Essential Points:

• Pre-practice strategies enhance learning: Clear, simple instructions and connecting tasks to a patient’s personal life increase motivation and understanding, laying the foundation for effective motor learning.

• Practice order and mental imagery matter: Using part vs. whole practice, adjusting practice order (blocked vs. random), and incorporating mental practice can significantly boost learning speed and adaptability.

• Feedback is key, but less is more: Intrinsic feedback promotes self-correction, while extrinsic feedback should decrease over time to encourage independence. Tailoring feedback schedules ensures better long-term retention and mastery.

In last week’s article, I introduced some basic motor learning principles including the three types of motor tasks, Gentile’s Taxonomy, and the stages of motor learning. If you missed that article, I highly suggest you read that first here. This week I want to add on to these concepts and discuss some basic strategies to enhance a patient’s learning experience. These strategies will include pre-practice factors, types of motor practice, and types of feedback. By understanding and utilizing the concepts discussed in both articles, a practitioner will increase a patient’s likelihood of fully learning and mastering new motor skills.

Pre-practice Factors

Although many of us never consider the pre-practice factors as an important part of the learning process, they give the foundation for future practical learning. Two important aspects of this pre-practice time is proper instruction of the task to be accomplished, and connecting the task to a patient’s life so that learning the task becomes a meaningful endeavor for them.

Instruction of the Task

The act of giving simple and succinct instructions with defined goals is often breezed over. Instructions should be given in a clear and concise manner with simple language. Expert jargon is never warranted at this stage unless there is no other way to describe the motor task. When simple and succinct instructions are given, less brain processing power is needed to problem solve and understand task components. Consequently, more attention can be given to completing the task itself and learning the new motor pattern. Explicit and simple instructions can additionally be enhanced with a successful demonstration of the task. After instructions are given, the practitioner should always ask the patient if they have any clarifying questions.

Meaningfulness of the Task

When a task relates to a patient’s life, they inherently find more meaning in the act of learning how to perform the task, and as a result learn more efficiently. As practitioners, too often we look at this meaning from a logical standpoint. Telling a patient that learning a task can help them walk again may not be enough to create meaning in the task. We should appeal to a patient’s emotions for this deep and innate meaningfulness instead. For instance, if we frame a task as a steppingstone to dancing with their daughter at their wedding, we can attach the meaning of a small motor task to that of a larger and more meaningful event in the future. Thus the larger goal is dancing at the wedding, but to do that, smaller motor tasks such as standing, stepping, and walking must be achieved first. With meaning comes motivation and perseverance despite the struggles of learning.

Practice Factors

Once a patient understands and has bought into the reasoning of a new motor skill, it is time to begin practice of that skill. Although simply practicing a task over and over can lead to effective learning, we can enhance this process by understanding the concepts of part versus whole practice, practice order, and physical versus mental practice. When these concepts are skillfully integrated into the practice structure for a client, the rate of motor learning can be greatly improved.

Part Versus Whole Practice

Part versus whole practice simply means working on a skill one segment at a time or in its entirety. Part practice is best for skills during the early stages of learning, especially when learning complex serial tasks that require high cognitive demand. The patient’s cognitive status will dictate how many chunks to break a full task into for appropriate training to occur. Lower cognitive ability may warrant training many smaller parts with a slow build into the whole task.

Whole Practice is especially useful during continuous tasks, discrete tasks that cannot easily be broken down into parts, and when beginning to piece part practice together for a whole skill. Additionally, if a motor tasks requires key timing or rhythm whole practice is preferred over part practice.

Practice Order

Practice order is a key piece in the motor learning equation. When I say practice order, what I mean is blocked-order practice, random-order practice, or random/blocked-order practice. These three types of practice structures can be used to create varying cognitive demands while learning a skill in addition to the current demand of the task itself.

Blocked practice means doing the same skill with no variation repeatedly. This type of practice is best in the cognitive stages of learning. By performing blocked practice initially, a high volume of single skill practice is done leading to rapid motor learning gains. This type of practice order is also beneficial in those with low cognitive ability.

Once the initial motor gains are made, it is imperative to transition the practice order to random-order or random/blocked-order practice to maintain the speed of learning. Introducing random order practice means that the task demands change slightly from trial to trial resulting in a more adaptable motor skill for the patient. Such randomness could include varying weights, heights, surfaces, and environments. In the initial stages of random-order practice, only one or two variables should be changed from each trial. Once a patient transitions into the late associative stage of learning, multiple variables may be changed in each trial to continue enhancing a patient’s adaptability. Overall, random-order practice improves the real-world ability of patient in terms of the specific motor skill being practiced.

Random/blocked-order practice is a fusion of the two previous practice orders. In this scenario, the patient undergoes a series of varying trial conditions, but each trial condition can be performed at a minimum of two times. This form of practice-order allows mistakes to be made and corrected in one trial condition before a variable is changed. A patient will have higher retention and learning rates when using this form of practice order in contrast to blocked-order or random-order alone.

Physical Versus Mental Practice

Although it is obvious that physically practicing a motor skill is superior to mental practice, mentally performing a skill has been found to enhance motor skill learning and retention. Mental practice is especially helpful for retention of motor skills when a patient is injured, or physically exhausted and unable to perform a task. By mentally performing a motor skill in as much detail as possible, the same brain pathways that are used while physically performing the skill are activated. Consequently, these pathways are strengthened and refined leading to higher levels of motor learning.

When I think of mental imagery, I always think about Michael Phelps and his gold medal win in 2008 wherein his goggles malfunctioned and lead to him essentially racing blind. Fortunately, Phelps rehearsed this exact scenario in his mind, so he already knew what to do physically. You can read about that event here.

Feedback

To learn properly, patients need some form of feedback to gauge the success of their movement attempts. Feedback is sensory information of any kind which is received and processed by the learner giving them information about the task being performed. This feedback has many facets including intrinsic feedback, extrinsic (augmented) feedback, knowledge of performance, knowledge of results, and feedback scheduling. Just like the other factors already covered, when used appropriately feedback can enhance the quality and value of a patient’s learning time.

Intrinsic Feedback

Intrinsic feedback is feedback that comes from within the person themselves and their own sensory system. This type of feedback naturally comes during or after a motor task is performed. It is continually occurring throughout our day in order to help us refine our movements to meet various goals. Once a patient understands how to perform a movement, this is the most beneficial form of feedback as it creates a sense of self-efficacy and confidence in ones own ability to correct errors.

Extrinsic Feedback

Extrinsic feedback is also known as augmented feedback. This type of feedback is used as supplemental information to intrinsic feedback and is given by the practitioner to the patient. Extrinsic feedback may be given in a verbal, tactile, or auditory manner. Additionally, technology such as ultrasound, EMG devices, and replaying videotapes fall under this category of feedback. These types of cues can be classified as any type of feedback that is used in addition to performing the motor task itself.

Knowledge of Performance

Knowledge of performance is feedback that gives information about the actual performance and quality of the movement task. This feedback can be given during or after the task itself. Such an example would be telling a patient that they are angling their upper arm wrong during a rowing movement. This type of feedback is best used in those with low cognitive ability or in those who need pristine form in high level movement activities.

Knowledge of results

Knowledge of results is feedback that gives information about the outcome of a task. This type of feedback is given after the task is completed either through verbal confirmation or through an identifiable end point in the task itself such as touching an object. Emphasizing this type of feedback over knowledge of performance may lead to greater retention of the whole motor skill for the average person.

Feedback Scheduling

Feedback scheduling is how often and when external feedback is given during practice sessions. When we refer to feedback scheduling, we are talking about extrinsic feedback only. Intrinsic feedback is occurring at all times and thus cannot be scheduled. Feedback schedules should be altered as the patient becomes more proficient in a motor task. Feedback scheduling can be concurrent, post-task, or done in summary after a batch of trials.

Concurrent Feedback

Concurrent feedback is feedback given during the movement task in real-time. This type of feedback gives a patient the knowledge of their performance and can be from mirrors, a practitioner’s verbal or tactile cues, or various technologies such as EMG. This type of feedback is great in the initial stages of learning, but should be weaned off over time to allow a patient’s intrinsic feedback to takeover and allow them to start recognizing errors.

Immediate Post-Task Feedback

Immediate Post-Task Feedback is feedback given at the end of a task that gives the knowledge of results to a patient. This type of feedback is often given verbally, instead of visually, after each task trial. Like concurrent feedback, this type of feedback is useful at beginning learning stages but should be weaned off as a patient’s motor skill increases.

Summarized Feedback

Summarized feedback allows multiple trials to be performed by the patient before any feedback is given. This form of feedback allows a patient to engage more with intrinsic feedback and learn to correct errors on their own. This type of feedback may lead to slower learning of a task in the moment, but potentially lead to improved proficiency and self-correction in the task later on.

How much feedback should be given?

When it comes to extrinsic feedback, the general adage is that “less is better”. At the end of learning a motor task our goal is to have a patient who is fully self-reliant and proficient at that task. The only way this occurs is if the patient learns to rely on their intrinsic feedback and correct errors on the fly. In the initial cognitive stage of learning, large amounts of extrinsic feedback are warranted. We should aim to decrease this amount of feedback as quickly as possible to prevent any reliance on external cueing. Decreasing the amount of feedback over time is termed fading the feedback. During the associative stage of learning, summarized feedback is the best tool to keep feedback infrequent but also help the patient improve their motor ability.  

Conclusion

Now that you have learned about the basics of motor learning, and concepts that can enhance the learning of your patient, it is time to apply these ideas. Every patient is different and requires a different motor learning lesson plan. The more you apply these principles, the easier it will be to determine the kind of practice a patient needs, what kind of feedback is the best for them, and when to start fading that feedback. These last two articles were fairly information dense so be sure to give them a quick read again in a few weeks to re-visit these concepts with fresh eyes.

Thank you for reading the article! If you want to learn a little bit more about motor learning check this article out on Medbridge. It takes a quick look at how motor learning changes in those with a damaged nervous system.

Have you found any sure fire ways to increase your patient’s learning ability? Do you use any of the above principles in your teaching practice? Comment below and let me know!

Happy Falling!