1. Distinction btwn Motor Learning & Motor Performance
   1. Motor Learning:
      1. Is an internal process associated with practice or experiences that result in a relatively permanent change in a person's ability to perform a motor skill
      2. – Is indirectly assessed through observation of motor behavior because it is an internal process – indirectly evaluated by measuring change in a patient's performance of a motor task
   2. Temporary Factors:
      1. – IE: motivation, physical or verbal guidance, fatigue, stress, & boredom during long therapy sessions – to measure motor learning, the effects of temporary factors of performance should be minimized – common method used to reduce temporary effects of variables on performance = allow a rest interval between the practice & evaluation session – separating the effects of temporary & permanent factors on performance is critical for documentation – evaluating & documenting the patient's performance of a practice skill at the onset of a subsequent therapy session and will more accurately reflect the long-term impact of our interventions
   3. Retention & Transfer tests are used for measures of learning
      1. Retention Test
         1. Is the evaluation in the same environment used during a practice/therapy session IE practicing ambulation on tiled floor
         2. Measure how well performers learn practiced tasks
      2. Transfer Test
         1. Is the evaluation in a different environment than that use during a practice session i.e. originally practiced ambulation on tile floor but now practicing on grass
         2. Measure how well performers generalize learning to perform the task on practiced in a different environment
2. Overview of Processes of Motor Learning
   1. – Involves developing strategies to cope with the complexities of performing a specific task under specific environmental conditions – learner must be able to solve motor problems (i.e. process information & engage in sensory encoding & memory retrieval processes) & respond to changes in the task & the environment – to optimize learning = provide patients with practice conditions that encourage/possibly force them to engage in problem-solving processes – is that of providing patients with solutions to motor problems, PT should act as educators & guide patients through learning processes that allow the patient to actively explore & discover solutions to motor problems
   2. Summary of Processes of Motor Learning Box 14-1 p. 232
      1. – Learners remember processes, not specific movement patterns – Relative to guidance, problem-solving enhances learning – The 3 sequential stages of learning are: Cognitive, Associated, & Autonomist – Automaticity develops by learning to focus on a critical subset of perceptual cues & motor strategies & by reorganizing information in units (chunking) – The capability to detect everything correct errors enhances learning. Error detection & correction occur online or during, slow, positioning movements. They occur after the movement in fast, timing tasks – Sensory & motor memories are thought to be stored in memory – Which are evil practice enhances learning more than repetitive drills – Is that of focusing on individual elements of a functional task, performer should focus on the goal of a task – With practice, actions become more efficient when performers learn to exploit the biomechanics of a task – Categorizing tasks based on task goals & environmental context & learner characteristics can enhance understanding of task requirements
3. Motor Learning Theories
   1. Popular Theories that attempt to explain Motor Learning
      1. 1. Adams' Closed-Loop Theory 2. Schmidt's Schema Theory 3. Newell's Ecological Theory
   2. Clinical applications:
      1. Schmidt's Schema Theory
         1. May consist of practicing a task under variety of conditions to assist learners in developing a set of rules/schema related to the specific task
      2. Newell's Ecological Theory
         1. Would suggest that the practicing a task under variable conditions will assist learners in understanding the relationship between perceptual cues & motor action (i.e. the glass looks heavy & therefore will require more force to lift)
4. Stages of Learning
   1. Fitts & Posner Motor Learning Stages:
      1. Cognitive Stage
         1. – Learner focuses on understanding the task, developing strategies to execute the task & determining ways to evaluate task success – Performance = inaccuracies, slowness & movements that appear stiff & uncoordinated – characterized by rapid improving & variable performance, it is thought to require a high degree of attention & other cognitive processes
         2. Facilitation:
            1. – PT can facilitate patient understanding of task & organize practice in ways that will specifically encourage early learning – emphasizing purpose of activity within a context that is functionally relevant to the individual patient may help patient better understand the task – structuring the environment to reduce distractions may help the learner to better attend to learning – clear, concise instruction should be provided in a manner that doesn't overwhelm the learner – demonstration & hands-on guidance as needed – use the feedback & practice schedules to promote learning
      2. Associative Stage
         1. – Goal = to fine-tune a skill – focus = on how to produce the most efficient action – characterized by slower gains in performance & reduced variability – represented in PT when patients practice a skill to increase the safety or efficiency of a task – the patient needs practice to enhance performance of the skill
         2. Facilitation:
            1. – PT can reduce the amount of hands-on guiding or assistance provided to the patient – the environment should be structured to gradually promote variation in practice conditions & demands
      3. Autonomous Stage
         1. – Performance = requires very little attention & information processing – in PT = autonomous stage is often achieved over the course of an episode of care when a patient progresses from ambulating with an assistive device, to ambulating independently and select close environments, to ambulating independently in a community setting under dual task demands
5. Error Detection
   1. Error detection capabilities are thought to require memory of sensory feedback from previously performed actions & are used differently for slow-positioning & fast-timing tasks
      1. Slow-Positioning Tasks:
         1. – Sensory feedback is used to guide the action to its end point – Learners move until feedback from the present action matches the memory of sensory feedback for the desired action
      2. Fast-Timing Tasks:
         1. – Learners are unable to use sensory feedback to alter an action online, or during an action – sensory feedback is used to detect errors after the action has ended
6. Motor Memories
   1. 3 Distinct Memory Systems:
      1. Short-term Sensory Store (STSS)
         1. – Numerous segments or streams of sensory info entering the system are briefly stored by sensory modality (i.e. visual, tactile, kinesthetic) – information here is not thought to reach a conscious level & is only retained for a matter of milliseconds – selected information from STSS (based on releavance & pertinence of info)is selected for further processing and STM
      2. Short-term Memory
         1. – a temporary workspace & may terminate as a form of working memory – people hold onto info ub STM for only as long as they direct their attention to the information
      3. Long-term Memory
         1. Stores info & experiences accumulated over a lifetime
         2. 2 Basic Forms:
            1. Declarative (explicit) Learning
            2. – Associated with knowledge that can be consciously recalled & stated, such as fax & events – requires attention, awareness & reflection
            3. Nondeclarative (Implicit) Learning
            4. – Memories that are less assessable to conscious recollection & verbal recall – i.e. several forms = exemplified by fairly passive learning processes in which learners acquire knowledge through exposure to information
            5. 3 Forms of Learning:
            6. Nonassociative
            7. – Occurs when individuals are repeatedly exposed to a single stimulus – simple forms = habituation & sensitization
            8. Associative
            9. – Patient learns to predict relationship such as the relationship of one stimulus to another (classical conditioning) or the relationship of a behavior to a consequence (operant conditioning)
            10. Classical Conditioning
            11. –- i.e. associated verbal cue & physical prompt when patient transfers, over time patient will begin to associate verbal & physical cueing & begin to perform transfer w/ verbal cues only
            12. Operant Conditioning
            13. – The patient may learn that behaviors leading to rewards should be repeated & behaviors that have negative results should be avoided
            14. Procedural
            15. – Relates to learning tasks through intense practice to the point at which the task can be performed without conscious thought or active attention
7. Focusing on Actions, not Movements
   1. The principle suggests that patient should practice tasks/actions, not individual movements – i.e. practice riding a bike versus enhancing enter limb coordination between legs
8. Learning to Exploit Biomechanics
   1. – Increased consistency in kinematics & coordination also occurs with practice – learners are taught to discover ways to take advantage of the passive inertia properties of muscles/joints/limbs – PT's must be able to help patients exploit biomechanics to achieve a goal
9. Variables that Influence Skill Learning
   1. Factors that Influence the selection of teaching strategies in motor learning:
   2. Gentile's Task Taxonomy
      1. The Task:
         1. Task Attributes:
            1. 1. Discrete task: w/discernible beginning & endpoint 2. Continuous Task: w/a variable endpoint 3. Whether BOS is Stationary or Changing
      2. – When analyzing movement tasks, PT's must also consider biomechanical factors of the specific muscle groups & muscle actions involved in an activity; ROM requirements for the movement; & coordination, power & speed demands of the task – the sensory, motor and was in cognitive demands of a task are dependent on task goals & on environmental & performer context – PTs can use the taxonomy to identify the degree of difficulty associated with the movement task & to progress the complexity of a task by altering its taxonomy
      3. Categorizing Gentile's Taxonomy allows PTs to:
         1. 1. Understand the processes required for different activities & goals 2. To evaluate the types of tasks likely to be less challenging & those more likely to be difficult for an individual patient 3. Design an effective exercise program based on an individual's needs & the tasks he/she would like to perform 4. Educate patients & families on the types of tasks that are safe & unsafe for patients to perform
      4. Terms:
         1. 1. No Inter-trial variability – environment remains constant from trial to trial 2. Inter-trial variability – the environment changes from trial to trial 3. Closed tasks – tasks with little or no variation that are performed in a stable environment; require consistent patterns of movement everything can be done automatically 4. Open tasks – tasks that vary with each repetition, or that are performed in a changing environment; require attention & a relatively high amount of information processing 5. Body stability – person focuses on maintaining a posture 6. Body transport – person focuses on transporting himself/herself to another location 7. No manipulation – person focuses on one task (holding a posture, transporting to another location) 8. Manipulation – person is required to perform 2 tasks simultaneously (holding a posture & manipulating an object, or transporting to another location while manipulating an object)
   3. Prepractice Variables
      1. Include:
         1. – Motivation – Goal setting
   4. Practice Variables
      1. Intensity of Practice
         1. – The rate of improvement at any point during practice is related to the amount of improvement left to achieve; thus learners in the early stages of practice would be expected to experience more rapid improvement the learners who had already undergone a large amount of practice – The sheer number of practice trials performed during these intensive therapy programs (ie CIT) is thought to accelerate the learning process & result in rapid improvements in performance
      2. Massed vs Distributed Practice
         1. Massed Practice Schedule
            1. def: the amount of actual practice time is much greater than the amount of rest time between practice trials –Practice > Rest btwn trials
            2. Benefit:
            3. For patients who have sufficient stamina, attention & concentration
            4. Disadvantages:
            5. – Concerned with mental & physical fatigue – when practicing continuous tasks, massed practice may decrease performance but the real issue may be related to the impact of fatigue on the patient safety
         2. Distributed Practice Schedule
            1. def: the amount of time allowed for rest is equal to or even greater than the amount of time spent practicing – Rest = Practice or Rest > Practice
            2. Benefit:
            3. – For patients with short attention spans or poor concentration abilities – for highly complex tasks, tasks that are very energy consuming, & tasks that require a large amount of time to complete
      3. Constant Practice & Variable Practice
         1. Variable Practice
            1. Variable Conditions:
            2. – Learner practice different versions of the same task with in the same practice session & thus develop competence in creating parameters for various dimensions of the motor action required to perform a task
            3. Variable Speeds:
            4. Benefit:
            5. Valuable when learning is focused on a task that will be performed under a variety of conditions
         2. Constant Practice
            1. Practice sessions that are focused on one version of a single task
            2. Benefit:
            3. For skills that aim at exactly replicating a task each and every time
      4. Contextual Interference
         1. Contextual Interference
            1. Refers to intertrial inconsistency that is generated by practice order
         2. Blocked Practice
            1. Where several trials of 1 task are practice before initiating practice of a second task
            2. Low contextual interference
            3. Repeated rehearsing the same task in block practice = improve motor performance
         3. Random Practice
            1. Where patient practices different tasks on consecutive trials
            2. High contextual interference
            3. Actual motor learning of a skill (LT skill retention & transfer) = facilitated by random practice – most effective when the sequence of skills being practiced involve different patterns of coordination & movement
            4. May not be beneficial in the early stages of learning & should not be undertaken until the learner exhibits an understanding of the characteristics of the task to be learned
      5. Part- and Whole-Task Practice
         1. Part-Task Practice
            1. – Most beneficial to learning tasks that involve a serial skill – are acting to a series of discrete skills and that one part of the task is not affected by the actions of the next part of the task – i.e. wheelchair transfer: viewed as a serial skill in which locking the brakes is one discrete component of the overall task – when the task to be learned involves information, part task practice may also prove to be beneficial
         2. Whole-Task Practice
            1. – With the task is to be learned in a continuous task or requires timing between segments – ie: include wheelchair wheelies & momentum transfers
      6. Mental Practice
         1. – Learner mentally rehearse is a task with the intent of enhancing motor learning – learner focuses on cognitive processes such as seeing & feeling themselves performing the skill – it activates the same neural structures as physical practice of the same skills – patients who are familiar with the motor task to be learned generally will experience greater benefit from the mental practice than patients who are not familiar with the task
      7. Use of Guidance Techniques
         1. Guidance should be withdrawn as soon as possible to help promote long-term learning & retention
      8. Use of Feedback
         1. 2 Subclasses:
            1. Intrinsic Feedback
            2. Comes from various sensory systems as a result of the production of the movement
            3. Extrinsic/Augmented Feedback
            4. Acts as a supplement to intrinsic feedback & is provided to the learner by an outside source (PT, stopwatch)
            5. Ways to be Given:
            6. Concurrent Feedback
            7. Terminal Feedback
            8. Classified As:
            9. Knowledge of Results (KR)
            10. Terminal feedback about the outcome of a movement as related to the goal of the movement
            11. Knowledge of Performance (KP)
            12. – Related to the kinematics or quality of the movement pattern used to achieve the goal – provide learner with information related to the essential components of the movement patterns
      9. Video Feedback
         1. – A split screen or display of the learner only = effective videotape feedback that is been found to relate to both the learner's skill level & use of verbal cues – even at their physicians typically occur on the early stages of skill learning, videotape replay may be an effective method for learning – PT should focus patient attention on critical aspects of the videotape
      10. Motivation & Reinforcement
          1. Positive Reinforcement
             1. – Increases the likelihood that a learner will repeat the performance on subsequent trials – is thought to generate greater improvement in learning the negative reinforcement or punishment
          2. Negative Reinforcement
             1. When an aversive condition/stimulus is removed following performance, thus increasing the chances that the action will be repeated
          3. Punishment
             1. Decreases the likelihood that a response will be repeated
      11. Frequency & Timing of Feedback
          1. PTshould consider ways of providing feedback that discourage patients from becoming dependent on the feedback such as:
             1. – Allowing learners time to think about an action before feedback is provided *delayed extrinsic feedback allows the learner time to process the intrinsic be back created by the execution of a task – asking learners to estimate their own errors before feedback is provided – withholding feedback on some practice trials (especially near the end of practice) – providing feedback on a reduced or faded schedule (ie slowly removing the visual feedback of a mirror)
      12. Focus of Attention
          1. – Providing and external focus of attention using feedback directed at the effects of movement (" Hit the ball as if using a whip") was more effective than feedback that provided an internal focus of attention directed at the movement itself ("Snap your wrist when hitting the ball") –another ex: "Think about the size & shape of the mug) when working on reaching tasks – clinically: when working on weight shifting ask patient to reach for strategically placed objects rather than to focus on the weight shift itself – using gait training strategies: instruct patient to imagine kicking a ball during terminal swing = more effective in improving heel strike than simply asking the patient to "Hit the ground w/your heel" – placing lines on the floor & asking patient to "Step over the line" – these techniques help patients to focus on the effects of movement & perhaps may function in ways that permit more unconscious control processes to emerge
10. A Framework for Motor Learning
    1. The Challenge Point Framework by Guagagnooli & Lee
       1. –Is a theoretical framework that helps to conceptualize the optimal challenge point for motor learning by considering characteristics of the learner, the task to be learned, & the condition of practice – under this framework, learning is related to the amount of information available to the learner compared with the amount of information viewed as a challenge to the learner
       2. The difficulty of the task to be learned is said to relate to both the nominal & functional factors
          1. Nominal Task
             1. Difficulty reflects the perceptual & motor requirements of the task & is constant regardless of who is performing the task
          2. Functional Task
             1. Refers to how challenging the task is relative to the skill level of the person attempting the task & the conditions under which the task is being performed