan or execution if he task was not successful - Reassessing task performance - Refining and diversifying movement strategies and patterns to attain functional competency 5. Motor planning is not entirely cognitively mediated - Biomechanical constraints - Emergence of a self-organized plan - Perception-Action Coupling 6. What is the capacity of clients to plan? - Clients: CVA, PD, TBI, CP - Tasks: 7. What can therapists do to promote the motor planning of clients? - Clarify the goal - Discuss possible movement strategies and patterns - Help the client assess task performance - Share observations - Probe - Model/physically assist the client in appreciating the possibilities - Provide the client the plan - Why? - When? - How? C. Performing, Information Processing, and Practicing: What needs to be practiced and learned? 1. The processes that lead to motor learning, not merely motor output 2. Different classes of actions (functional tasks) that contain Rules for performance (the 10s ) 3. Task performance utilizing three contributing levels of neuromotor organization - Cognitive direction - Subcortical automaticity - Spinal level motor regulation 4. Movement diversity within coordination modes of task performance 5. The same processes as motor planning (perception, action, and assessment): - Picking-up information - Creating or using previously learned movement strategies to accomplish tasks - Selecting appropriate movement patterns to carry out movement strategies - Analyzing results of actions - Assessing the plan and the execution of the motor plan - Making appropriate corrections to the plan or execution if he task was not successful - Reassessing task performance - Refining and diversifying movement strategies and patterns to attain functional competency 6. What is the capacity of clients to learn? -

4 7. What can therapists do to promote the learning of clients? - Structure and manipulate tasks - Embedding desirable movement strategies and patterns into functional tasks - Provide external feedback and physical assistance with a frequency and timing that optimally engages clients in the processes underlying motor learning - Boundary conditions - Augmented information - Knowledge of Performance - Knowledge of Results - Transitional Information - Timing: - Frequency: - Structure the manner and schedule of practice that optimally engages clients in the processes underlying motor learning - Intensity: - Massed vs. Distributed: - Specificity of Practice - Part vs. Adapted: - Self-guided vs. Physically guided: - Random vs. Blocked: 8. The three dimensional, non-linear, optimal engagement workspace (Majsak, in press)

5 High Level of Assistance Needed High Frequency/Concurrent AI? Physical assistance? Blocked Practice? optimal engagement workspace Low Capacity or Early Learner Intrinsic Processing Capacity of Clients Much Less Assistance Needed Intermittent AI? Less Physical Assistance? Random Practice? Simple High Capacity or Later Learner Limited Extensive Complex Task Complexity Opportunity for Practice (# of Trials) GOAL Side Tilt Pitch Distance

6 V. Summary and Concluding Comments A. We must do all we can to try to understand the ability of clients to: perceive their intrinsic constraints and the constraints of tasks and environments; to motor plan; and to perform, process information, and practice. B. The main principle for motor learning is to optimally engage the client in the processes underlying motor learning. C. The key to promoting motor learning is to appropriately manipulate the structure of tasks, the delivery of external information, and practice structure to optimally engaging clients in the processes underlying motor learning the key is the processes, not the techniques. D. The ways in which therapists can optimally engage clients in the processes underlying motor learning will depend upon the learning skills of the client, the complexity of the tasks to be learned, and the opportunities for practice that are available. References for Handout and Slides Baddeley A, and Wilson, BA. When implicit learning fails: amnesia and the problem of error elimination. Neuropsych, 1994; 32: Bernstein NA. The Coordination and Regulation of Movement. Oxford: Pergamon Press; Boyd LA, and Winstein CJ. Explicit information interferes with implicit motor learning of both continuous and discrete movement tasks after stroke. J Neur Phys Ther. 2006;30: Chiviacowsky S, and Wulf G. Self-controlled feedback: does it enhance learning because performers get feedback when they need it? Res Quart Exer Sport. 2002;73: Cushman L and Caplan B. Multiple memory systems: evidence from stroke. Percep Motor Skills. 1987;64: Del Rey P. Effects of contextual interference on the memory of older females differing in levels of physical activity. Percep Motor Skills. 1982;55: Del Rey P, Wughalter EH, & Whitehurst M. The effects of contextual interference on females with varied experience in open sport skills. Resh Quart Exer Sport. 1982;53: Duff S and Gordon AM. Learning grasp control in children with hemiplegic cerebral palsy. Dev Med Child Neur. 2003;45: Fitts PM and Posner MI. Human Performance. Belmont, CA: Brooks-Cole; Frank JS and Earl M. Coordination of posture and movement. Phys Ther. 1990;70: Gentile, AM. Skill acquisition: Action, movement, and neuromotor processes. In: Carr JH. & Shepherd RB, eds. Movement Science: Foundations for Physical Therapy in Rehabilitation. 2 nd ed. Rockville, MD: Aspen Publishers; 1987:

7 Gibson JJ. The Senses Considered as Perceptual Systems. Boston, MA: Houghton-Mifflin; Gibson JJ. The theory of affordances. In: Shaw RE and Bransford J, eds. Perceiving, Acting, and Knowing: Toward an Ecological Psychology. Hillsdale, NJ: Erlbaum; Gordon NB. Guidance versus augmented feedback and motor skill. J Exp Psych. 1968;77: Green TD and Flowers JH. Implicit versus explicit learning processes in a probabilistic, continuous finemotor catching task. J Motor Behav. 1991:23: Jacoby LL. On interpreting the effects of repetition: solving a problem versus remembering a solution. J Verb Learn and Verb Behav. 1978;17: Kleim JA and Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. Amer Speech-Lang-Hear Assoc. 2010;51:S Lee TD, Swanson LR, & Hall AL. What is repeated in a repetition? Effects of practice conditions on motor skill acquisition. Phys Ther. 1991; 71: Lin C, Fisher BE, Winstein CJ, Wu AD, & Gordon J. Contextual interference effect: elaborative processing or forgetting-reconstruction? A post hoc analysis of transcranial magnetic stimulation-induced effects on motor learning. J Motor Behav. 2008;40: Lintem G, Roscoe SN, Koonce JM, & Segal LD. Transfer of landing skills in beginning flight training. Hum Fact. 1990;32: Majsak MJ. Application of motor learning principles to the CVA population. Top Stroke Rehab. 1996;3: Majsak MJ. Concepts & Principles of Neurologic Therapy. In: D.W. Fell, ed. Therapeutic Approaches in Neurology: Evaluation, Intervention, Outcomes. New York: Prentice Hall; in press. Newell KM, McDonald PV, & Kugler PN. The perceptual-motor workspace and the acquisition of skill. In: Requin J & Stelmach GE, eds. Tutorials in Motor Neuroscience. Dordrecht: Kluwer; Newell KM, Morris LR, & Scully D. Augmented information and the acquisition of skill in physical activity. Exer Sport Sci Rev. 1985;13: Newell KM, Scully DM, Tenenbaum F, & Hardiman S. Body scale and the development of prehension. Dev Psychobio. 1989;22:1-13. Pigott RE and Shapiro DC. Motor schema: the structure of the variability session. Res Quart Exer Sport. 1984;55: Pinto Zipp G and Gentile AM. Practice schedule and the learning of motor skills in children and adults: teaching implications. J Coll Teach Learn. 2010;7: Schmidt RA and Wrisberg CA. Motor Control and Learning: A Behavioral Emphasis (4 th Ed.). Champaign, IL: Human Kinetics Publishers, Inc; 2008.

8 Schmidt RA, Lange C, & Young DE. Optimizing summary knowledge of results in motor learning. Hum Move Sci. 1990;9: Shea JB and Morgan RL. Contextual interference effects on the acquisition, retention, and transfer of a motor skill. J Exp Psych: Hum Learn Mem, 1979;5: Shea JB and Zimney ST. Context effects in memory and learning movement information. In: Magill RA, ed. Memory and Control of Action. Amsterdam: North Holland; 1983: Squire LR. Memory: neural organization and behavior. In: Mountcastle VB, Plum F, & Geiger SR, eds. Handbook of Physiology: The Nervous System, Higher Functions of the Brain (Vol. V). Bethesda, MD: American Physiology Society; 1987: Sullivan KJ. Functionally distinct learning systems of the brain: implications for brain injury rehabilitation. Neur Rep. 1998;22: Thelan E and Ulrich BD. Hidden skills: a dynamic systems analysis of treadmill stepping during the first year. With commentary by Peter H. Wolff. Monographs of the Society for Research in Child Development, Serial; 1991:223, 56. Vander Linden DW, Cauraugh JH, & Greene TA. The effect of frequency of kinetic feedback on learning an isometric force production task in nondisabled subjects. Phys Ther. 1993;73: Van der Weel FR, Van der Meer AL, & Lee DN. Effect of task on movement control in cerebral palsy: implications for assessment and therapy. Dev Med Child Neur.1991;33: Winstein CJ. Designing practice for motor learning: clinical implications. In: Lister MJ, ed. Contemporary Management of Motor Control Problems: Proceedings of the II Step Conference. Fredricksburg,VA: Bookcrafters (APTA); 1991: Winstein CJ, Pohl PS, & Lewthwaite R. Effects of physical guidance and knowledge of results on motor learning: support for the guidance hypothesis. Res Quart Exer Sport.1994;65: Winstein CJ and Schmidt RA. Reduced frequency of knowledge of results enhances motor skill learning. J Exp Psych: Learn, Mem, and Cog.1990;16: Wulf G and Toole T. Physical assistance devices in complex motor skill learning: benefits of a selfcontrolled practice schedule. Res Quart Exer Sport.1991;70: Wulf G and Shea CH. Principles derived from the study of simple skills do not generalize to complex skill learning. Psych Bull Rev.2002;9: Wulf G, Shea CH, & Matschiner S. Frequent feedback enhances complex motor skill learning. J Motor Behav.1998;30: Wulf G, Shea CH, & Whitacre CA. Physical-guidance benefits in learning a complex motor skill. J Motor Behav. 1998;30: