MS LECTURE NOTES.docx

Movement Science For Physiotherapy Week 1: Motor Learning **1.1 Discuss and apply the task-specific training approach** [Task oriented training/ Task specific training ] - The goal of rehabilitation is to regain optimal motor performance of everyday tasks/activities, specific and relevant...

Movement Science For Physiotherapy Week 1: Motor Learning **1.1 Discuss and apply the task-specific training approach** [Task oriented training/ Task specific training ] - The goal of rehabilitation is to regain optimal motor performance of everyday tasks/activities, specific and relevant to the individual's lifestyle and context/stage of rehabilitation - Best way to improve is to specifically practice the task and make training as close to the task as possible - Keep training goal directed to see better results. **1.2 Discuss and apply a systematic approach to analyse and (re)train functional tasks** [Task specific training -- how?] 1. Functional task analysis -- watch patient complete the task they want to get better at performing - Essential components - Kinematic deviations - Compensations - Potential underlying impairments 2. Practice the essential components (part practice) 3. Practice the whole task (whole practice) 4. Transfer of learning to relevant contexts **1.3 Discuss and apply the concepts pf essential task components, kinematic deviations, primary and secondary impairments** [Functional task analysis ] - Essential components: what are all the necessary movements required to perform the task? - Kinematic deviations: movements that deviate from the normal way that movement should be performed therefore effecting the task -- eg. ROM - Impairments: potential underlying impairments include pain, ROM, coordination, reduced sensation, motor control - cannot directly be visualised, can only be hypothesised and then tested **1.4 discuss and apply principles of task-specific training including part and whole practice** [Part task practice ] - Practice the essential movement components -- parts of the whole task - Therefore we individually practice these parts that make up the whole task. It is important that it remains very specific to the task. - Set up practice to: required appropriate type of muscle contraction relevant to the task and or simulate the load demands of the task -- for example if task requires eccentric control make sure you are training eccentric contraction - Skills and strategies used: - Handling/guidance - Choice of training position and set up of the environment - Augmented feedback through the various sensory systems: - Visual - Proprioceptive - Tactile - Vestibular - Auditory [Whole task practice ] - Strengthen muscles and develop control of movement while practicing the whole task - Set up practice to achieve - Correct selectivity and timing of muscle activation - Appropriate muscle force to meet task demand - Incorporate physiotherapy skills and strategies - Eg. Manual, verbal, technical applied in the context of function [Skill complexity and organization] - The decision to practice a skill as a whole or in parts can be based on the complexity and organization characteristics of the skill - Complexity: Number of parts or components and the degree of information processing that characterize a skill - More complex tasks have more component parts and place more demand on information processing - Note: "complexity" is different to "difficulty" - Organization: the relationships among the component's parts of the skill - Skill has a high level of organization when its component parts are spatially and temporally interdependent - Eg. A jump, it would be hard to break up the components of a jump - Low level of organization: when component parts are relatively independent - Eg. Buttoning a shirt Low complexity High organisation Whole skill ----------------- ------------------- ------------- High complexity Low organisation Part method [Skill classification Approach] - Discrete skills (specific start and finish -- e.g. flicking a switch) = Whole practice - Serial skills (more discrete movements performed in a continuous way -- e.g. playing piano) = Part practice - Continuous skills ((no defined start or finish -- e.g. walking) = whole or part Practicing part of a skill: Three strategies - Fractionization - Practicing individual limbs first for a skill that involves the asymmetric and simultaneous coordination of the arms or legs - Segmentations - Begin practice with first part of the skill, then progressively add each part until the skill is practiced as a whole - Simplification - Practice an easier variation of the skill before practicing the skill itself **1.5 Discuss, differentiate and apply knowledge of results (KR) and knowledge of performance (KP) feedback** [Feedback] Intrinsic feedback = built into the task/ Augmented feedback: = the feedback comes from an external, or supplementary, source Knowledge of results feedback methods: - Number of reps - Distance - ROM - Speed Knowledge of performance feedback methods: - Weight shift -- quantify - Reach to touch target -- muscle activation **2.1 Motor control** Definition: - the ability to regulate or direct the mechanisms essential to movement - involves the study of how the neuromuscular system functions to activate and coordinate the muscles and limbs involved in the performance of motor skill Why is motor control important? - Normal movement control is the goal of rehabilitation - Understanding motor control is critical to physiotherapy practice to assist individuals who have motor control problems producing movement disorder - Enables targeted Ax and Rx - "we are born to move, but we learn to move skilfully" - Skill is a biological imperative, without it we would quickly perish **2.2 Discuss the degrees of freedom problem and apple knowledge of this to physiotherapy practice** [Degrees of freedom problem ] - Degrees of freedom = number of independent components in a control system and the number of ways each component can vary - Degrees of freedom problem: control problem that occurs in the designing of a complex system that must produce a specific result - As physios we can help patients maximise efficiency of degrees of freedom, can limit degrees of freedom to allow task practice at a level appropriate for patient **2.3 Discuss the impact and clinical relevance of factors related to the individual, the task and the environment on motor control** [Shumway-cook's model of movement ] Human movement is a complex phenomenon that is a function of the interaction of three elements - The individual - The task - The environment The individual generates movement to meet the demands of the task being performed in a specific environment The individuals capacity to meet interacting task and environmental demands determines the persons functional capacity *Environmental constraints on movement control:* - CNS consideration of attributes of environment when planning task-specific movement - Regulatory features: aspects of environment that shape movement itself -- eg. Uneven surface, slope - Nonregulatory: features of the environment that may affect performance, but movement does not have to conform to these features -- eg noise, light *Individual systems underlying motor control* - Sensory/ perceptual systems: poor vision - Cognitive: reduced attention - Motor/action: weakness *Task constraints on movement control* - Types of task performed has great impact on neural organization of movement - Open movement: adapt movement strategies to constantly changing and unpredictable environment - Closed movement: relatively fixed or predictable environment  **2.4 Describe and apply different systems of classifying motor tasks** [The task] - An understanding of task attributes can provide a framework to assist clinicians to structure tasks - Tasks can be sequenced from least to most difficult based on their relationship to a shared attribute - Therapists can understand what is difficult for the patient and then prescribe a program for a patient that is appropriate for them and subsequently set suitable progressions [Classifying Tasks ]  [One dimensional Systems ] +-----------------------------------+-----------------------------------+ | Task organisation (discrete, | Size of primary musculature | | serial, continuous) | required | | | | | |  | +===================================+===================================+ | Stability versus mobility | Manipulation continuum | | | | | |  | +-----------------------------------+-----------------------------------+ | Stability of Environmental | Manipulation continuum | | context (Open versus closed | | | tasks) |  | +-----------------------------------+-----------------------------------+ | Stability of Environmental | | | context (Open versus closed | | | tasks) | | +-----------------------------------+-----------------------------------+ [Gentile's Two-Dimensional Taxonomy] - Taxonomy: A classification system that is organized according to relationships among the component characteristics of whatever is being classified. - Each skill category poses different demands on the performer. - Box 1 very easy, closed skills and consistent. Box 16 most difficult - Skills that demand the least of the performer are the simplest; those that demand the most are the most complex. - Skill categories begin at the top leftmost category with the simplest skills and progress to the most complex in the bottom rightmost category. - Environmental context dimension and the action function dimension form the basis for creating sixteen categories of motor skills. - Two-dimensional classification system enabling a more precise description of tasks. The 16 boxes of Gentile's taxonomy represent a gradual increase in task complexity - Environmental Context - Action Function (Task characteristics) *Environmental context* *-- Regulatory conditions: Features of environmental context\* to which movements must conform to achieve the action goal.* *-- Nonregulatory conditions: Features of environment that have no influence or only an indirect influence on movement characteristics.* *-- Intertrial variability: Variations in the regulatory conditions associated with the performance of a* *skill change or stay the same from one trial to the next. (e.g. Walking in a shop is different every time)* *Function of the action.\ -- Body stability: Skills that involve no change in body location during the performance of the skill.\ -- Body transport: Includes active and passive changes of body locations.\ -- Object manipulation: Maintaining/changing the position of moveable objects.* To summarise: 4 characteristics can describe any motor task TWO Environmental context characteristics 1. Are the regulatory conditions stationary or in motion? 2. Do the regulatory conditions change from trial to trial? TWO Action function (task) characteristics 1. Does the action goal require maintaining the body in the same location or transporting the body from one place to another? 2. Is an object manipulated? Week 2: Motor Learning **PART 3 -- MOTOR LEARNING** **3.1 Define motor learning** [Motor Learning] - The acquisition of motor skills. - The performance enhancement of learned or highly experienced motor skills - The reacquisition of skills following injury, disease and the like. - Study of understanding of the acquisition and/or modification of skilled action - Recovery of function: reacquisition of movement lost through injury Motor learning -- relevance to physiotherapy - As a physiotherapist you will teach patients to perform motor tasks - Understanding motor learning will increase your effectiveness in teaching motor tasks [Motor learning questions relevant to patients and physios ] - What contributes to recovery of motor function, and what factors constrain it? - How much initial recovery is due to "spontaneous recovery"? - How much recovery attributed to therapeutic interventions? - How much will continue to improve? **3.2 Differentiate between performance and learning** [Performance vs learning ] Performance - Observable behaviour - Execution of a skill at a specific time and in a specific location Learning - Definition: a change in the capability to perform a skill that must be inferred from a relatively permanent improvement in performance as a result of practice or experience Performance versus Learning - Learning: relatively permanent change - Performance: temporary changes in motor behaviour seen during practice sessions - Recovery of function involves reacquisition of complex tasks +-----------------------------------+-----------------------------------+ | Performance | Learning | +===================================+===================================+ | - Observable behaviour | - Inferred from performance | | | | | - Temporary | - Relatively permanent | | | | | - May not be due to practice | - Due to practice | | | | | - May be influenced by | - Not influenced by performance | | performance variables | variables | +-----------------------------------+-----------------------------------+ [Learning assessment techniques ] - Observing practice performance - Performance curves for outcome measures - Retention tests - Transfer tests: testing skill in a different context - Coordination dynamics: more efficient movements - Dual-task procedure Retention tests: tests of a practiced skill performed following an interval of time after practice has ceased - Length of time between the end of practice and the test is arbitrary - Purpose: assess permanence or persistence of performance level achieved during practice [Practice performance may misrepresent learning ] Two reasons: - Practice may involve a performance variable that artificially inflates or depresses performance - Practice may involve performance plateaus **3.3 Categorise types of knowledge/performance** [Basic forms of long-term memory ] - Nondeclarative (implicit) forms of learning = tying shoe laces - Declarative or explicit learning = explaining what you learnt in class **3.4 Outline the five performance characteristics of motor learning** [General performance characteristics of skill learning] - Improvement - Consistency - Stability - Persistence - Adaptability 1. Improvement - Performance of the skill shows improvement over a period of time - Learning is not limited to performance improvement - Practice can result in bed habits which may result in performance getting worse as practice continues 2. Consistence - As learning progresses performance becomes more consistent - Performance characteristics becomes more similar from one performance attempt to another - Early in learning, performance is typically quite variable 3. Stability - As learning progresses performance stability increases - Internal and external perturbations have less of an influence on performance - Internal -- eg. Stress, fear - External -- eg. Obstacles, weather 4. Persistence - A skill learning progresses the improved performance capability lasts over increasing periods of time 5. Adaptability - The improved performance is adaptable to a variety of performance context characteristics - Successful skill performance requires adaptability to changes in personal, task and environmental characteristics **3.5 Describe two key models of learning: Fitts and posners three-stage model and gentiles two-stage model** [Stages of motor learning ] - People progress through distinct stages as they learn a motor skill beginner highly skilled - Two key models describing the stages - Fitts and posner three-stage model - Gentiles two-stage model - Benefits of considering distinct characteristics at each learning stage: - Proves insight into skill learning process - Different instructions strategies needed for people in different learning stages [Fits and Posner Three Stage Model ]  +-----------------------------------+-----------------------------------+ | Cognitive stage | - Learner is working out what | | | to do and how to do it | | | | | | - Learner focuses on solving | | | cognitively- oriented | | | problems | | | | | | - Learner is getting the idea | | | of task goal, what to do, how | | | to do it | | | | | | - The learner will make many | | | errors | | | | | | - The learner may be aware they | | | are doing something wrong but | | | may not be sure what to do to | | | improve performance | | | | | | - Physiotherapist acts as a | | | coach -- giving instructions | | | and providing feedback | +===================================+===================================+ | Associative stage | - Person has learned to | | | associate cues from the | | | environment with required | | | movements | | | | | | - earner works to refine | | | performance to be more | | | consistent | | | | | | - Errors diminish | +-----------------------------------+-----------------------------------+ | Autonomous stage | - Final stage where performance | | | of the skill is "automatic" | | | (in terms of attention | | | demanded) | | | | | | - Speed and efficiency of | | | performance improve | | | | | | - Less cognitive control | | | required | | | | | | - Less affected by interference | | | | | | - Learner can detect and make | | | proper adjustments to correct | | | own performance errors | +-----------------------------------+-----------------------------------+ [Gentile's Two-Stage Model ] +-----------------------------------+-----------------------------------+ | Initial stage | Later stages | +===================================+===================================+ | Learner works to achieve two | Later stages involves learner | | goals: | acquiring three characteristics: | | | | | 1. Learn to discriminate between | 1. Adapting movement pattern | | regulatory and non- | acquired in Initial stage to | | | demands of any performance | | regulatory conditions in | situation | | environmental context (eg | | | colour of a ball) | 2. Increase consistency of | | | action goal | | 2. Movement coordination pattern | | | to enable some | Achievement | | | | | degree of success achieving | 3. Perform with an economy of | | action goal | effort | | | | | Learner explores a variety of | Learner's movement goals depend | | movement possibilities | on the type of skill being | | | learned. | | Through trial and error the | | | learner experiences movement | Closed skills: Require fixation | | characteristics that match and do | of movement coordination pattern. | | not match the requirements of the | | | regulatory conditions | - Learner must refine this | | | pattern so that he or she can | | Cognitive problem solving to | allow consistent action goal | | determine how to achieve the goal | achievement. | | | | | At the end of the initial stage | Open skills: Require | | | diversification of the basic | | - the learner has developed a | movement pattern. | | movement pattern that | | | | - Develop flexible movement | | allows some goal achievement | pattern that can adapt to the | | | continuously changing spatial | | - but performance is not | and temporal regulatory | | consistent or efficient | conditions of the skill. | | | | | *Example Task: Reaching to grasp | | | a cup on a table* | | | | | | 1. Learn to discriminate | | | between: Regulatory | | | conditions eg size and shape | | | of the cup, amount and type | | | of liquid in cup. | | | Non-regulatory conditions eg | | | colour of cup, shape of | | | table, noise in the room | | | | | | 2. Initially focus on developing | | | the arm and hand movement | | | characteristics that match | | | the physical characteristics | | | associated with the cup | | +-----------------------------------+-----------------------------------+ **3.6 Outline the performance characteristics that change across stages of learning and those that do not change** [Performer and performance changes across the stages of learning ] 1\. Rate of performance improvement\ 2. Movement coordination characteristics\ 3. Altering preferred coordination patterns\ 4. Muscles used to perform the skill\ 5. Energy cost\ 6. Visual selective attention\ 7. Conscious attention demands\ 8. Error detection and correction capability\ 9. Brain activity +-----------------------------------------------------------------------+ | *Changes in rate of performance improvement* | | | | - Large amounts of improvement occur during early practice | | | | - Smaller improvement rates characterize further practice | | | | - Motor learning can occur in chunks with periods of acquisition | | and then consolidation | | | | - Work more intensely with patients during periods of rapid | | progress | | | | - Review after periods of consolidation when further progression | | may occur | +=======================================================================+ | *Changes in movement coordination characteristics* | | | | - Managing degrees of freedom required by a skill | | | | | | | | - beginner learner freezes certain joints | | | | - later stage learner allows functional synergy of limb segments | | | | | | | | - For early-stage learners, physiotherapist might control the | | degrees of freedom | | | | | | | | - Handling to stabilise a joint | | | | - Equipment to simplify task | | | | - Modify task | +-----------------------------------------------------------------------+ | *Altering preferred coordination patterns* | | | | - We all have a repertoire of preferred movement patterns | | | | - When learning a new skill: We may use movement characteristics | | similar to those of a skill we already know | +-----------------------------------------------------------------------+ | *Changes in muscles used to perform the skill* | | | | - Early in practice muscles are used inappropriately | | | | | | | | - More muscles than are needed | | | | - Incorrect timing of muscle activation | | | | | | | | - With practice | | | | | | | | - Number of muscles activated decreases | | | | - Timing pattern of muscle activation improves | +-----------------------------------------------------------------------+ | *Changes in energy cost* | | | | - Energy expenditure: Beginners ↑, Skilled performers ↓ | | | | - With practice: Movement efficiency increases, Rate of perceived | | exertion (RPE) decreases | +-----------------------------------------------------------------------+ | *Changes in visual selective attention* | | | | - Beginners typically look at too many things | | | | - Beginners direct their visual attention to inappropriate | | environmental cues | | | | - With practice, visual attention is directed to appropriate | | sources of information faster.\ | | → more time to select and produce a response to the situation. | +-----------------------------------------------------------------------+ | *Changes in conscious attention demands* | | | | - Beginners consciously think about almost every part of performing | | the task | | | | - With practice ↓ conscious attention automaticity | +-----------------------------------------------------------------------+ | *Changes in error detection and correction capability* | | | | - Ability to detect and correct performance errors increases with | | practice | | | | - ↓ reliance on physio for error detection and correction\ | | \*\* Don't allow over-reliance to develop | +-----------------------------------------------------------------------+ | *Changes in brain activity* | | | | - Changes in neuronal activation patterns from initial to later | | stages of learning | +-----------------------------------------------------------------------+ PART 4 -- (Re)training motor tasks **4.1 Discuss the practice variables that influence training of motor skill** [Practice variables] - Motor skill learning requires practice - Optimal practice requires consideration of consider of practice variables 1. Whole and part practice 2. Practice specificity 3. Practice intensity (amount of practice) + the challenge point 4. Practice variability + the impact of contextual interference 5. Distribution of practice 6. Practice environment 7. Modes of delivery of practice \*\*\* check list for training design +-----------------------------------+-----------------------------------+ | Whole and part practice | Whole practice | | | | | | - A practice strategy that | | | involves practicing a skill | | | in its entirety (i.e. as a | | | whole) | | | | | | Part practice | | | | | | - A practice strategy that | | | involves practicing parts of | | | a skill before practicing the | | | whole skill | | | | | | During rehabilitation it is | | | likely to be necessary to | | | practice parts of the whole task | | | | | | - i.e. practice the missing or | | | altered essential components | | | of functional tasks | | | | | | - THEN reassemble and practice | | | the whole task | | | | | | *Transfer training to relevant | | | contexts* | | | | | | 1. Simple, closed skill | | | performance | | | | | | - Start Simple closed = | | | Predictable environment; | | | movements easier to | | | reproduce. Eg practice | | | walking in a well-lit gym on | | | level non-slip floor surface | | | | | | 2. Task variation | | | | | | - Task variation is introduced | | | that requires demand on | | | movement execution but in a | | | predictable environment. Eg | | | walking at increased speed, | | | stopping and starting and | | | changing direction | | | | | | 3. Added task variation from | | | external factors | | | | | | - comes from an external factor | | | in relation to the task; | | | environment still predictable | | | and allows for movements to | | | be reproduced | | | | | | 4. Complex, open ended tasks | | | | | | - Involve demanding | | | environments that can be | | | unpredictable and require | | | diversifying movements. Eg | | | walking in a crowded area | | | e.g. a shopping centre or | | | busy footpath near traffic, | | | crossing roads, walking on a | | | travelator or a bus or train | | | while it is in motion | +===================================+===================================+ | Practice specificity | Test performance is directly | | | related to the similarity between | | | characteristics of the practice | | | and "test" (real world) | | | conditions | | | | | | Task-oriented training provides a | | | way of strengthening muscles and | | | increasing endurance as well as\ | | | increasing control over dynamics | | | of particular action being learnt | | | | | | Practice characteristics: | | | | | | 1\. Sensory/perceptual | | | characteristics | | | | | | 2\. Performance context | | | characteristics | | | | | | 3\. Cognitive processing | | | characteristics | | | | | | Exercise effects are specific to | | | task and context | | | | | | - Joint angle | | | | | | - Muscle length | | | | | | - Type of contraction | | | | | | - Velocity of contraction | | | | | | - Posture (e.g. NWB vs FWB) | +-----------------------------------+-----------------------------------+ | Practice intensity | Motor learning requires | | | repetition -- How much is enough? | | | | | | - Likely that 1000's of | | | repetitions are needed to | | | develop skilled action | | | | | | - Lasting neuroplastic changes | | | may take days or weeks of | | | practice | | | | | | - Motor learning requires | | | adequate intensity | | | | | | Challenge point | | | | | | - Specific practice conditions | | | that will optimally challenge | | | the person in a way that will | | | enhance skill learning | | | | | | - Consider both the difficulty | | | level of the skill and the | | | skill level/ability of the | | | learner | +-----------------------------------+-----------------------------------+ | Practice variability | Refers to the variety of movement | | | and context characteristics the | | | learner experiences while | | | practicing a skill. Movement and | | | context characteristics that can | | | be varied in practice: | | | | | | - Skill variations that will be | | | required in real-life | | | conditions | | | | | | - Environmental context in | | | which the skill is performed | | | | | | More practice variability is | | | better for learning and | | | performance in future "test" | | | situations than less variability | | | | | | Practice variability benefit can | | | be related to the increased | | | amount of performance error | | | during practice | | | | | | - Why would performance errors | | | during practice benefit | | | learning skills? | | | | | | *Contextual interference* | | | | | | - The memory and performance | | | disruption that results from | | | performing variations of a | | | skill within the context of | | | practice | | | | | | - Various amounts of contextual | | | interference can occur during | | | practice depending on the | | | scheduling of the practice | | | variability | | | | | | Higher contextual interference | | | results in: | | | | | | - Poorer performance during | | | practice | | | | | | - Greater attention demands | | | during practice | | | | | | - Better performance during | | | retention and transfer tests | | | | | | Low contextual interference eg | | | with blocked practice schedules: | | | | | | - Learners overestimate their | | | learning during practice | | | | | | - Perform | | | ance | | | during practice misleads them | | | to judge they are learning | | | more than they actually are | +-----------------------------------+-----------------------------------+ | Distribution of practice | The practice distribution | | | problem: | | | | | | - You have a specific amount of | | | time to practice for a future | | | "test" | | | | | | - What is the best way to | | | schedule the available time | | | in terms of: | | | | | | Two types of practice | | | distribution schedules | | | | | | *Distributed practice sessions | | | are better for learning. Why?* | | | | | | - [Fatigue:] | | | Fatigue may negatively | | | influence learning with | | | massed practice schedules | | | | | | - [Cognitive | | | effort:] Massed | | | practice may become boring. | | | The learner may decrease the | | | amount of cognitive effort | | | used which may lead to | | | decreased learning. Better | | | learning results when people | | | practice skills in more | | | frequent and shorter practice | | | sessions | | | | | | - [Memory | | | consolidation:] | | | Distribution of practice | | | across several days may | | | provide a better opportunity | | | for long-term memory storage | | | to take place | +-----------------------------------+-----------------------------------+ | Practice environment | An optimal rehabilitation | | | training environment provides an | | | enriched environment for learning | | | | | | - Stimulating and challenging = | | | Plenty to do | | | | | | - Replicates real world tasks & | | | environment = Relevant | | | activities | | | | | | The training environment can be | | | structured to enable safe | | | independent practice by | | | | | | - Arranging the furniture | | | | | | - Using equipment | | | | | | Task and environment set-up | | | | | | [Novice learner set up | | | ] | | | | | | The task and environment set to | | | enable the client to experience | | | success with the task i.e. make | | | it easier to succeed | | | | | | - This increases motivation to | | | learn | | | | | | - Learning requires experience | | | | | | [Later learning set | | | up] | | | | | | Task and environment set-up to | | | progress and challenge the | | | sensory and motor systems for | | | transfer of learning | | | | | | - Vary the task practice e.g.: | | | | | | | | | | | | - starting position | | | | | | - Foot position | | | | | | - Speed | | | | | | - Type of object | | | | | | - Surface | +-----------------------------------+-----------------------------------+ | Modes of delivery of practice | - Individual sessions | | | | | | - Partner/ group training | | | | | | - Circuit training/classes | | | | | | - Independent Practice | | | | | | | | | | | | - Self monitored practice | | | | | | - Supervised practice: | | | family/carers, nursing staff, | | | therapy assistant | | | | | | Use of a variety of training | | | formats: | | | | | | - To maximise the intensity of | | | practice | | | | | | - For sustained attention | | | during task practice | | | | | | - To foster active | | | participation and development | | | of self- management skills | +-----------------------------------+-----------------------------------+ **4.2 Discuss how a variety of practice models including mental practice can facilitate motor skill acquisition** [Mental Practice]\ Definition: The cognitive rehearsal of a physical skill in the absence of overt physical movements - MP can take the form of: - Thinking about the cognitive or procedural aspects of a motor skill - Engaging in visual or kinesthetic imagery of the performance of a skill or part of a skill = feels self performing activity [Aids Motor Skill Acquisition]\ To determine the influence of mental practice on skill learning, researchers have typically compared three practice conditions: - Physical practice only (PP) - Mental practice only (MP) - No practice (NP) - PP \> MP \> NP - Similar to PP only [Examples] of learning situations that benefit from mental practice: - Rehabilitative settings - Power training - Part of a general preparation strategy that aids learning Imagery is the most common mental practice strategy for skilled athletes preparing to perform a skill - Between competitive events - Immediately prior to a competitive event - Rehabilitating an injury **PART 5 -- INSTRUCTION AND FEEDBACK** **3.1 Describe the different types of instructions and feedback used in motor skill training and discuss how instructions and feedback can be used by physiotherapists to optimize motor skill training g** [Instructions ] - Demonstration - Manual guidance - Verbal instructions/ cues - Non-verbal auditory cues Demonstration - The most important characteristic that determines whether a demonstration will be beneficial is whether the skill being learned requires the acquisition of a new pattern of coordination. What is Demonstration? - The terms modelling and observational learning often are used interchangeably with the term demonstration. - Demonstrating how to do a skill typically involves visual observation on the part of the learner. - Question of interest. - When is demonstration a more effective instructional strategy than some other way to give information about how to perform a skill? - Provide patient with opportunity to directly observe a person performing a skill - Useful way to reduce complexity of verbal instructions Can novices benefit from observing other novices? - Yes. When observing other novices: - Observer perceives information about the strategy used by the other person to learn to perform the skill - Encourages the observer to engage in more active movement problem solving +-----------------------------------+-----------------------------------+ | When and how frequently should a | | | demonstration be given? | | | | | | - Frequency and timing of | | | demonstrations | | +===================================+===================================+ | Frequency | Timing | | | | | - Demonstrations should be | - Demonstrations should be | | performed several times | performed before and during | | | practice | | | | | | - Most advantageous in initial | | | learning stage | +-----------------------------------+-----------------------------------+ Potential Downsides to Demonstration - Unlikely that there's an "ideal" movement form that is appropriate for all learners. - Providing learners with other people's solutions for solving movement problems via demonstrations can subvert the problem solving. - Watching skilled performers can foster a potentially dangerous illusion of skill acquisition that does not coincide with the observer's capability. Manual Guidance - Manual handling skills to guide performance - Especially useful in early stages of motor learning to: - Give an idea of the movement sequence - Provide an experience of successful task performance - With clients who cannot effectively receive: - Instructions: Verbal or Non- verbal - Demonstrations Verbal Instructions: Words and/or sentences to guide skill acquisition Amount of information - Consider attention capacity /limits of working memory (keep it simple!) Attention focus - on skill: movement outcomes, movement patterns - on environment: regulatory conditions - Focusing on movement outcomes is more effective than focusing on movements required by the skill. Long vs short sentences/phrases/verbal cues - "shoulders forward", "look up", "back straight" (keep it simple!) Use verbal analogies where possible - Analogies may encourage implicit learning - Give verbal instructions that influence goal achievement strategies. - Eg Speed vs Accuracy, vs Speed and accuracy. Be careful of ironic effects. - There is an unintentional tendency to perform actions you are intentionally trying to avoid. - Eg "Don't miss" can make the learner more likely to miss +-----------------------------------+-----------------------------------+ | Attention focus | | +===================================+===================================+ | Internal attentional focus | External attentional focus | +-----------------------------------+-----------------------------------+ | - Instructions that direct | - Instructions that direct | | attention to the movement | attention to the effect of | | themselves | movement on environment | | | | | - Example: shift your weight | - Example: shift your weight | | from back leg to front leg | towards the table | +-----------------------------------+-----------------------------------+ Non-verbal cues - Example: clapping, counting, metronome - Particularly effective when the goal is to move within a certain movement time or in a certain rhythm. - Can be very effective with people with Parkinson's disease +-----------------------------------+-----------------------------------+ | Frequency and timing of | | | instructions | | +===================================+===================================+ | Frequency | Timing | | | | | - Depends on | - Long sentences: usually | | | before movement | | | | | | - Short sentences/ phrases/ | | - Attentional capacity of | verbal cues: usually during | | client | movement | | | | | - Characteristics of skill and | - Non-verbal cues: usually | | client | during movement | | | | | - Example: previous skill | | | experience | | +-----------------------------------+-----------------------------------+ **5.2 Discuss how augmented feedback can enhance or hinder the learning of motor skills** Two Types of Performance-Related Information (Feedback) - Task-intrinsic feedback - Sensory information that is naturally available when performing a skill. - Augmented feedback. - Performance-related information that is added to task-intrinsic feedback and comes from a source external to the person performing a skill. Why use augmented feedback? - The person may be able to detect task-intrinsic feedback but may not be able to use it due to inexperience - AF may make the available task-intrinsic feedback more meaningful The Roles of Augmented Feedback in Skill Acquisition - Facilitates achievement of the action goal of the skill. - Motivates the learner to continue striving toward a goal. \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- SOMETIMES ITS BETTER NOT TO ADD AUGMENTED FEEDBACK \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- If it's not necessary for skill learning - AF is redundant if the task provides sufficient task- intrinsic feedback / there is an external reference the person can use to determine success of their performance If it is likely to hinder or slow skill learning - Avoid dependence on AF, particularly when AF is not available in real life performance environment Augmented feedback examples ----------------------------- ----------------------------------------------------------------------------------------------------------------- Visual demonstrations, mirror, EMG biofeedback, videos (real-time, playback analysis), scales, Wii Fit, Balance Master Auditory instructions by PTs, metronome, clapping, EMG biofeedback Proprioceptive manual handling /manual guidance, taping, compressive bandage, orthoses Tactile Manual handling/manual guidance Week 3: Gait + Pathological Gait: Foot & Ankle **NORMAL GAIT & INTRODUCTION TO PATHOLOGICAL GAIT** **5.1 - Describe the functional requirements of each phase of normal gait** [The phases of the gait cycle ] STANCE 1. Initial contact (IC) -- 0-2% 2. Loading response (LR) -- (2-10%) 3. Mid-stance (MSt) -- 10-30% 4. Terminal stance (TSt) -- 30-50% 5. Pre-swing (PSw) -- 50-60% SWING 6. Initial swing (ISw) -- 60-73% 7. Mid-swing (MSw) -- 73-87% 8. Terminal swing (TSw) -- 87-100% +-----------------------------------+-----------------------------------+ | Initial contact | - Heel of leading leg makes | | | contact with the ground | | | | | | - Back leg is still in contact | | | with the ground | +===================================+===================================+ | Loading response | - Leading leg accepts body | | | weight | | | | | | - Back leg preparing to lift | | | off the ground | +-----------------------------------+-----------------------------------+ | Mid-stance | - First half of single leg | | | support | | | | | | - Leading leg begins to extend | | | at the hip | +-----------------------------------+-----------------------------------+ | Terminal stance | - Heel raise initiates second | | | half of single limb support | | | | | | - Original leading leg is now | | | in extension at the back and | | | opposite leg is now leading | +-----------------------------------+-----------------------------------+ | Pre-swing | - Body weight transferred from | | | training to lead limb | | | | | | - Unweighting enables limb to | | | prepare for swing | +-----------------------------------+-----------------------------------+ | Initial swing | - Foot lifts from ground during | | | first one-third of swing and | | | advances to opposite stance | +-----------------------------------+-----------------------------------+ | Mid-swing | - Limb advances during middle | | | one third of swing until | | | tibia achieves vertical | +-----------------------------------+-----------------------------------+ | Terminal swing | - Tibia advances during final | | | one-third of swing and limb | | | prepares for heel first | | | initial contact | +-----------------------------------+-----------------------------------+ [Tasks during stance & swing] WEIGHT ACCEPTANCE -- IC, LR - Smooth transfer of body weight to lead limb requires - Shock absorption - Stability - Forward progression SINGLE LIMB SUPPORT -- MSt, TSt - Advancing body weight over single limb requires - Stability - Forward progression SWING LIMB ADVANCEMENT -- PSw, ISw, MSw, Tsw - Preparing and advancing limb through swing - Foot clearance - Forward progression **5.2 - Describe the impairments and mechanisms that may contribute to pathological gait.** [Underlying impairments] - Abnormal Gait pattern - Muscle coordination - Pain - Sensory function - Muscle strength - ROM **Altered Range of Movement** - Excessive or insufficient joint ROM - Limits ability to achieve postures & ROM required for normal gait - Why? - Abnormal joint contours or congenital disorders - Joint laxity/instability - Reduced muscle length - Contracture - Lower limb disorders affecting ROM and altering gait such as OA, joint laxity/instability (Ligament rupture: ACL. MCL) - Contracture: structural change in fibrous connective tissue components of muscles, ligaments or joint capsule. - Can occur following prolonged inactivity or immobilisation, scarring from injury or surgery **Decrease muscle strength** - Insufficient force production of muscles to meet demands of walking - Some causes: - Disuse muscle atrophy: decrease in muscle fibre size from prolonged immobilisation or inactivity. - Eg. Quadriceps weakness post-ACL or TKR surgery - Neurological impairments: from central nervous system lesion - Eg. CVA, SCI, TBI can result in functional deficits: muscle weakness (paralysis/patesis) spasticity **Altered muscle co-ordination** - Problems with: - Selection - Timing - Sequence of muscle activity/force production **Pain** - Affects gait pattern by causing: - Restricted ROM: with pain, will assume protective posture - Eg. Calf muscle tear -- will assume a resting posture that minimises tension on tissues but will limit ROM needed for normal gait sequence - Altered muscle activity: inhibition/overactivity of muscles due to pain, reluctance to move through normal gait sequence or perform activity - can result in muscle imbalance and disuse atrophy if over a prolonged period & over activity of other muscles to compensate. **Altered sensory function** - impaired proprioception or sensory loss affects gait pattern because unable to feel exact position of limb & type of contact with floor - may substitute by: using visual system to provide information about limb position or walking or slower or walking with wider base of support **5.3 - Describe the changes in the spatial and temporal characteristics of gait that may occur with pathology.** [Spatio-temporal characteristics of gait ] - spatial = distances - temporal = times [Spatial (distance) variables] - stride length = linear distance between successive points of initial contact of the same foot - i.e right heel contact to subsequent right heel contact (144cm) - step length = linear distance between successive points of initial contact of opposite feet - i.e right heel contact to left heel contact (72cm) - foot progression angle = degree of in-turning or out-turning of the foot (10-degree toe-out) Changes in spatial characteristics - *Stride length:* tends to decrease with age, pain, disease and fatigue may decrease if step length is altered - *Step length:* may decrease on one side: due to reduced ability to weight bear on one leg or due to factors influencing ability to lengthen advancing limb - *Step width:* can be wide to provide wider base of support for increased stability eg cerebellar or vestibular disorders can be narrow (eg Parkinson's disease) [Temporal (timing) variables ] Duration - Amount of time spent, eg during stance/swing/step/stride - 1 stride \~ 1 sec; 1 step \~ 0.5 sec (500ms); - Stance \~ 0.6 sec; swing \~ 0.4 sec Cadence - The number of steps (foot falls) per minute - Typically \~ 90-120/min Gait speed - Distance covered in a given time (distance / time) - 1.1 -- 1.4 m/s - Correlated to cadence and stride length Changes in temporal characteristics - *Duration of Support Phase:* Ratio of swing to stance phase can be altered i.e. time spent on each leg changes, could have an increase in double leg support time - *Cadence:* could increase or decrease - *Walking Speed:* may be slow due to pathology **5.4 - Describe the kinematics and kinetics of stance and swing phases of walking.** [Kinematics ] - "what you see" - Motion: description of position, velocity, acceleration - Kinematics of gait: sagittal, frontal, transverse - Kinematics graphs [Kinetics ] - "what causes what we see" - Examines the forces acting on a system, such as the human body - Forces cannot be seen, but effects of forces can be observed External forces = forces outside the body - Inertia: inertial forces due to acceleration of body segment (eg. Swinging leg) - Gravity: weight of the body segment (eg. Weight of the foot) - Ground reaction force: forces acting between the foot & ground (eg. surface) Internal forces = forces outside the body - Muscle forces: the muscle activity required is often to brake or control the motion of the body parts as well as generate movement - Ligaments/other soft tissue forces: tension generated in stretched tissue such as ligaments, joint capsule **5.5 - Describe the various methods of measuring gait.** **5.6 - Apply a structured approach for the identification of deviations during the gait cycle.** [Visual Gait Analysis] - Need a structured approach - Identify deviations in sagittal, frontal and transverse planes - at each joint (ankle, knee, hip & pelvis) during stance & - swing phase - Ask patient to walk in usual manner (+/- aids) - General observations eg. obvious limp or deformity - Observe from side, front & behind - Observe proximal to distal & distal to proximal - Don't forget about trunk & upper limbs **5.7 - Use a systematic approach to observe the characteristics of normal gait and for the identification of impairments and their effect on the gait cycle** **5.8 - Identify appropriate outcome measures that may be used in gait rehabilitation.** - Timed 10m Walk - measure of gait velocity, cadence & stride length - Timed Up & Go (TUG) - measure of functional mobility, postural control, balance & gait speed - Dynamic Gait Index - for use with people with vestibular dysfunction - Modified Elderly Mobility Scale (MEMS) - for use with elderly subjects with mobility problems - High level Mobility Assessment Tool (HiMAT) - to assess high level tasks in adults with brain injury - Lower Extremity Functional Scale - measure of function if have a lower limb problem ability to walk/run measured in some items - Patient Specific Functional Scale - measure of functional outcome for people with any orthopaedic condition - can be used if walking or mobility is specified as an activity that is a problem for the patient **PATHOLOGICAL GAIT: ANKLE & FOOT** [Identifying deviations from normal ] **PRIMARY DEVIATION** - Sagittal plane - Inadequate dorsiflexion (excessive planter flexion) - Inadequate planter flexion (excessive dorsiflexion) - Inadequate MTP extension - Coronal plane - Excessive eversion - Excessive inversion SAGITTAL: INADEQUATE DF/EXCESSIVE PF Possible underlying impairments - Muscle coordination - Pain -- heel pain + ankle joint - Sensory function -- ankle proprioception - Range of movement -- TCJ stiffness, Tightness/overactivity, posterior tibial muscles - Muscle strength -- pre-tibial muscles (tibialis anterior) Impact of deviation - Results in more forefoot contact & altered loading of foot (forefoot instead of heel) - Disrupt tibial advancement - Will result in poor foot clearance, impaired limb advancement & compromised preparation of foot for contact Secondary deviation +-----------------------------------+-----------------------------------+ | Initial contact foot flat | A. Forefoot contact suistained | | | throughout -- knee will | | | remain more flexed | | | | | | B. Flexible ankle -- knee will | | | be more flexed at contact | | | then extend as heel drops | | | rapidly | | | | | | C. Rigid ankle -- to get heel to | | | the ground knee will | | | hyperextend | +===================================+===================================+ | Mid-stance | - Toe-in: often internal | | | rotation of entire limb. | | | Associated knee deviation | | | frontal plane | | | | | | - Toe-out: often excessive | | | external rotation of entire | | | limb | | | | | | - Premature heel lift "bouncy | | | gait" | | | | | | - Knee hyperextension | | | | | | - Forward trunk lean & anterior | | | pelvic tilt | | | | | | - Excessive pronation: | | | internally rotated tibia, | | | squinting patella, internally | | | rotated femur, increased hip | | | adduction | +-----------------------------------+-----------------------------------+ | Swing | - Will result in poor foot | | | clearance, impaired limb | | | advancement & compromised | | | preparation of foot for | | | contact | | | | | | - Compensate by increased hip | | | and/or knee flexion | +-----------------------------------+-----------------------------------+ SAGITTAL: EXCESSIVE DF/INADEQUATE PF Possible underlying impairments - Muscle coordination -- Calf muscles - Pain -- ankle joint - Sensory function -- ankle proprioception - Range of movement -- TCJ stiffness, Tightness/overactivity, posterior tibial muscles - Muscle strength -- calf muscle weakness Impact of deviation - Will result in exaggerated heel rocker response - Will disrupt controlled tibial advancement - Shortens the limb affecting pelvic support/stability Secondary deviations +-----------------------------------+-----------------------------------+ | Initial contact foot flat | - Accentuates heel rocker | | | | | | - Leads to greater knee flexion | | | | | | - Increase quadriceps demand | +===================================+===================================+ | Mid-stance | - Lack of tibia control results | | | in greater knee flexion | | | | | | - Unstable base for quadriceps | | | increased demand | +-----------------------------------+-----------------------------------+ | Terminal stance | - Prolonged heel contact -- | | | body will be well forward of | | | foot but heel on ground | | | | | | - Shortens limb & reduces | | | support to pelvis -- | | | excessive ipsilateral pelvic | | | drop | +-----------------------------------+-----------------------------------+ FRONTAL: EXCESSIVE EVERSION Possible underlying impairments - Muscle coordination -- invertors (TP, TA) Hip ERs, ABDs - Pain - Sensory function -- leg length discrepancy - Range of movement -- TCJ stiffness (i.e. compensation to gain DF ROM, Tight/overactive peroneals, skeletal alignment) - Muscle strength -- Invertors (TP, TA) Hip ERs, ABDs Impact of deviation - Foot placement compromised for initial contact. Increased rotary stress in ankle mortise - Increase rotary stress in ankle mortise & lower limb - Loss of rigid lever for heel off and forward progression Secondary deviations +-----------------------------------+-----------------------------------+ | Initial contact -- Loading | - Subtalar joint rapidly everts | | response | as weight is loaded onto limb | | | | | | - Coupled to internal rotation | | | of tibia which may in turn | | | affect femoral position | | | | | | - Excessive tibial & femoral | | | internal rotation (squinting | | | patella) | +===================================+===================================+ | Mid-stance | - Coupled to internal rotation | | | of tibia which may in turn | | | affect femoral position | | | | | | - Excessive tibial & femoral | | | internal rotation (squinting | | | patella) | +-----------------------------------+-----------------------------------+ | Terminal stance | - Disrupted heel rise | | | | | | - Possibly increased hip & knee | | | flexion due to inefficient | | | push-off | +-----------------------------------+-----------------------------------+ FRONTAL: EXCESSIVE INVERSION Possible underlying impairments - Muscle coordination -- Peroneal muscles - Pain -- 1^st^ ray/arch - Sensory function -- ankle proprioception - Range of movement -- skeletal alignment (structural), tight/overactive invertors - Muscle strength -- peroneal weakness Impact of deviation - Rigid midfoot impairs shock absorbing capacity - Rigid midfoot impairs shock absorbing capacity. Weight towards lateral side of foot provides unstablr BOS - Difficulty with foot clearance as lateral side of foot drops Secondary deviations +-----------------------------------+-----------------------------------+ | Initial contact -- Loading | - Increased knee & hip flexion | | response | to provide shock absorption | | | that is lacking at foot & | | | ankle | +===================================+===================================+ | Mid-stance | - Possibly increased knee & hip | | | flexion to provide shock | | | absorption | | | | | | - Increased lateral shift of | | | pelvis and trunk | | | | | | - Possible varus thrust | +-----------------------------------+-----------------------------------+ | Swing | - Increased hip and knee | | | flexion to improve foot | | | clearance | +-----------------------------------+-----------------------------------+ FRONTAL: LIMITED TOE EXTENSION Possible underlying impairments - Muscle coordination - Pain -- 1^st^ ray/arch/ metatarsal/forefoot - Sensory function -- plantar surface - Range of movement -- tight/overactive flexors, hallux rigidis, OA - Muscle strength -- Impact of deviation - Interferes with forefoot and toe rockers Secondary deviations +-----------------------------------+-----------------------------------+ | Terminal stance / Initial contact | - Foot displaced into varus | | | | | | | | | | | | - May be associated with roll | | | off & frontal plane knee | | | movement | | | | | | | | | | | | - Early toe-off (lacks | | | plantarflexed position) | | | | | | - Impaired push-off & forward | | | progression of body results | | | in reduced contralateral step | | | length | +-----------------------------------+-----------------------------------+ [Assessment + Management ] +--------+--------+--------+--------+--------+--------+--------+--------+ | Talocr | Tight/ | Skelet | Weak | Weak | Contro | Contro | Leg | | ural | overac | al | invert | hip | l | l | length | | Joint | tive | alignm | ors | extern | of | of Hip | discre | | -- | perone | ent | | al | invert | extern | pancy | | Stiffn | al | (struc | | rotato | ors | al | | | ess/ | muscle | tural) | | rs/ | | rotato | | | Limita | s | | | abduct | | rs | | | tion | | | | ors | | / | | | | | | | | | abduct | | | | | | | | | ors | | +========+========+========+========+========+========+========+========+ | ASSESS | | | | | | | | | MENT | | | | | | | | +--------+--------+--------+--------+--------+--------+--------+--------+ | - Ac | - Pa | - Ob | - Ma | - Ma | - Pa | - Pa | - Le | | tive | lpatio | servat | nual | nual | lpatio | lpatio | g | | jo | n | ion | mu | mu | n | n | le | | int | | -- | scle | scle | | | ngth | | RO | - Ob | FP | te | te | - Ab | - Re | me | | M | servat | I | st | st | ility | cruitm | asure | | TC | ion | | (T | (H | to | ent | -- | | J | | - Te | ibiali | ip | li | pa | AS | | do | - Ac | sts | s | ER | ft | ttern | IS | | rsifle | tive | of | po | , | & | (o | to | | xion | jo | fo | sterio | Gl | ma | rder | ma | | WB | int | ot | r | ut | intain | of | lleolu | | or | RO | mo | an | me | ar | mu | s | | NW | M | bility | d | d + | ch | scle | | | B? | in | & | ti | mi | | ac | - X- | | | versio | fo | bialis | n, | - In | tivati | ray | | - Pa | n | ot | an | TF | trinsi | on) | | | ssive | | lo | terior | L) | c | | | | ph | - Pa | ading | ) | | fo | | | | ysiolo | ssive | (N | | - Dy | ot | | | | gical | ph | WB | - Dy | namome | mu | | | | jo | ysiolo | WB | namome | try | scle | | | | int | gical | ) | try | | te | | | | RO | jo | | | | st | | | | M | int | - Pa | | | | | | | ta | RO | ssive | | | | | | | locrur | M | ac | | | | | | | al | in | cessor | | | | | | | do | versio | y | | | | | | | rsifle | n | jo | | | | | | | xion | | int | | | | | | | | | gl | | | | | | | - Pa | | ides | | | | | | | ssive | | (s | | | | | | | ac | | ubtala | | | | | | | cessor | | r, | | | | | | | y | | mi | | | | | | | gl | | dfoot, | | | | | | | ide: | | fo | | | | | | | AP | | refoot | | | | | | | ta | | ) | | | | | | | lus | | | | | | | | | | | | | | | | | | - Ca | | | | | | | | | lf | | | | | | | | | mu | | | | | | | | | scle | | | | | | | | | le | | | | | | | | | ngth | | | | | | | | | te | | | | | | | | | st | | | | | | | | | ga | | | | | | | | | stric | | | | | | | | | or | | | | | | | | | so | | | | | | | | | leus | | | | | | | | | (b | | | | | | | | | oth?) | | | | | | | | +--------+--------+--------+--------+--------+--------+--------+--------+ | MANAGE | | | | | | | | | MENT | | | | | | | | +--------+--------+--------+--------+--------+--------+--------+--------+ | \- | - So | - Ex | - Re | - Re | - Fo | - Ex | - He | | Passiv | ft | ternal | sistan | sistan | ot | ercise | el | | e | ti | de | ce | ce | fo | s | in | | access | ssue | vices | ex | ex | rm | wi | serts | | ory | ma | (t | ercise | ercise | ex | th | | | mobili | ssage | aping, | s