If consistency and efficiency is the end result of skilled movement the methods for getting there are numerous. However, for clarity the approaches that we can use generally fall into two categories:
· Behavioural approaches
· Cognitive approaches
The approach you use to improve motor learning with your patients will vary depending upon the context, the patient and your skills as a mentor or coach of motor learning.
Behaviour approaches :
This is essentially repetition of movement practice until the movement is perfect! This approach is often associated with a patient responding to a stimulus and developing a learned behaviour. For example, this might be a learned behaviour in that every time I slouch when sitting my back hurts … when I sit up straight my back feels better (less pain). This type of behavioural approach assumes that the response "in this case sitting up straight" will become a habit as a consequence of the number of times it is associated with the given stimulus.
So in clinical practice this is often the default approach that most therapists use to re-educate movement. This approache focuses on extensive repetition of a specific task or skill with us ( the therapist ) providing the patient with feedback on the success of each repetition and their overall performance. It is heavily dependent upon the therapist providing feedback on each and every repetition. So our positive feedback reinforces success and our negative feedback promotes correction of the next attempt.
Is it useful ?
Well, behavioural approaches have a place and are very good at getting rapid gains in motor performance in the short term. However, they may be less effective in longer term learning and the retention of motor skills. The improved gains in short term learning are often very large! But this is only in controlled, discrete, low stress, simple and closed activities. It does not appear to develop higher order cognitive skills that allow patients to understand and shape their own performance in complex situations.
However , it can be very good for learning basic movement skills in predictable closed situations. e.g isolated joint movements
Cognitive approaches:
Cognitive approaches are exactly what it says on the tin! They are concerned with the patient actively trying to solve movement problems with an active mind, fully engaged in the process of self-discovery. This approach is feedback light from the therapist , in that the therapist sets a task to be performed and provides very little instruction or feedback on how to achieve the task.
It is based upon the theory that movement skills will emerge through practice and a process of self-organisation. This idea of self-organisation is an important concept because each time the patient attempts the task and gets it wrong, learning takes place ! The patient learns how to control a particular variable that is affecting their performance and refines the task. These variables are called degrees of freedom and the more challenging and complex the activity the more degrees of freedom need to be controlled. For example during a hop and stick task the patient needs to control jump height, jump distance, speed/velocity of the jump, hip, knee and ankle range of motion, consider the floors compliance at take off with two feet and its compliance on landing with one leg not to mention the change in base of support from two to one leg !
For another example, imagine you are retraining a patients ability to climb a ladder while holding a bucket of water after a total knee replacement, there are several degrees of freedom in relation to the patients musculoskeletal system. This broadly includes the environment, the patients physical impairments and the task which provide a challenge to consistent and energy efficient performance.
In a cognitive approach to motor learning the therapists role is reduced somewhat and the emphasis is placed on the patient self-organising to effectively find a movement solution to the problem of too many degrees of freedom. Clinically, what tends to happen is the patient will reduce the degrees of freedom to comlete the task. So in this example the patient may change the task by stepping with both feet on each step rather than using every other step.
This method of motor relearning and skill acquisition tends to favour a long term approach to learning becuase the patient is encouraged to find novel solutions to the problem of movement. This is great for the development of motor skills in unpredictable situations ….
Sounds a little like life really!
So this is a good time to stop and to reflect on the two different approaches that can be used in clinical practice to improve a patients motor learning . Which one do you use , do you even think about what you use on a day to day basis , should you ? Do you ever consider the classification of the skill and therefore whether a behaviour or a cognitive approach will work best for your particular patient … I hope it provides some food for thought !
Further reading
Handford, C., Davids, K., Bennett, S., & Button, C. (1997). Skill acquisition in sport: Some applications of an evolving practice ecology. Journal of Sports Sciences, 15(6), 621–640. https://doi.org/10.1080/026404197367056
Newell, K. M. (1991). Motor skill acquisition. Annual Review of Psychology, 42, 213–237. https://doi.org/10.1146/annurev.ps.42.020191.001241
Ste-Marie, D. M., Clark, S. E., Findlay, L. C., & Latimer, A. E. (2004). High levels of contextual interference enhance handwriting skill acquisition. Journal of Motor Behavior, 36(1), 115–126. https://doi.org/10.3200/JMBR.36.1.115-126
Wulf, G., Shea, C., & Lewthwaite, R. (2010). Motor skill learning and performance: A review of influential factors. Medical Education, 44(1), 75–84. https://doi.org/10.1111/j.1365-2923.2009.03421.x
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