Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
Motor Learning
50 Plays2 months ago
In this episode, Dr. Michael Powers dives into motor learning. He highlights the differences between declarative and procedural learning, including the importance of retrieval practice for declarative learning. He discusses motor learning theories not as abstract concepts, but as tools for clinicians to utilize in establishing evidence-based practice approaches to optimize patient outcomes. Expect multiple clinical pearls you can immediately apply in clinical practice!
Show References
- Uncommon sense Teaching: Practical Insights in Brain Science to Help Students Learn by Barbara Oakley, Beth Rogowsky, and Terrence Sejowski
- The New Science of Learning: How to Learn in Harmony With Your Brain by Terry Doyle, Todd Zakrajsek, and Kathleen Gabriel
- Motor Control: Translating Research into Clinical Practice by Anne Shumway Cook, Marjorie Woollacott, Jaya Rachwani, and Victor Santamaria
- Optimizing Performance Through Intrinsic Motivation and Attention for Learning: The OPTIMAL Theory of Motor Learning by Gabriele Wulf and Rebecca Lewthwaite
All music courtesy of Free Music Archive and used via attribution 4.0 international license.
- Intro and Outro: Stylin' by JMHBM
- Transitional: Our Reality by Ketsa
Recommended
Transcript
Introduction to Motor Learning
00:00:05
Speaker
I'm
00:00:12
Speaker
I'm your host and neurological navigator, Dr. Michael Powers, physical therapist, board certified in neurologic physical therapy and clinical electrophysiology. Let's get started.
Declarative vs Procedural Learning
00:00:23
Speaker
Today's episode will be a three-parter, three distinct areas, all centered on motor learning, but broken down into chunks so that it's easy to follow in terms of how to apply motor learning information into clinical practice.
00:00:39
Speaker
First, I'll start by distinguishing between declarative and procedural learning, talking about the role that both of those play, not only in clinical practice, but also especially for declarative learning, how students can leverage information about this process to enhance studying and learning as you progress through your journey to becoming a physical therapist.
Motor Learning Theories
00:01:01
Speaker
Next, I'll take a look at motor learning theories, not for the sake of looking at theories and just getting book smart, but really looking at two that I consider fundamental for clinical practice. Those are include Fitz and Posner's three-stage model and the optimal theory.
00:01:20
Speaker
Again, the point of going through these theories is not to bore you to death with abstract ideas, but to provide you with tools that can be applied in clinical practice to enhance your outcomes.
00:01:31
Speaker
Finally, the last section will be about practice schedules and considerations. When I say practice, we know that practice and repetition is the key to motor learning.
00:01:42
Speaker
So how do we use the information we've learned previously about motor learning and motor learning theories, and apply these to set up practice schedules and treatment parameters to optimize motor learning.
00:01:56
Speaker
That's what we'll be covering today in a nutshell, three-parter, so let's start by talking about actual motor learning.
Performance vs Learning
00:02:03
Speaker
And before we talk about learning, I want to distinguish between what we mean by performance versus learning.
00:02:12
Speaker
I think very often it's easy to get seduced into an over-reliance on performance such that we forget the the importance of learning and that learning is a relatively permanent change in behavior or ability to do a task.
00:02:31
Speaker
Whereas performance is more of that immediate improvement that you see. In a classroom example, an improvement in performance might be that as I'm studying notes or looking over materials, I'm able to reproduce it right there within that class session, and that's fantastic. But that doesn't mean that next week when I have my exam that I've actually learned the material, and that's a key point we'll dive into a little bit more when we talk about declarative learning.
00:03:04
Speaker
In order to see that learning has occurred, we want to reassess Whatever the metric is or whatever we're we're seeking to find out, so maybe in a patient case, its ability to walk up and down stairs safely, we want to reassess that after a certain amount of time has happened.
00:03:22
Speaker
I can't give you the exact amount of time. We could be talking about checking from morning till afternoon. We could be talking about a few days. But the key take-home point is if we are providing instruction and demonstration,
00:03:37
Speaker
And our only method ah or the only time we reassessed patient's understanding or ability to do this is immediately after we've provided that information and instruction, we're looking at performance. We have not assessed learning.
00:03:53
Speaker
I'd like you to underline that and highlight that.
Declarative Learning Process
00:03:56
Speaker
Again, that applies not only a clinical practice, that applies to any of our own learning as we're learning new material. So learning is a change, a relatively permanent change in behavior or skill over time.
00:04:10
Speaker
When we talk about motor learning, two primary aspects of learning that I want to distinguish between. And there's some debate about the terminology here. So I'll use a couple different terms, but try and make sure I've clarified them.
00:04:23
Speaker
One is called implicit. So implicit means that it's below the level of conscious thought. There's some amount of automaticity or it's automatically happening. That's implicit.
00:04:36
Speaker
Explicit is at the level of conscious thought. And I'm going to start by talking about explicit learning first. And the main thing we're talking about here is what's known as declarative learning.
00:04:49
Speaker
Very simple way of remembering this is when you say, i declare something, I'm saying something, that's declarative learning. That's the ability to recall and produce facts, events,
00:05:03
Speaker
When I'm telling someone and when we're in the classroom and I'm going over information in class, that's declarative learning. That involves different neurologic structures and different practice schedules than the implicit learning.
00:05:20
Speaker
For declarative learning, we need to move information from our working memory into more long-term memory systems. And we also need to be able to bring that those memories back out to utilize them.
00:05:37
Speaker
Here I'll be referencing the book on common sense teaching. It's an excellent textbook for educators and they have a great chapter on declarative learning. And so I'll use some of their analogies here. And the authors have said educators are free to use these analogies. So I just want to give credit They recommend thinking of your working memory as an octopus with anywhere between four to maybe eight arms or legs, whichever ones octopus have.
00:06:06
Speaker
Each arm is capable of working with a chunk of information. This is your working memory. So each of us has an octopus with a different number of arms and or legs. Again, I'm still stuck on whether it's arms or legs for an octopus. Each arm, I'll call it an arm, handles a chunk of information. So you may have heard people talk about, well, you need to chunk your information into smaller units. And we want to have information in small enough chunks that the octopus can, each arm can balance that appropriately. So think about an octopus. I'll say mine has four arms, so I can deal with four little chunks of information. My octopus is carrying and or juggling these balls as the information's moving around in my brain and I'm focused on it.
00:06:52
Speaker
Good news is whether you have a smaller or larger working memory can somewhat be irrelevant over the long term. If you have a larger working memory, maybe you get information in a little quicker. But once we get that information into long term storage, having a smaller working memory doesn't necessarily put you at a disadvantage.
00:07:11
Speaker
My first goal is I'm learning new information. I've got it in my working memory. I need to get it into a better storage system because as soon as I stop focusing on my working memory, my octopus drops all those balls. This can be me trying to learn a phone number or trying to remember a sequence that's longer than four or six. It's gone as soon as you stop focusing on that and that working memory. So I need to get it from working memory into brain structures called or brain structure called the hippocampus, We actually have, its it's a set, we have one on each side of the brain. And that's my main goal in is getting that working memory into the hippocampus.
00:07:52
Speaker
As I'm taking new information in what I really want to do is encode this information. Maybe I'm looking at a PowerPoint, I'm listening to a podcast, I'm reading, and the information I'm taking in is put there, is presented in the fashion that the the person, the author, the podcast host, whatever it is, the way they wanted it presented. It doesn't mean that it makes sense to me.
00:08:19
Speaker
So I may have to rework the information in my head Maybe I need to engage in other senses. So if I'm reading something, maybe i have to say it out loud so I can hear it. Maybe I need to write it down so I get some tactile, some kinesthetic information as well.
00:08:38
Speaker
I just need to take this information and have it make sense to me. So there's an encoding process there. That's very important. Once I've done that, I've gotten it is somewhat encoded. I've gotten it into the bite-sized chunks I want.
00:08:51
Speaker
Then I need to get it into my storage system. I need to move it into um the hippocampus. And as I continue to work with this information, I also need to consolidate the information. One thing that's happening at the neurologic level is I've got these neurons, these nerve cells, and as I'm trying to work with new material, I'm actually forming new connections.
00:09:17
Speaker
And at first, as the memory's taking hold, these connections are a little bit weaker. And over time, as I keep working with the content, I strengthen the i strengthen the connection. So this is the consolidation of the learning. So we see this as we keep going through, keep practicing, we're going to consolidate the information, which means that it's going to be safer in storage. And eventually we can move this learning or these memories from the hippocampus actually into the neocortex.
Retrieval Practice Techniques
00:09:49
Speaker
The authors of the book Uncommon Sense Learning make the analogy that really, as it relates to long-term learning and declarative learning, we don't necessarily have a storage problem because of this tremendous capacity we have, the the tremendous amount of neurons we have. They make the example, think about Spotify with millions, possibly even billions of songs. We have similar capacity The problem is getting the information in, indexing it appropriately so we know how to find it, and then getting it back out.
00:10:23
Speaker
That brings us to one of the final considerations with declarative learning, which is the retrieval process. This is evidence-based, highly effective mechanism for long-term learning. And what's happening here is the learner is actively recalling and retrieving information from memory. Let me make an example or an analogy here that I think may resonate with some students in the difference between working memory and then retrieval practice from long-term memory.
00:10:58
Speaker
So maybe you've been in this situation, you're reading the textbook, maybe you're listening to an audio lecture on 1.5 or 2x speed, lot of content, you got to get through it. And as you're engaging in the content, it makes sense. You feel like, you know what, I've got it.
00:11:14
Speaker
And the reason for that is you're engaging your working memory, your octopus is juggling those bite-sized pieces of information, And it all makes sense. However, you have not truly learned the information. It's not gone into long-term storage because when the exam comes up next week, all of a sudden that information is gone without the cues and the guiding information in front of you, whether that's the audio lecture, the reading, the podcast, et cetera.
00:11:44
Speaker
you You've not stored the information and you've not practiced retrieving it. And I think that's a common thing that students will run into. to engage in retrieval practice, think about any activities that force you to pull the knowledge out and to see what you actually have.
00:12:03
Speaker
Flashcards are a very effective way, making sure that you can correctly provide the answer before flipping it over. What's called a brain dump or a free recall, writing down everything you know about a topic on a sheet of paper Me personally, and this is not an endorsement for everyone, I love flashcards to get that initial information in.
00:12:25
Speaker
And then I love doing a form or a combination of a brain dump and a concept map. So a concept map is drawing diagrams to connect ideas. What I typically will like to do is kind of brain dump or start writing what I remember. And then I'll start making connections. I'll start thinking, well, I learned this about memory. And then that triggers, oh, I remember about memory. He talked about working memory. And in working memory, we need to encode and store the information in our hippocampus before it goes out to the neocortex.
00:12:58
Speaker
Really finding out how can you pull that information back out will help you in terms of locking this information in. A big challenge with declarative learning and moving this information into long-term memory is that it takes time. And this is where teachers probably from the beginning of when classrooms started said, please don't cram, please engage in the content a little bit at a time. And this is why, because you need time to get the information not only in,
00:13:29
Speaker
but be able to retrieve it out. And the evidence will also indicate that you can't study two, three, four hours in a row. You also need to take breaks and get rest because that helps the consolidation of these memories.
Transitioning to Procedural Learning
00:13:44
Speaker
If nothing else, as we talked about explicit learning, declarative learning, I want you to think about the concept of moving items from working memory into more of a long-term memory process.
00:14:00
Speaker
How can we also think about this in clinical practice? Well, we go in, let's say we see a patient that we need to educate them. They have a non-weight-bearing status. We'll tell them about it. We'll ask them to repeat that back to us. We may provide multiple opportunities for them to say that to us.
00:14:19
Speaker
Now, let's think about this, though. We typically don't want someone just telling us they're non-weight-bearing. We need to see that they can maintain the non-weight-bearing status for their safety. Here is where we're thinking more about the implicit learning the what's called maybe below the conscious level. And I want to emphasize procedural learning.
00:14:42
Speaker
This is when with enough practice, let me back up here with enough practice. The goal in most areas is going to be to move from declarative learning to procedural learning.
00:14:56
Speaker
Think about any time you've learned a new skill, and may I'll use ah PT students again as an example. Perhaps you're learning how to do a manual therapy technique.
00:15:09
Speaker
As you first learn the skill, you're going to be maybe talking to yourself. You're using declarative learning. Here's my hand placement. Here's where I need to put my other hand. I need to stand in line with the area or with the way I want to transmit the force. I need to sink down on my legs so I'm using my body weight and I'm not lifting with my arms, etc.,
00:15:31
Speaker
with enough practice, you're going to move this into procedural learning. areas There's multiple areas involved in the nervous system here, but we're looking primarily through the basal ganglion cerebellum. And we can store some procedural learning throughout the neocortex as well, but the basal ganglion cerebellum are going to be most important here.
00:15:52
Speaker
As you continue to practice, you're moving from declarative to procedural, you're not going to be consciously thinking about that manual therapy technique. You could be thinking about your grocery list. You could be thinking about what you're going to watch on Netflix that night when you're done with your with your day. But it's so automatic that you don't think about it.
00:16:13
Speaker
This is also why sometimes some of the best clinicians struggle initially when trying to teach content to students or to novices, because once someone has mastered a motor skill through procedural learning, they're their ability to talk about it, they almost have to translate it.
00:16:33
Speaker
A little sneaky tip here too is if you're engaged in an athletic competition with someone who's very skilled, a possible way to throw them off their game is to compliment them on their form, get them thinking about it, and knock them out of that procedural area, that procedural learning. back into declarative. So maybe you're playing basketball and you just start complimenting someone on their follow through or you're playing tennis and you say, wow, the way you throw that ball up for the serve is just excellent.
00:17:02
Speaker
Again, it's sneaky. I'm not saying you should be doing this, but what's happening is you're moving someone forward from that implicit, unconscious procedural pathway into declarative.
00:17:14
Speaker
Let's go back to our patient example. So we said we had someone who's non-weight-bearing. We're going to cue them. We're going to say, hey, what's your weight-bearing status? And they should be able to provide it. And a lot of times we do that quite often, and it makes sense for safety. But what we really want to see is that they're able to reproduce it. And the way we get that is with continued practice. So for many of our patients, as it relates to motor learning, whether it's learning a new skill or relearning a task or skill after neurologic injury, we want to provide the practice opportunities to move from declarative to procedural. I'd argue the goal in most cases is that we start out maybe talking and instructing.
00:17:57
Speaker
then as quick as we can, we want to get into some good practice schedules and allow for opportunities to safely make mistakes. We'll talk about that in future episodes about the importance of learning from our mistakes. But we just want as much practice as possible to move into that procedural area of learning.
00:18:16
Speaker
This will tie in in our next
Fitz and Posner's Model
00:18:18
Speaker
section. We're going to be talking about motor learning theories, and we can see how depending on the stage of where someone's at along the stages of motor learning that we can leverage moving from declarative to procedural.
00:18:32
Speaker
And we'll also talk about some specific strategies as it relates to autonomy, enhanced expectations, how we can really bolster a therapeutic alliance and enhance motor learning as well.
00:18:51
Speaker
Motor learning theories. The way I just said it and maybe the thought of it sounds not the most exciting, but it's actually very exciting. I'm going to hone in, as previously mentioned, on two key theories. Fitz and Posner's three-stage model and a very, or a much more recent one the optimal theory. Fitz and Posner's The main premise here is that a learner and let's talk about motor learning specifically.
00:19:17
Speaker
I'm going to use myself as an example because I don't mind being embarrassed by learning new tasks. I'll use my example of when I learned to snowboard because that was a very painful activity and involves a lot of motor learning concepts. So we'll use that here as an example.
00:19:32
Speaker
As I was learning how to snowboard, I moved from a cognitive stage of learning, so high cognitive demands. We can think back to claritive and procedural learning. Someone in the cognitive stage of learning is really going to be more into claritive learning. Lots of thinking, lots of thinking about facts, where do I need to go? Things aren't very automatic.
00:19:55
Speaker
A learner in this model moves from cognitive to associative stage. Associative stage movements are starting to become a little more automatic. There's less...
00:20:06
Speaker
declarative learning, more procedural learning. And then finally, the last stage is autonomous. That's expert level. And I really like this theory because it can be used clinically fairly easily to set up practice schedules. But I think it also makes a lot of sense if you reflect back maybe on activities you've learned or skills you've learned, how much work it takes initially and how you progress. And that's what this theory, I think, helps and helps do quite nicely.
00:20:37
Speaker
Cognitive stage of learning of motor learning. This is where, as PTs, we probably spend a good chunk of time. Again, maybe we have someone who's had a stroke, who is is relearning a skill after neurologic injury, or is trying to learn a new skill um without having had an injury, perhaps. Big point here is in the cognitive stage of motor learning, The patient is figuring out, what do I do? They don't even know what to do. If you think about yourself, if you're a PT student learning anew, I'll use the manual therapy technique.
00:21:11
Speaker
What do you probably want most from your instructor? You probably want them to show you what the technique is and to tell you why you would need to use it. This is not an area where if you're learning a brand new skill, you want someone to say, well, just figure it out.
00:21:29
Speaker
In the cognitive stage of motor learning, the patient, the student, whoever's learning the skill needs to figure out what to do. Throughout this process, the learner is going to be developing a cognitive map. So sorting out what's called the reference of correctness. So there's ah some trial and error here, and I did not mention operant conditioning an associative models as well, kind of trial and error as part of implicit learning.
00:21:58
Speaker
But you're getting a little bit of that as you practice. So you're developing this reference of correctness, rejecting things that don't work and keeping things that do. A frustrating, very understandably frustrating portion of being in this stage is there's going to be a high. I have not performance been a big golfer myself, but I've heard from people that pick up golf, how frustrating it is because there's really nothing else happening except for you and the club and I suppose the ball. But new new golfers, their swings are highly variable where the ball goes is highly variable. And there's a high cognitive demand. I'll come back to my example of learning how to snowboard.
00:22:39
Speaker
I would my biggest goal at first was not learning how to snowboard. It was not falling and trying to ah minimize injury while falling. It's very painful. So high variability of performance. Maybe I get down a green slope. while only falling twice, maybe another time I'd fall a lot or I'd overcompensate or overcorrect.
00:22:59
Speaker
And what'll happen here, because of the high cognitive demands, learners get tired quickly. It's not a physical fatigue. It is a mental fatigue.
00:23:10
Speaker
Later, when we discuss practice schedules and considerations, this is where we'll tie in the concept of distributed practice. Learners, and this is for a task, so I don't want to confuse taking breaks with someone maybe doing cardiovascular exercise or high-intensity training.
00:23:32
Speaker
I'm talking here about someone trying to master or learn a new skill. There's such high cognitive demands that there will need to be rest breaks allowed for in order to optimize learning.
00:23:46
Speaker
Keep that in mind for yourself as well. If you're learning new tasks, figuring out when you've kind of hit that little bit of that wall and when you need to take a mental break. During the cognitive stage of motor learning, a hallmark of movements in this stage is that the movements are not efficient. People look stiff.
00:24:07
Speaker
Co-contraction, so the contraction of agonist and antagonist muscles at the same time, is very common. Learners are trying to control all the degrees of freedom throughout the body. They cannot release degrees of freedom, so you're going to see stiff movements.
00:24:24
Speaker
Going back to my snowboarding example, my knees were locked out as much as I could. My arms are in a high guard position kind of up by the side. All the joints are locked out. Very, very stiff, not very efficient. So this is also quite fatiguing as well.
00:24:41
Speaker
In this stage, in terms of feedback, The learner needs a lot of feedback, needs to see, well, is is what I'm doing even close to what I'm supposed to be doing? In this stage of learning, visual feedback is paramount. So the use of mirrors, the use of recording devices, getting some external feedback is going to be very beneficial for the learner.
00:25:04
Speaker
If we are the therapist working with someone who's in the cognitive stage of learning, ways that we can approach this stage that'll be beneficial for the patient include providing clear instructions.
00:25:17
Speaker
And if possible, try and point out similarities to other learned tasks. I mentioned learning how to snowboard. And before that, I lived in Florida for a while, so i actually grew up surfing. And now, unfortunately, i don't know that there's a lot of transferability between the two because the weight shifts are completely different. However, I tried to leverage, well, I'm on a board and it's moving on something that's a form of water, I guess. So that was maybe minimally helpful in that example. But on a patient case,
00:25:48
Speaker
If there's other learned tasks, find out what your patient enjoyed doing, what they're good at. Try and point out similarities to other things they already know how to do. I think this is just good information in general. In most cases, try to avoid overloading the learner with excessive instructions.
00:26:07
Speaker
Sometimes we can come in and we get so excited as therapists and we want our patients to do well that we start talking a lot. Sometimes it could be nervousness. We want to prove maybe we're a new grad or a student. We want to prove we know what we're talking about. But I'd like you to consider that often less is more.
00:26:24
Speaker
So shorter instructions, let the person think about it Think back to working memory. We've got all of us have an octopus with four plus or minus a couple arms or legs. I think I said we'll go with arms. If you're giving six-part instruction, you've just completely overloaded that person's working memory. So short, direct instructions, making sure that they're clear.
00:26:48
Speaker
Provide opportunities for rest breaks. This is distributed practice. We're going to talk more about this in a little bit, but make sure you allow for cognitive rest. Again, I'm not necessarily talking about physical rest, although with the amount of co-contractions in the cognitive stage, you might need some of that, but allow for rest breaks as the learner is working on the skill.
00:27:10
Speaker
We do want to allow safely for some trial and error. Trial and error learning is actually very powerful a powerful form of implicit learning. So here,
00:27:21
Speaker
By doing trial and error, we're moving from declarative learning into a little bit more of unconscious and implicit learning. Key here, though, is we want to be safe. So as a therapist, you may consider, well, if I'm working with someone who's non-weight-bearing, I'm I can't really let them put the foot down. I can't allow trial and error learning there.
00:27:40
Speaker
But maybe in some other areas, if they got the walker too far in front of them, but it was still relatively safe, maybe you let them sort it out. You don't jump in to fix everything because at the end of the day, you're not going home with the patient.
00:27:55
Speaker
Providing too much feedback overloads them cognitively, and it provides for more autonomy if we allow for individuals correcting their own mistakes.
00:28:05
Speaker
Now, lot of information on the cognitive stage of learning, but that's, I think, where we spend most of our time as therapists working with patients and clients. We'll talk briefly about the associative stage of motor learning and then very briefly about the autonomous stage. So, associative stage of motor learning is the next stage in the Fitz and Posner three-stage model. Here, someone's moving from asking what to do to how to do it. And the way we know someone's moving into the stage is we see the the movements become a lot smoother. The co-contractions are going down. Patients can release those so-called degrees of freedom and extraneous movements are are much less. So just in general, the movement is more reliable. It looks more consistently the same. It looks smoother.
00:28:56
Speaker
Here we're less reliant on visual feedback, a lot more reliant on proprioceptive feedback. So we don't need to be looking outwards as much. Now we're sensing what's happening within our own bodies.
00:29:10
Speaker
Here we are refining and advancing our frame of reference for the correctness of performance. And this stage is going to persist for a long time. So this is the stage at which most patients, I would argue, depending on setting, are probably discharged from physical therapy in this associative stage. So we'll probably continue to see improvements in skills in some way. But at this point, the learner, by developing their own frame of reference of correctness and really figuring out kind of how to do it, they don't need nearly as much coaching or guidance.
00:29:47
Speaker
As the therapist in this case, if someone's in the associative stage, a couple of things you can do to help out would be encourage a lot of self-assessment, asking the patient how did that feel, and seeing to what extent their report matches up with what you saw or perceived as well.
00:30:04
Speaker
Practice considerations here become very important. We're going to start varying the practice and the environment. Before, when someone's in the cognitive stage, we mentioned distributed practice. That's where we provide multiple rest breaks or where we're resting essentially as much time as we're practicing. But someone in the associative stage of motor learning, we can start moving towards massed practice, which is more practice than rest.
00:30:34
Speaker
We'll also talk about random practice and how we can start rolling that in when someone's in the associative stage. But instead of practicing the same thing over and over, we can start now mixing in other things that we're practicing as well.
00:30:48
Speaker
Here, for sure, we want to get out of any hands-on cueing, any hands-on assistance. We really need to let the patient take charge and complete the movement with as little help and or cueing from us. And here we really want the learner to be empowered for active control and decision-making in modifying these skills. So that was the associative stage. The autonomous stage, this is expert level. we You may be involved in this stage if you're working with high-level athletes. um You may be in this stage also for
00:31:24
Speaker
um Individuals with neurologic conditions, I'm thinking about maybe spinal cord injury that have just figured out exceptional ways of transferring and maybe you're working with them to modify a couple small things about how they're doing certain functional tasks. But this is expert level. This is called autonomous. Here the key question or concern is how to succeed.
00:31:45
Speaker
This person, this learner is going to have a high performance across multiple environments. Something I didn't mention previously, especially in cognitive stage of learning, the environment can really mess someone up. So in the cognitive stage, you probably want what's called a closed environment, not a lot of distractions. You need things to be the same to succeed.
00:32:06
Speaker
As your skills improve and you move to the autonomous stage, whatever skill you are working on, you can do it in a loud environment. You can do it in the rain. it doesn't matter. You're an expert level. The movements are going to look error free and with minimal cognitive demand. And I think that's a good way of checking yourself on a motor skill is can you think about something else while you're doing the skill?
00:32:31
Speaker
Most of us who know how to ride a bike can ride a bike without having to actively think about it. We can most of us tie our shoes while having a conversation. But if you're a student and you're learning that new manual therapy technique, you really can't talk to someone and have a conversation while you're focusing on that technique, right? So that's a way that you can check yourself and your patient in terms of how are they on the autonomous stage of motor learning.
00:32:59
Speaker
In future discussions, we'll also talk about what's called dual tasking by adding a cognitive demand to a task. So by trying to distract someone, you can see does their motor skill performance breakdown.
00:33:12
Speaker
If you are fortunate enough to work with someone in the autonomous stage of learning, you really can think about adding environmental distractions and challenging practice schedules. That's really what we're looking at doing in this area.
00:33:27
Speaker
To recap, that was the Fitz and Posner's three-stage model. We talk about a cognitive stage of learning. So the person is figuring out what what am I trying to do?
00:33:40
Speaker
Movements are not going to be efficient. We need a lot of visual feedback. We need a lot of cognitive rest breaks. Next would be the associative stage. Here are the learners figuring out how to do it.
00:33:52
Speaker
Movements become much smoother. We move from relying on visual feedback to proprioceptive feedback. And the learner really has a good sense or a good, their own frame of reference for the correctness of performance.
00:34:06
Speaker
Final stage is autonomous. This is expert level. Learners thinking, well, how do I succeed? Very high performance across multiple environments. And the movements are going to be error free with minimal cognitive demand.
Optimal Theory
00:34:21
Speaker
The next theory that I'd like to cover is called the optimal theory. The optimal theory, the paper on this was published back in 2016, so possibly a little bit newer than some of the other theories you may be familiar with. The optimal theory is shorthand for optimizing performance through intrinsic motivation and attention for learning theory. So obviously optimal is much less of a mouthful.
00:34:48
Speaker
I love this theory. This is probably my favorite theory as it relates to engaging not only with patients in a clinical setting. I think there's a lot of this theory that can be incorporated in our own not only movements, but in our own goal directed behaviors.
00:35:05
Speaker
um So if you're engaging in some metacognition or thinking about learning in general, I just find this theory to be outstanding. So this is, I get very jazzed about this theory.
00:35:16
Speaker
This theory incorporates importance of motivation, which we can think about as being learner autonomy. So the learner having choices and enhanced expectations with an external focus. And so combining these the evidence suggests will give us better motor learning, better outcomes. The authors of this paper note that this theory takes into account the social, cognitive, affective, motor nature of motor behavior. Really, they're identifying that as humans, there's multiple factors involved in movement. It's not just a signal from the brain to the muscles. It goes beyond, well, it doesn't go beyond the movement goal, but the movement goal incorporates all of these additional factors. And so this theory is looking at those factors as well.
00:36:11
Speaker
The three key principles that I want you to remember about optimal theory are these. We want to work with the learner, the patient, and to promote enhanced expectations for future performance. we are going This is going to help drive the dopaminergic systems.
00:36:30
Speaker
It's going to set the stage or set the expectations that there's improvement In the future, this is going to realistic. This is you those of you that know me in person. I'm not a big believer in toxic positivity. This is not fake or this is not bravado, but we are providing and promoting enhanced expectations for future performance.
00:36:52
Speaker
We are supporting and providing opportunities for patient autonomy. In general, healthcare has moved from paternalistic, where the provider, the physician, whichever person is is providing the healthcare, as the know-it-all, I'm just going to use that term, towards a more collaborative interaction. Now,
00:37:14
Speaker
As a physical therapist in most situations, you're going to have more expert level information than your patient. However, the patient is the expert on their own life. And i want you to underline that and highlight it. So your job is to provide opportunities for autonomy within the boundary of what you know is a movement system expert.
00:37:38
Speaker
This theory provides evidence that providing these opportunities for patient autonomy yields greater motor learning. Then finally, what I want you to keep ah mindful of, a third key principle, is we want to provide an external focus of attention.
00:37:55
Speaker
Typically, in in most areas, when providing cues, the cues might be something like keep your elbow in or bend your elbow this way, straighten your knee. Those are examples of cues with an internal focus.
00:38:10
Speaker
focus of attention. What these authors are saying with optimal theory is if we think back to dynamic systems theory that the system will self-organize in the most efficient and optimized way, if we just give an external focus of control, so if we say, reach for this target, and I don't tell you how to bend your elbow, I don't tell you how to straighten your knee, you reach for the target, that's an external focus. Your system will arrange how to do it, and by not focusing on
00:38:42
Speaker
yourself and individual body parts and instead focusing on the task, motor learning is improved. One thing I also, like I probably am taking this a little bit out of context, but I like to think about this external focus of attention as it relates any time where any of us is engaged in an activity where where maybe we're feeling under pressure, under duress, maybe we're being observed and we don't like that. I will typically make the example here of students going in for a practical exam.
00:39:17
Speaker
If you're focused on yourself and your self-talk and you're thinking someone's watching me, oh no, what am i going to do? Your motor performance is going to suffer versus if you're focusing on the task goal and the task goal is I'm going to help this patient or in a practical, this simulated patient as best I can, because this is what I came to school to do You're going to have a better motor output. You're going to have your motor performance is going to be improved. So I'm taking this slightly out of context from a motor learning perspective, but I think it's relevant. and I think it has carryover that anytime we're wanting to see improved motor performance, think about what you're trying to achieve versus thinking about yourself.
00:40:04
Speaker
Let's talk a little bit about motivation then. So motor performance may be enhanced when we perceive a future positive outcome And this is definitely more impactful when our patients think of themselves as the agent of change. So this is that intrinsic motivation.
00:40:23
Speaker
We want to tap into that as we're working with patients. How do we do that? Well, a ah powerful way of doing that is via enhanced expectations.
00:40:34
Speaker
Really setting the bar high. We want to have high expectations, but realistic expectations. And we want to help the patient see that these enhanced expectations are a reality. What these enhanced expectations will do is they create outcome expectations. So the patient is expecting it. This is going to happen. And when we expect things and they happen or we're anticipating a future reward, that taps into our dopaminergic systems.
00:41:06
Speaker
Now here, we're not only talking about dopamine as a reward. Think about the role of dopamine in movement as well. So these enhanced expectations, I would argue, are giving us kind of a double-barreled benefit here.
00:41:18
Speaker
Ways that we can tap into these hand enhanced expectations would be positive feedback, Here, what we're talking about is really emphasizing trials or practice episodes that were so more successful versus emphasizing poor trials. Now, there might be exceptions to this rule, but generally speaking, um most of us have a negativity bias where Focusing on poor trials really pulls someone into not having enhanced expectations. It may pull into more of an internal focus of control or internal focus of attention, that is. So we want to emphasize the good trials. That's one way to encourage enhanced expectations.
00:42:05
Speaker
When possible, when your patient is in an area where social comparative feedback would be helpful, we want to use that. So maybe we're working with someone who's 80 and we say, well, for 80-year-olds without significant underlying pathology, a timed up and go score of blank amount of seconds is considered normal.
00:42:26
Speaker
I would argue that most of us want to not only be normal, most of us, even though it's mathematically impossible, think we're above average. So tap into that when working with your patients.
00:42:39
Speaker
Self-modeling can also be helpful. having patients watch videos of themselves. And here we want to again, focus on the good trial. So if they see the successful trials, that's very beneficial.
00:42:49
Speaker
One that I really love is perceived task difficulty. I love this across both education and in clinical practice, setting criteria up for early success, then ratcheting up the difficulty. So not setting the bar low by by having some early wins, but setting something that's attainable getting that buy-in, getting that patient feeling that they can be successful, then ratcheting up the difficulty.
00:43:14
Speaker
Now, believe it or not, extrinsic rewards, even though there's probably, you've probably heard a lot of discussion, well, we need to have everything be internally motivated. Don't sleep on extrinsic rewards. In younger kids, sometimes this could be money. I'm not advocating you pay your pediatric patients money. but there's actually some evidence that suggests allowance or other monetary rewards can be beneficial in younger people. Extrinsic rewards can be as simple as your, i don't want to say praise, but I'll use that term, your praise or your positive terms as a therapist, your patients, generally speaking,
00:43:49
Speaker
want to make you happy. Generally speaking, most students want their instructors to think highly of them. When I go into the doctor, I want my doctor to think like I'm doing a good job for my health care. So most of us being social creatures do appreciate positive affirmation. So don't sleep on the importance of telling your patient you did a good job and that praise when used correctly can be a powerful extrinsic motivat extrinsic reward that will drive up motivation.
00:44:19
Speaker
Then finally, on this area for how we tap into enhanced expectations, positive affect, that is probably the single most important one. And so positive affect, your demeanor, how you engage with the patient.
00:44:33
Speaker
And by no means here am I saying that everyone has to be smiling all the time or you have to be a social butterfly if you're more introverted. I challenge each and every one of you to really think about engaging with your patient in a way that they walk away feeling that they are an important person to you.
00:44:52
Speaker
Doesn't mean we don't hold them accountable. Doesn't mean that you can't have a professional relationship But that positive affect will go such a long way for that patient reaching the pinnacle of their potential. So my positive affect might look very different from yours. Please don't try to be me. Don't be someone you're not. Be the best a version of yourself so that each patient that comes in knows that they're important and they know that you care about them achieving their highest potential level.
00:45:26
Speaker
Let's talk about autonomy. This is another key concept here. Humans have an innate need to have control over themselves. we can What you'll find throughout multiple areas of your life is anytime you are in a position of power, you can use it. You can use force, but there's a limitation there because at some point people will either resist, they'll leave, they won't go along with what you're doing,
00:45:51
Speaker
Any power differential, and you have a power differential when you're seeing a patient, technically you're in charge of them in many ways. Please keep in mind, though, that everyone has the need to have control over themselves. So to the fullest extent possible, again, we're the movement system experts. We need to bring some of that expertise here.
00:46:12
Speaker
But to whatever extent you can provide opportunities for the learner to control some aspects of the treatment conditions and the practice conditions, it's going to increase task interest and the learner's motivation to learn.
00:46:25
Speaker
Some ways we can do this would include asking the patient, or maybe the patient comes in for treatment. We're going to do treatment one, two, and three. do you have a preference on what order you want to do them in? Let's assume the order doesn't matter to you, or in terms of treatment efficacy. Give them a choice of what order they want to do the treatments in.
00:46:44
Speaker
If, again, it's possible, the weather's nice, can we do a treatment outside? Does a person want to get outside? How much feedback would they like? How would they like to challenge themselves today within that treatment? Those are all ways of increasing autonomy.
00:47:01
Speaker
Think also about the language you use. possibly so something as simple as saying, we're going to be working on this today, as opposed to you need to do this today, very different. And believe it or not, even incidental choices, even as small as what color ball they want to use in therapy, what kind of assistive device, if it's safe to change assistive devices, all of those can vastly increase the level of autonomy.
00:47:27
Speaker
Let's close out optimal theory then by talking about the external focus of attention. So here we're talking about directing attention away from one's body parts or self and to the intended movement effect.
00:47:40
Speaker
This is, again, consistent with dynamic systems theory, and it's going to improve the movement effectiveness, so the accuracy of skill and the efficiency. There's going to be more efficient muscle recruitment because we're allowing muscles to move in normal synergies instead of isolating out individual joints or sub-movements of a task.
00:48:01
Speaker
We can think about this as maybe a couple examples if we're working on balance, maybe someone's standing on a balance board. Instead of saying, keep your feet level,
00:48:12
Speaker
Tell the person, well, keep the balance board level. So focus on that external target. This external focus of attention is initially, I feel, very difficult. Either implicitly or explicitly, most trainers, coaches, therapists, we're used to saying, giving feedback with an internal focus of attention. Keep your elbow in when you shoot. follow through with your hand. And these aren't wrong per se. These might be nice little bits for parts of a movement. But in terms of long-term learning and skill acquisition and retention, the more we can incorporate the external focus of attention, the more successful we will be.
00:48:54
Speaker
Let's summarize then the optimal theory of motor learning. We talked about three key principles. We want to promote enhanced expectations for future performance, support and provide opportunities for patient autonomy, and finally provide an external focus of attention.
00:49:16
Speaker
We've covered declarative and procedure learning. We've covered motor learning theories. And we're going to conclude with a discussion of how to tie this all together into practice
Practice Schedules and Feedback
00:49:28
Speaker
considerations. How why might we set up a treatment schedule, practice schedule to loop all of this information in together so you have something tangible you can take with you into the clinic.
00:49:46
Speaker
Let's talk about then motor learning strategies as they relate to practice schedules. What are some of the variables that we can manipulate? And when I say manipulate, I'm not saying we're doing anything manipulative, but what are some of the, if we think of ourselves as that we are manipulating variables, which are those variables that we can work with to enhance outcomes for our patients?
00:50:09
Speaker
I'm going to draw heavily here upon the Fitz and Posner's three-stage model. Really want to think about distinguishing between is our patient in the cognitive stage of learning?
00:50:20
Speaker
Think back to what that was versus the associative stage. So is someone trying to figure out what to do are they trying to figure out how to do it? That's really going to drive some of our initial decision making. And then we want to keep in the back of our minds, are we trying to go more for short term performance?
00:50:43
Speaker
Are we trying to look better right now? Or are we trying to drive a little bit more learning where and what we'll find is that that it may actually look worse in the short term, but we're going to have better long term retention. So those are the big considerations we're going to have here as we move forward in talking about our practice scheduling.
00:51:06
Speaker
First thing we're going to think about is the distribution of practice. So here we're talking about working on a task or a motor skill. I'm not talking about someone doing high-intensity gait training, or someone doing some aerobic exercise. When I talk about rest and practice, I'm talking about learning a specific skill. Let's use my example of learning how to snowboard.
00:51:29
Speaker
I can tell you for sure I took a lot of rest breaks, some intentional, some not, depending on how many times I fell. But I would need to sit and think and consolidate the information as I was learning. That's a key take home point. We're talking about learning a skill.
00:51:44
Speaker
In our practice distribution, we have two main options. Distributed practice. Distributed means spread out. Or masked practice. Masked means all at once.
00:51:55
Speaker
We previously mentioned this, but if someone's in the cognitive stage, they need a lot of rest breaks. Distributed practice is going to be recommended. Distributed is defined as the rest time is equal to or less than practice time. So you're resting as much or a little bit more than what you're practicing.
00:52:15
Speaker
This is shown to lead to improved learning, but it takes longer. Obviously there's more rest time. This is also in recommended a more geriatric population as well. Not a hundred percent across the board. I don't, I'm not implying to be ageist here, but there's some references that indicate that in an elderly population, the distributive practice may be a little more beneficial.
00:52:43
Speaker
Masked practice means practice time is more than rest time. This requires high motivation and high levels of endurance and attention. So this is most appropriate for associative and or autonomous stage of learning.
00:52:58
Speaker
What about the practice conditions? We have a couple options here in terms of do we want to perform the same task multiple times or do we want to intermix or interleave one task performed with others? And we're going to see some carryover here, not only for motor learning, but to to learning in general.
00:53:23
Speaker
So blocked practice is when you're doing the same thing over and over and over and over again. I'm going to use a basketball analogy here. Free throw shooting.
00:53:34
Speaker
If I sit down, sit down, I'll be standing up. If I'm standing at the free throw line and I shoot 50 free throws in a row, that's blocked practice. Now, this may help get that skill in initially, but on retention trials, so long-term learning not going to be as solid. Probably a reason for that is you've just done something the same way multiple times, so you get good at that one way of doing it, but you may not be able to do it under a variety of conditions.
00:54:06
Speaker
Blocked practice, probably beneficial for those initial stage of cognitive learning when someone doesn't even know what they're supposed to do. Doing it repeatedly can be helpful, but then you want to move into what's called random practice. That's The intermixing, or some people have called it interleaving or interweaving, of one task performed with others. This is better for long-term learning because you're working harder to keep that task in mind while there's some other interference. So it may look worse in the moment. But on retention tests and on learning tests, you're going to have it a little bit better. Think also about the real world applicability here. So if we use free throw example, if I'm shooting 50 free throws in a row and that's all I practice when I get in a game,
00:54:56
Speaker
There may not be as much carryover because in a game I'm sprinting up and down the court. We got a rebound. The crowd's yelling. And now I have two free throws and the game is tied. i may do worse than if during my practice schedule we do a scrimmage and every now and then I shoot free throws. That's much more real world. So blocked practice, same thing over and over again.
00:55:17
Speaker
Probably best early and cognitive stage of learning. But then when you can get to that random practice where you mix things up. An example for a patient, let's use our patient that has a non-weight-bearing status, and we wanted to work on sit-to-stand, gait, and bed mobility.
00:55:35
Speaker
Maybe that initial safety considerations, we do some blocked practice of sit to stand, some blocked practice of gait, but then to make sure that they can recall and perform and keep that non-weight bearing status through everything.
00:55:49
Speaker
Maybe we set up a little, it's not an obstacle course, but maybe we have them practice. Okay, now get out of bed, walk to this chair, now get out of that chair, come stand at the counter That would be an example of random practice.
00:56:02
Speaker
couple other things practice-wise I wanted to mention in terms real-world applicability would be are we practicing something in a constant fashion or a variable fashion? So constant means that you're doing the task the same way each time. Variable is that you're performing it in various ways.
00:56:22
Speaker
I live in Kansas City. The example here I'm going to use about variable practice is going to be Patrick Mahomes and the way he throws the football. And that's his ability to throw it sidearm, overhand, running left, running right, probably doing a somersault. That would be variable practice versus constant practice would be standing in the same area, throwing a football the same way. For your individual patient, you probably need to consider How adaptable do they need to be? i think a possible failure in some some areas, ah in some physical therapy practices, we probably don't consider this enough. We probably overly do constant practice because we like to see that good performance and maybe we underappreciate
00:57:07
Speaker
how variable practice may allow patients to be more adaptable, especially out in the community or as they they are fulfilling their societal roles. Let's talk about part practice a little bit. That's not a practice schedule necessarily, but part practice is exactly what it implies, is breaking down a task into smaller components.
00:57:29
Speaker
And that can be a powerful strategy if you wanted to work on subsets of a movement. So maybe you're working with someone who's had back surgery and they need to learn how to log roll to get out of bed. You could very well do part practice to work on going from supine to sideline to pushing up, and you could break that down and practice any areas of that that you wanted to work on.
00:57:54
Speaker
Finally, let's talk about feedback and feedback types. Two main types of feedback we can provide. One is called knowledge of results, and that is feedback on the end result. So was the goal achieved? Then there's knowledge of performance. That's feedback about movement patterns used to complete the task. Generally speaking, knowledge of performance is going to be more beneficial when someone's in the cognitive stage of learning.
00:58:22
Speaker
They probably have not released those degrees of freedom. Their movements are inefficient. So knowledge of performance about how their movement looked is going to be beneficial.
00:58:33
Speaker
As soon, though, as the learner's moving more into that associative stage of learning and has an idea of, their own frame of reference of correctness, we want to move to knowledge of results. Was that end result achieved? And hopefully that makes sense because if we stay in knowledge of performance too long, we're staying in that declarative mode. We're staying in that cognitive stage of learning and we want to get out of there as quickly as we can.
00:58:59
Speaker
One other thing about knowledge of results, think about how often do you provide feedback. There is a concept of fading your feedback. So maybe as the learner is starting to progress, we give a little more frequent feedback and then we start giving less and less feedback as practice progresses.
00:59:18
Speaker
One thing I found that this is challenging a lot of times for students, students want a lot of feedback repeatedly, which is understandable. However, too much feedback can actually inhibit the learning process. So we want to be mindful, not providing too much feedback as the learner is progressing.
00:59:36
Speaker
Give the learner the opportunity to check the movement against their own frame of reference. Early on, you might consider, well, I'll give feedback after each trial or each episode of movement to then maybe doing more of a summary, letting multiple trials happen before you provide feedback.
00:59:55
Speaker
In this section, we talked about practice considerations, including considerations of whether we want to be doing masked versus distributed practice. We linked those to is someone in the cognitive stage of learning or associative stage. So distributed practice is better for cognitive stage of learning. Masked practice better for distributed practice.
01:00:19
Speaker
talked about blocked versus random practice. And think about too how blocked practice might be similar to your own studying that you do. If you study everything in the same order all the time, you'll get good at recalling it in that order, but test questions don't come up that way, right? So you start out a general rule of thumb.
01:00:40
Speaker
Of course, it's PT. The answer is always, it depends. But a general guideline is as a novice, as a cognitive stage of learning, start blocked. then move to random as quickly as you can because you're going to get better long term retention.
01:00:54
Speaker
Think also for practice schedules. Do you want your patient performing it constant? is it Is the movement the same every time or the task practice the same way? Or do you want it variable? And most times you do want variable. I use the Patrick Mahomes example. But if we think about a patient, most chairs they're transferring in and out of are going to be different. They're not all going to look like the chairs in the clinic or the mat table in the clinic. So variable practice is more real world and leads to better adaptability.
01:01:23
Speaker
Talked about the importance of part practice. If a task can be broken into parts, you can put the pieces back together. And then finally, we talked about feedback types, knowledge of performance. How did the movement look? That's best and initially for cognitive stage of learning. Knowledge of results, maybe a little bit better as a patient's moving into the associative stage.
01:01:45
Speaker
And think about fading your feedback as well as the patient improves in their ability to perform the task. Thanks for listening to the NeuroPowerHour. I'm your host, Dr. Michael Powers, and I hope to catch next time to continue learning.