13th February 2012
HERE ARE SOME NOTES FROM ISHA DOSHI – SHE ATTENDED OUR COURSE
Kinetic Control: Managing Movement – Solutions for the Low Back
With Sarah in Mumbai last month. This course focused on the assessment and retraining of uncontrolled movement. We spent much of the workshop time retraining uncontrolled movement and Isha led a session on applying motor learning principles to movement retraining. Thanks Isha for making such a valuable contribution. How Motor Learning Principles can help Movement Retraining Phases of Learning
Coming from a Movement Science background, I give a lot of impetus to the principles of Motor Learning and Control in Movement Retraining.
Learning consists of two phases Early Learning: cognitive phase, Intermediate Learning: associative phase, and Late Learning: autonomous phase. As a physical therapist, I would use the early learning phase to increase the patient’s cognitive awareness by educating them about their condition, the problem area (anatomical location, uncontrolled movement), how it can be treated, importance of retraining, and how a recurrence can be prevented. The intermediate phase would be where after an introduction of how to retraining a movement, the patient becomes more and more aware of the correct movement patterns and through trial and error gets better with practice. The above two phases allows maximum learning to occur along with motor reorganization of a movement pattern with efficient feedback mechanisms. The last phase of learning leads to fine tuning of a movement such that the retrained movement becomes more automatic and requires less or no conscious control with efficient feedforward mechanisms.
Feedback
Once I make the patient more cognitively aware of the movement pattern, I would like to observe the patient as they perform the movement naturally and then give feedback, if they have completed the movement (reached the benchmark) and their performance (provide knowledge about uncontrolled movement when present). The informational content of the feedback is viewed as an important determinant of the success of the consequent action. In motor learning research, two types of feedback are roughly distinguished in which the content of information differs: knowledge of results (KR) and knowledge of performance (KP). KR (here, reaching the benchmark) refers to information about the outcome of the movement in relation to the task goal. KP (here, awareness of uncontrolled movement) consists of information about the movement pattern that led to the performance outcome. Feedback in the form of KR guides the performer towards the goal state, resulting in a better performance during the skill acquisition stage, but in the absence of KR, the performance significantly deteriorates.
Similarly, during movement retraining, feedback in terms of visual (mirror, pictures), tactile, or proprioceptive cues can provide both KP as well as KR. During retraining, cues to make the patient aware of the uncontrolled movement and reducing its recurrence while performing the movement is more important then retraining the movement. Subsequently, in order to maximize the effects of learning a positive feedback like ” You can do this in a better way” instead of “You are doing it in the wrong way” is necessary. A fading schedule of feedback, that is frequent feedback early in practice that reduces towards the end as skill develops and learning improves, is optimal to make the performer less dependent on feedback later. Also, information overload should be avoided as the patient may become confused and distracted, resulting in rapid deterioration of task performance. However, even if sufficient amount of feedback is provided, what guarantees development and retention of the learned task is practice. Practice
Motor learning gives a lot of importance to Schmidt’s schema theory which describes schema as a program stored in memory that acts as a rule or reference for correctness, where current outcome is compared to a previously stored outcome developed through practice with feedback. A consistent finding in the literature is that as the learner begins to perform the motor task in a blocked manner, the task is repeated until it is learned and becomes automatic, such that it can be performed even when conscious attention towards that task is not given. On the other hand, when a learner executes the motor task in a random order, they begin to identify the distinctive nature of each task, which is retained in long term memory and retrieved every time a similar task is performed. For example, in the early phases of movement retraining, feedback and practice (10 x 10) applied during supported positions can help increase proprioceptive input then non-supported positions. Once the patient has learned to contract the muscle in static positions through blocked practice, then the learning of dynamic positions can be added.
Progression
As the patient begins to retrain their movement easily with good breathing control, with no substitution and retains consistency in performance then we can progress to retrain their movement in various positions to train processes responsible for scaling the action properly to meet various environmental demands. We can challenge the movement with complexities and with little or no feedback at the end of the rehabilitation period. Hence, when learning a complex skill, the efficient use of feedback, varying practice schedules, and gradual introduction of task complexities is important until the patients becomes fully aware of the contraction and has reached automatic level where conscious control is not needed. This is because, the patients might become dependent on the feedback given and in the absence of the same, a significant decline of the learned effects could be possible. Practice schedules play an important role not only in learning and acquisition of contraction and relaxation of muscles, but also in retention and better performance of the learned movement in activities of daily living (transfer of skill from clinical setting to real world). Therefore, along with recommended treatment duration and frequency of contractions, practicing the same in a variety of tasks helps make the consciously learned task automatic where attention would not be needed.