Maximize Motor Learning (Part II) PDF

Facilitation Motor learning in patients Part II  Objectives Students will understand basic principles underlying Neuroplasticity related to motor learning. Students will identify motor learning principles and use them to assist a person with improving performance of...

Facilitation Motor learning in patients Part II  Objectives Students will understand basic principles underlying Neuroplasticity related to motor learning. Students will identify motor learning principles and use them to assist a person with improving performance of a motor skill Students will learn and implement the components in optimizing motor learning during a treatment session Students will define recovery of function and understand how motor learning applies to this concept Motor Learning Following a CNS injury The injury in the systems results in reorganization of the system components Focus on: Recovery of Function: Refers to reacquisition of movement skills lost through injury Reorganization of both perception and action systems in relation to specific tasks and environments Motor Learning Following a CNS injury Recovery of Function: Person has (potentially) altered system so some structures may not be available Person uses Task Solutions (Ecological Perception Action Theory) New strategies for perceiving and acting As Physical Therapists, Appropriate use of motor learning to: Maximize Recovery Promote Task Solutions that involve continued neuroplasticity & learning  Contemporary View for Facilitating learning of motor skills Know the Characteristics of the individual learner for optimal challenge. Varied Learning Effortful Styles Practice High intensity Active OPTIMAL Learning Engagement theory (Wulf & w/ Task Lewthwaite 2016 ) Challenge Point Framework Box 2-1 SC & W  Big Concepts The individual needs to be “Ready to learn” Optimize learning when a patient is highly motivated and attending fully on the task and is able to integrate new information to information they already know about the task Shumway-Cook & Woollacott p26 Law of Effect (from operant condition) Behaviors that are rewarded will be repeated at the cost of other behaviors while those that produce adverse effect will be less likely to occur (Shumway-Coo k& Woollacott p24)  OPTIMAL Learning Theory Optimize Performance through Intrinsic Motivation and Attention for Learning Wulf & Lewthwaite 2016 Three components: Autonomy: Learner has choices or can control elements of learning Goal directed practice External focus: Focusing on external object to be manipulated is better than focus on the body Enhancing expectancies: Leaning is better when goal is determined, performance expectations are explicit. https://pubmed.ncbi.nlm.nih.gov/26833314/ https://www.youtube.com/watch?v=TGNh5TTT2gI https://www.youtube.com/watch?v=x4I0NY8XPSg Activity (task or skill) Specific Practice Effects Evidence supports Activity Specific Training Task Oriented Approach Practice tasks: improves movement strategies for that task Activity Specific Neuroplasticity Development Motor learning Motor Recovery after injury - Activity specific physiology effects - Muscle Strength and endurance - Cardiovascular changes  Task Oriented approach to Motor learning. (Shumway-Cook, & Woollacott,2012) Movement (strategy) Address Impairments Task Proficiency Practice movement strategies specific to task Effectiveness Accuracy Efficiency Environment Practice adaptation of task to changes in environment Individual Safety Person = Individual Learned through interaction and exploration of the environment What is a “skill”? Observable movement or outcome of the task Skill (skillful) = Proficiency Skill = Task (Activity: ICF) Characteristics of Performance Accuracy Characteristics of Tasks Correctness Consistency Effectiveness Success Efficiency Reduced energy Adaptability Ability to detect and correct one’s own errors Setting up a Practice Session to maximize learning 1. Task Analysis 2. Understanding the Understanding the task capability of the person (skill or activity) and or individual to perform the environment demands (were the the task with in the task will take place) environment that it will be performed Selecting practice conditions to support learning  Task Classification: Cognitive versus Motor Skills Organization  Discrete skills – well defined  Perception, Knowledge or Strategy beginning and end, usually of brief (cognitive) versus performance duration elements Skills high on perception, knowledge or strategy considered cognitive skills  Serial skills – a series of discrete skills Skills high on performance elements that follow in a specific sequence – considered motor skills take somewhat longer to perform  Most skills are combinations of  Continuous skills – often repetitive or cognitive and motor elements rhythmic, without specific beginning perceptual-motor skills or or end continue until a goal is psychomotor skills accomplished Task Classification: Control elements Mobility What elements in motor control system need to be controlled? Manipulation Does it involve movement of UE?, LE? Stability Trunk?, or All 3? Task Task and Environment Variability Closed movement tasks No variability between each execution Environment is predictable Open movement tasks Variability Task changes between each execution Environment is unpredictable  Ann Gentile’s Taxonomy of Tasks Task components Arrows represent Increasing attentional demands Environmental Variability Motion Constant (3a-d) vs. Motion Variable (4a-d) Maximizing Learning of Skill Environment Crowded? Quiet? Who/What is present? Stationary? / Moving? Is this typical environment that this patient will encounter when leaving PT? Having a Person Do a Task Now that you’ve decided on the task, how are you going to get person to do it. Decisions need to be made BEFORE you start the session Maximizing Learning of Skill Person Consider: Motor learning emerges from a Stage of Learning complex system of Cognitive Status perception/cognition/action Do they have any knowledge of task being performed? processes Can they attend to task and the Involves motor processes, environment? learning new strategies for sensing Are they motivated? as well as moving Readiness to learn ROM Strength Balance Functional Mobility Performance and Learning What Stage of learning? Early Late Performance Trials across weeks/months (Acquisition) Fitts & Posner: Stages of Learning [Early] [Intermediate] [Late] What to do? How to do? How to Succeed?  Timeline for Learning Level of Attention Number of Practice Trials Cognitive Stage Associative Stage Autonomous Stage Cognitive Stage of Learning Learner Facilitators (The PT!) Develops understanding of task Provide info & demonstration on Determines “what to do” by what to do? cognitive mapping Discuss goal or performance Behavior goes from clumsy to expectation organized Constant, blocked, whole practice Relies heavily on vision to guide Precise & frequent feedback movements Tries many strategies and makes many errors  Associative Stage of Learning Learner Facilitators Determines a strategy & practices it Makes necessary adjustments Allow learner to be more self- Works on “how to do” evaluative Spatial & temporal aspects create coordinated Allow learner more Autonomy pattern Use implicit learning processes Learning to control degrees of freedom. Beginning to take advantage of the intrinsic properties of the Less frequent feedback system. (Bernstein) Refinement of skills Precise feedback Decreased errors Serial practice Increased consistency Decreased reliance on conscious thought Autonomous Stage of Learning Learner Practices & Refines movement Facilitators Works on “how to succeed” Challenge for type of task. (open: Performs well on closed/stable & diversification versus closed: open/changing tasks fixation) Spatial & temporal aspects are highly organized Less frequent feedback Moves with increased autonomy with Random practice decreased cognitive monitoring Methods of analyzing stages of learning Methods of analyzing stages of learning By carefully measuring Reaction Time (RT) RT is a measure of Sensorimotor processing before movement Early, more time to searching environment and select strategies Late, search and selection is quick. RT Movement Time Response Time Time Stimulus Response Begins Response Ends  Methods of analyzing stages of learning Use of Dual task paradigm to determine, if stages of learning are dependent on different processes of learning One task at associated stage and other task at cognitive stage If they involve the same processes, they should interfere and performance on one task should decline If they don’t involve same processes, performance will not suffer Motor Cortex Contribution to Procedural Learning Implicit or Explicit to knowledge Learning sequential finger movement task (Pascual-Leaone et al, 2004) Early: No knowledge of sequence: Decrease in reaction times- increase cortical maps for fingers Middle: recognizes a sequence is present but does not state sequence improved perform and increase in cortical maps Late: Knows the sequence and performance is improves: Cortical maps go back to baseline The assumption is other areas of brain increase role in task execution Complex Motor Learning ↑synaptic efficiency between Somatosensory and motor cortex ↑ efficiency in thalamocortical pathways Once learned: the somatosensory cortex takes ↓ role in activation of motor cortex Maybe switch to greater role of information from thalamus (by pass somatosensory cortex) Acquisition to Skill: The Shift toward Automaticity Automaticity allows attentional resources to be available to other tasks. Early learning associated with increase activity in widely distributed cerebral cortical structures Prefrontal, sensorimotor, parietal cortices Shift to automatic stage associated with Reduction in cortical activity Increase activation in subcortical centers Basal ganglia, cerebellar nuclei, and thalamus Leonard 1998, Fig. 7-1: Redistribution of neural control after learning Bernstein’s 3 Stage Model Three Stage Model Stages based on a systems model to control of a mechanical system Emphasizes controlling degrees of freedom Novice: Coordination gross = Simplify movements and reduce the degrees of freedoms Advanced: Improving coordination= allow for more movement or “releasing the degrees of freedom” Expert Stage: all degrees of freedom are released. Expert exploits passive and dynamic forces in the system for efficiency (low energy) of movement Timeline for Learning of Bernstein’s 3 stages Degrees of freedom Number of Practice Trials Novice Stage Advanced Stage Expert Stage Selecting Parameters for Practice Parameters of a Motor Learning Session Feedback Feedback types Extrinsic Feedback Modes: Intrinsic Verbal cues Person’s sensory systems relay Manual Guidance information (during & after)  Performance regarding task  Learning Extrinsic  Retention Supplemental (Augmented) Observational Learning (person watching Information themselves) Knowledge of Results (KR) and  Performance Knowledge of Performance (KP)  Learning  Errors DO NOT provide extrinsic information, if it is Known research of how feedback affects motor learning REDUNDANT : ↑ = increases, ↓ decreases Feedback Feedback to be utilized: Type: Timing: Knowledge of Results (KR) Bandwidth Knowledge of Performance (KP) Summary Transitional information Faded Delayed Concurrent Using extrinsic information (feedback): KR is part of development of Schema or Motor program theory or Schmidt’ Motor learning theory  Types of Feedback Knowledge of Results (KR) Terminal Feedback Focus is on success of movement outcome Usually a numerical number Types of Feedback Knowledge of Performance (KP) Feedback about the nature/quality of movement How did I move? Types of Feedback Transitional Information Information that is given to improve SUBSEQUENT performance Timing of Feedback No feedback given during practice - Green Feedback given- Black. Bandwidth Summary Faded Delayed Concurrent Feedback Evidence Fading feedback (KR) or summary feedback is better than constant feedback (100% of trials) to improve retention and transfer of motor learning (Weinstein & Schmidt, 1990: Lavery, 1962) This type of research suggests that Constant feedback makes learners dependent and does not promote self evaluation More recent research suggest “self controlled feedback”(when the learner ask for feedback) is better than feedback given when learner does not ask. Think about OPTIMAL Theory- PT autonomy Parameters of a Motor Learning Session Practice Schedules Types of practice- Single Tasks Session length Task order- Multiple tasks Schedule may depend on the Type of task to be learned. Types of Practice: Practice Variability Constant: Practice of same task for multiple repetitions Evidence: helps performance early, but hurts retention and generalizability Variable: Practices the same basic task, but frequent changes: the performer is constantly confronting novel instances of “to-be-learned” information Evidence: Early performance is poor, but retention and generalizability enhanced Supported by Motor (schema) program and Systems Theory Gentile’s Stages of practice Based on Learner’s goals and type of skill to be learned: open or closed movement tasks Early practice: task dynamics stage Late practice: fixation or diversification stage Task Dynamics Stage Learner’s goal is to understand the task Understanding the goal of the motor task Developing movement strategies to accomplish the goal Developing an understanding of how the environment influences the task What features of the environment regulate the task? What features are irrelevant?  Fixation/Diversification Fixation Related to progress closed skills Where the environment is stable Diversification Related to progress in open skills Where the environment is changing Movement patterns need to be adaptable Timeline for Learning Early learning Late learning Practice Variability Open skills Closed skills Number of Practice Trials Task Dynamics Stage Fixation/Diversification Stage Parameter of a Motor Learning Session Amount of Practice in a Session Massed – time spent in practice > rest May lead to fatigue Usually: 3 a day practices (athletes) CIMT Distributed – rest periods are scheduled t/o the practice session May be beneficial if: ↓ motivation ↓ attention span Motor planning deficit Considerations should include: Type of task: continuous, discrete, serial Individual capability Parameter of a Motor Learning Session Type of Practice Whole Practice: To allow person to understand Mental Rehearsal / Imagery: movement in its entirety Often completed prior to motor If do Part Practice, need to make sure task you finish up with Whole Practice Can give as “homework” Continuous or discrete tasks Evidence: Works best combined with physical Part Practice: practice For tasks that have discrete stop & start within the task (e.g. serial tasks) Or person has decreased capability Virtual Reality Simulated environments Increase time on Task & increase external focus Virtual Reality (Proffitt & Lange, 2014) Motivating & may improve adherence to exercise protocols Lack of structured exercise in people post stroke due to: Fatigue Poor health Lack of motivation Musculoskeletal issues Virtual Reality (Proffitt & Lange, 2014) Wii Kinect Results from several studies: hothardware.com/  ADL participation  UE movement  Static standing balance  Engagement Caution: One Size May Not Fit All Parameter of a Motor Learning Session Task Order (When multiple tasks need to be learned) Blocked Go back to facilitator role based on Fitts 7 (1, 1, 1) Posner’s stage of learning slides for application Serial → (1, 2, 3, 1, 2, 3, 1, 2, 3) Random → (1, 2, 3, 1, 3, 2,1,1, 3..) Neuroplastic Principle- interference Want to match task order with stage of learning Remember is their experience with the TASK that makes them in the different stages of learning Task Order: Blocked Serial Random Parameters of a Motor Learning Session Assessment: Performance Retention Transfer Generalizability Outcome Assessment: How know you achieved goals for session? Need time delay to assess retention Important Motor Learning Issues Attentional Focus External Focus Patient engagement Motivation and Autonomy (OPTIMAL) Patient Self-Assessment Must have prior expectation (Goal) Prior to therapist feedback Variability in movement practice may actually improve motor performance of the task (Both motor program theory and Ecological theory predict this)  Other Motor Learning Issues Speed / Accuracy Trade-off (Want BOTH Components- takes practice) Accuracy Speed Maximizing Learning of Skill Movement Identification As a therapist, once you know what movement you want to see, you need to: Organize treatment session to maximize motor learning of that skill Requires PREPARATION What is the goal of the task? How do I set up the environment? How do I provide instruction to prepare the learning? - How will I vary the task? - How will I provide feedback? (what is best for the learner/)  Summary Recovery of function through reacquisition of lost movement skills, involves reorganization of perception, action, and cognitive systems related to specific tasks. Use an optimal challenge point framework - balance challenge with the individual's capabilities and learning style. Understand the stage of learning (cognitive, associative, autonomous) and tailor instructions, practice conditions, feedback accordingly. How can you set up practice conditions to enhance learning? Provide feedback focused on the goal of the task and the quality of movement (knowledge of results and knowledge of performance). Type of feedback that my help learning include faded feedback, use summary/bandwidth feedback, and allow self-controlled feedback. Emphasize active engagement in tasks, motivation through autonomy, and an external focus of attention. Allow opportunities for self-assessment. Assess performance, retention over time, and ability to generalize the skill to different contexts. Treatment sessions should be organized to maximize learning of the target skill.