Understanding the power of motor learning is an incredibly useful tool for a physical, occupational or speech therapist to have. Knowing the stages of motor learning, and how to give feedback to your patient, may be the most effective thing you could do to ensure that the person carries over the skills you are teaching them.
But first- what is motor learning, and how do we use it in therapy?
As we help our patients move through the stages of motor learning, we want to facilitate their recovery in the most effective, meaningful way! Whether they are recovering from an elective surgery, a stroke, are deconditioned from prolonged bedrest, or have a life-long disability… therapists are going to use our expertise to help them re-learn the skills they need to live their best life. But how do we know the best way to teach these skills, when everyone is so different?
Luckily, this has been well researched!
The three stages of motor learning
Stage 1 – Cognitive Stage: This is the stage in which the person is trying to learn what to do. They are taking in visual, auditory, and tactile information in order to have conscious knowledge (or at least a certain level of intuition about) what is being asked of them.
Stage 2 – Associative Stage: Now the learner is trying to figure out how to do it. In this stage there are usually awkward and disjointed movements, and things may take a little extra time to complete. There are constant adjustments being made so the quality of the skill improves.
Stage 3 – Autonomous Stage: This is where the movement or skill becomes more automatic. The cognitive demands and processing are minimal in relation to the learned skill. Now, the person can attend to other (different) cognitive tasks. Walking and talking is a good example. Walking has become automatic, so now a conversation can be attended to.
As someone makes their way through these stages, several things need to be in play for motor learning to occur. Those things include (but are not limited to):
Having a GOAL:
Your patient needs to know why they are doing each activity. This should ideally be tied directly to something that is important to them. A simple example could be trying to improve shoulder range of motion and strength in order for the person to be more independent with grooming and dressing. You wouldn’t want to say, “Our goal is to lift your arm more.” Lifting their arm (in and of itself) may not be important to them. What once was a very natural thing for them to do is going to be difficult because they are weaker and the patient will often will be discouraged from the amount of effort it will take to do what we consider a simple movement.
Framing it in functionality will be far more motivational than if you try to get a patient to simply improve impairments. So instead you would say, “I want you to move your arm better so you can brush your hair or put on your shirt. This is how we are going to do that…”
TASK SPECIFICITY:
Working on impairments themselves is often necessary in order for your patient to have the building blocks to perform the skills you’re teaching… but they must also go through the motions of the actual skill itself for motor learning to occur. A concert pianist does not get to their elite level of performance by simply stretching their fingers, cracking their knuckles, and spending hours with their blue digiflex! They must play scales and practice playing pieces of music! An NBA player won’t measure up to the competition by only shooting hoops – they have to play the game!
The same principle applies to the skills we teach in rehab. For someone to get better at walking – they have to do more than long arc quads and marches. They must to be given the opportunity to walk. For someone to become more independent with bathing and dressing – you have to hand over that washcloth!
PRACTICE:
It makes perfect, right? Well it certainly will speed up motor learning! The more opportunities you provide for your patients to practice the skills you’re teaching… the faster they will learn them. This could be a great opportunity to work with other departments in your facility to make sure the things the patients are doing in therapy are carried over throughout the rest of their day. During your therapy sessions, there are several different ways you can train skills and structure the way you give the patients opportunities to practice. Blocked practice, massed practice, and random practice can all be useful ways to approach any given skill.
They need FEEDBACK:
Your patient can practice the task specific skill to achieve their goal all they want… but if they don’t know how they are doing, they may not make any gains. We as their skilled teachers need to know how to provide feedback so they have knowledge of results and can make adjustments accordingly for subsequent trials. In the world of motor learning, you can provide extrinsic feedback and facilitate intrinsic feedback. They are both necessary at times, but how do they measure up with helping your patients learn and retain skills?
Click here to read our article on Attentional Focus and learn how to best cue your patients through their motor learning experience as well!
Extrinsic Feedback
When providing extrinsic feedback to a patient as you’re teaching them a new or re-learned skill, you are going to use (as you may imagine) things that are external or outside of them. Commonly used extrinsic feedback would be the use of a mirror as a visualization of midline orientation in a patient after a stroke. We’ve all gotten the tape out and marked the middle of the mirror and usually get great performance from our patients when we constantly ask them to reference the tape and make sure they are lined up with it.
Extrinsic feedback can also come in the form of tactile or auditory cueing. You may tap on their quad muscle to let them know they are losing control during a standing activity or it could be as simple as praising them each time they do a movement correctly. All of these examples come from an outward source.
Intrinsic feedback
Intrinsic feedback, on the other hand, comes from within the patient. This is not something we can put in front of them or provide to them. Intrinsic feedback is produced through processing the visual, vestibular and somatosensory stimuli around them.
However, we can help to facilitate intrinsic feedback for our patients by providing them with knowledge of results, or letting them know how successfully they performed the task. So, in practice you have them perform the skill you are teaching (whatever it may be), then you let them know how they did. You can also have them weigh in on their performance before you provide it to them. You can ask open ended questions like… “How do you think you did?”, “What do you think you can do better next time?”, “What went well and what needs improvement?” Then you watch the wheels turn… They may give you an answer or they may not know what to say. But whatever their response is, you will then tell them how they actually performed. As they practice, they will use this information (this knowledge of results) to adjust their performance and get better at the skill!
Which type of feedback should I use?
I can say with confidence, that therapists are really good at providing extrinsic feedback! It seems to come naturally – give the praise, grab the mirror, tap the arm or the leg. But what does the research say about its effectiveness?
Studies have shown that continued use of extrinsic feedback actually promotes dependency instead of learning and retention of skills! Your patients must be able to detect the errors that they make and be engaged in the process in order for motor learning to be effective. Research has also shown that it really does matter how engaged your patients are in learning. Even if they are given knowledge of results 100% of the time after performing a task… they may not actually learn and retain it if they are not somehow engaged and actively participating.
Additionally, you want to slowly phase out how frequently you provide the knowledge of results because, remember – you are trying to facilitate intrinsic feedback and don’t want you providing them with the knowledge of results to inadvertently become extrinsic feedback that they become dependent on! Whew! (If your head isn’t spinning by now… I’m impressed!)
Click here and here to read more about how knowledge of results and motor learning are related.
We all want to provide the best possible learning experience for all of our patients! With a few tweaks on how we word things and how we practice, we will always get great results and really help our patients achieve the highest level of function and best quality of life.
If you liked what you learned here, make sure to check out our 3-CEU Update your Care Plan: Balance webinar! We discuss some other principles of motor learning and how to best choose interventions based on your comprehensive assessment!
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