Rebecca Lewthwaite

Motor skill learning and performance: a review of influential factors

Objectives  Findings from the contemporary psychological and movement science literature that appear to have implications for medical training are reviewed. Specifically, the review focuses on four factors that have been shown to enhance the learning of motor skills: observational practice; the learner’s focus of attention; feedback, and self‐controlled practice.

Effects of Physical Guidance and Knowledge of Results on Motor Learning: Support for the Guidance Hypothesis

The guidance hypothesis (Schmidt, 1991) predicts that the guiding properties of augmented feedback are beneficial for motor learning when used to reduce error, but detrimental when relied upon. Therefore, a heavily guiding form of feedback might be detrimental for learning. In addition, the guidance hypothesis predicts that practice with a high relative frequency of augmented feedback would be detrimental for learning. An experiment is described that crossed two forms of feedback with two levels of relative frequency. Subjects practiced movements to a target with either physical guidance or knowledge of results, and with either a high or faded relative frequency. The high frequency physical guidance condition resulted in the poorest retention, and both high frequency feedback conditions resulted in the least accuracy in transfer. These results provide support for the guidance hypothesis and suggest consideration of the combined effects on learning of the type and relative frequency of augmented feedback and acquisition-test conditions.

External Focus Instructions Reduce Postural Instability in Individuals With Parkinson Disease

Background: Postural instability while standing, walking, and interacting with objects or the environment places individuals with Parkinson disease (PD) at risk for falls, injuries, and self-imposed restrictions in activity. Recent research with motor skills, including those demanding postural stability, has demonstrated performance and learning advantages when performers are instructed to adopt an external rather than an internal focus of attention. Despite the potential benefits in stability-related risk reduction and enhanced movement effectiveness, attentional focus research in individuals challenged with postural instability is limited. Objective: The present translational research study examined the generalizability of the attentional focus effect to balance in older adults with PD. Design: A within-participant design was used to account for potentially substantial individual variations in balancing capabilities. Methods: Fourteen participants diagnosed with idiopathic PD (Hoehn and Yahr stages II and III) participated in the experiment. They were asked to balance on an unstable surface (inflated rubber disk). In counterbalanced orders, they were instructed to focus on reducing movements of their feet (internal focus) or the disk (external focus), or they were not given attentional focus instructions (control). Results: The adoption of an external focus resulted in less postural sway relative to both internal focus and control conditions. There was no difference between the internal focus and control conditions. Limitations: Mental functioning was not formally assessed, and comprehensive clinical profiles of participants were not obtained. Conclusions: The results are consistent with previous findings on attentional focus in samples of patients and people without disabilities. Subtle wording distinctions that direct attention to movement effects external to the mover reduce postural instability during standing for individuals with PD relative to an internal focus. The findings have potentially important implications for instructions given by clinicians and the reduction of fall risk.

Social-comparative feedback affects motor skill learning

This study examined motivational effects of feedback on motor learning. Specifically, we investigated the influence of social-comparative feedback on the learning of a balance task (stabilometer). In addition to veridical feedback (error scores reflecting deviation from the target horizontal platform position) about their own performance after each trial, two groups received false normative information about the “average” score of others on that trial. Average performance scores indicated that the participants performance was either above (better group) or below (worse group) the average, respectively. A control group received veridical feedback about trial performance without normative feedback. Learning as a function of social-comparative feedback was determined in a retention test without feedback, performed on a third day following two days of practice. Normative feedback affected the learning of the balance task: The better group demonstrated more effective balance performance than both the worse and control groups on the retention test. Furthermore, high-frequency/low-amplitude balance adjustments, indicative of more automatic control of movement, were greater in the better than in the worse group. The control group exhibited more limited learning and less automaticity than both the better and the worse groups. The findings indicate that positive normative feedback had a facilitatory effect on motor learning.

Effect of a Task-Oriented Rehabilitation Program on Upper Extremity Recovery Following Motor Stroke: The ICARE Randomized Clinical Trial

IMPORTANCE Clinical trials suggest that higher doses of task-oriented training are superior to current clinical practice for patients with stroke with upper extremity motor deficits. OBJECTIVE To compare the efficacy of a structured, task-oriented motor training program vs usual and customary occupational therapy (UCC) during stroke rehabilitation. DESIGN, SETTING, AND PARTICIPANTS Phase 3, pragmatic, single-blind randomized trial among 361 participants with moderate motor impairment recruited from 7 US hospitals over 44 months, treated in the outpatient setting from June 2009 to March 2014. INTERVENTIONS Structured, task-oriented upper extremity training (Accelerated Skill Acquisition Program [ASAP]; n = 119); dose-equivalent occupational therapy (DEUCC; n = 120); or monitoring-only occupational therapy (UCC; n = 122). The DEUCC group was prescribed 30 one-hour sessions over 10 weeks; the UCC group was only monitored, without specification of dose. MAIN OUTCOMES AND MEASURES The primary outcome was 12-month change in log-transformed Wolf Motor Function Test time score (WMFT, consisting of a mean of 15 timed arm movements and hand dexterity tasks). Secondary outcomes were change in WMFT time score (minimal clinically important difference [MCID] = 19 seconds) and proportion of patients improving ≥25 points on the Stroke Impact Scale (SIS) hand function score (MCID = 17.8 points). RESULTS Among the 361 randomized patients (mean age, 60.7 years; 56% men; 42% African American; mean time since stroke onset, 46 days), 304 (84%) completed the 12-month primary outcome assessment; in intention-to-treat analysis, mean group change scores (log WMFT, baseline to 12 months) were, for the ASAP group, 2.2 to 1.4 (difference, 0.82); DEUCC group, 2.0 to 1.2 (difference, 0.84); and UCC group, 2.1 to 1.4 (difference, 0.75), with no significant between-group differences (ASAP vs DEUCC: 0.14; 95% CI, -0.05 to 0.33; P = .16; ASAP vs UCC: -0.01; 95% CI, -0.22 to 0.21; P = .94; and DEUCC vs UCC: -0.14; 95% CI, -0.32 to 0.05; P = .15). Secondary outcomes for the ASAP group were WMFT change score, -8.8 seconds, and improved SIS, 73%; DEUCC group, WMFT, -8.1 seconds, and SIS, 72%; and UCC group, WMFT, -7.2 seconds, and SIS, 69%, with no significant pairwise between-group differences (ASAP vs DEUCC: WMFT, 1.8 seconds; 95% CI, -0.8 to 4.5 seconds; P = .18; improved SIS, 1%; 95% CI, -12% to 13%; P = .54; ASAP vs UCC: WMFT, -0.6 seconds, 95% CI, -3.8 to 2.6 seconds; P = .72; improved SIS, 4%; 95% CI, -9% to 16%; P = .48; and DEUCC vs UCC: WMFT, -2.1 seconds; 95% CI, -4.5 to 0.3 seconds; P = .08; improved SIS, 3%; 95% CI, -9% to 15%; P = .22). A total of 168 serious adverse events occurred in 109 participants, resulting in 8 patients withdrawing from the study. CONCLUSIONS AND RELEVANCE Among patients with motor stroke and primarily moderate upper extremity impairment, use of a structured, task-oriented rehabilitation program did not significantly improve motor function or recovery beyond either an equivalent or a lower dose of UCC upper extremity rehabilitation. These findings do not support superiority of this program among patients with motor stroke and primarily moderate upper extremity impairment. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00871715.

Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning

Effective motor performance is important for surviving and thriving, and skilled movement is critical in many activities. Much theorizing over the past few decades has focused on how certain practice conditions affect the processing of task-related information to affect learning. Yet, existing theoretical perspectives do not accommodate significant recent lines of evidence demonstrating motivational and attentional effects on performance and learning. These include research on (a) conditions that enhance expectancies for future performance, (b) variables that influence learners’ autonomy, and (c) an external focus of attention on the intended movement effect. We propose the OPTIMAL (Optimizing Performance through Intrinsic Motivation and Attention for Learning) theory of motor learning. We suggest that motivational and attentional factors contribute to performance and learning by strengthening the coupling of goals to actions. We provide explanations for the performance and learning advantages of these variables on psychological and neuroscientific grounds. We describe a plausible mechanism for expectancy effects rooted in responses of dopamine to the anticipation of positive experience and temporally associated with skill practice. Learner autonomy acts perhaps largely through an enhanced expectancy pathway. Furthermore, we consider the influence of an external focus for the establishment of efficient functional connections across brain networks that subserve skilled movement. We speculate that enhanced expectancies and an external focus propel performers’ cognitive and motor systems in productive “forward” directions and prevent “backsliding” into self- and non-task focused states. Expected success presumably breeds further success and helps consolidate memories. We discuss practical implications and future research directions.

Normative Feedback Effects on Learning a Timing Task

This study investigated the influence of normative feedback on learning a sequential timing task. In addition to feedback about their performance per trial, two groups of participants received bogus normative feedback about a peer groups average block-to-block improvement after each block of 10 trials. Scores indicated either greater (better group) or less (worse group) than the average improvement, respectively. On the transfer test 1 day later, which required producing novel absolute movement times, the better group demonstrated more effective learning than the worse group. These findings add to the mounting evidence that motivational factors affect motor skill learning.

Motor learning benefits of self-controlled practice in persons with Parkinson's disease

The present study examined the effectiveness of a training method to enhance balance in people with PD, which could potentially reduce their risk for falls. Specifically, we investigated whether the benefits of the self-controlled use of a physical assistance device for the learning of a balance task, found previously in healthy adults, would generalize to adults with PD. Twenty-eight individuals with PD were randomly assigned to one of two groups, a self-control and a yoked (control) group. The task required participants to stand on a balance platform (stabilometer), trying to keep the platform as close to horizontal as possible during each 30-s trial. In the self-control group, participants had a choice, on each of 10 practice trials, to use or not to use a balance pole. Participants in the yoked group received the same balance pole on the schedule used by their counterparts in the self-control group, but did not have a choice. Learning was assessed one day later by a retention test. The self-control group demonstrated more effective learning of the task than the yoked group. Questionnaire results indicated that self-control participants were more motivated to learn the task, were less nervous, and less concerned about their body movements relative to yoked participants. Possible reasons for the learning benefits of self-controlled practice, including a basic psychological need for autonomy, are discussed.

Infusing Motor Learning Research Into Neurorehabilitation Practice: A Historical Perspective With Case Exemplar From the Accelerated Skill Acquisition Program

&NA; This special interest article provides a historical framework with a contemporary case example that traces the infusion of the science of motor learning into neurorehabilitation practice. The revolution in neuroscience provided the first evidence for learning-dependent neuroplasticity and presaged the role of motor learning as critical for restorative therapies after stroke. The scientific underpinnings of motor learning have continued to evolve from a dominance of cognitive or information processing perspectives to a blend with neural science and contemporary social-cognitive psychological science. Furthermore, advances in the science of behavior change have contributed insights into influences on sustainable and generalizable gains in motor skills and associated behaviors, including physical activity and other recovery-promoting habits. For neurorehabilitation, these insights have tremendous relevance for the therapist–patient interactions and relationships. We describe a principle-based intervention for neurorehabilitation termed the Accelerated Skill Acquisition Program that we developed. This approach emphasizes integration from a broad set of scientific lines of inquiry including the contemporary fields of motor learning, neuroscience, and the psychological science of behavior change. Three overlapping essential elements—skill acquisition, impairment mitigation, and motivational enhancements—are integrated. Video Abstract available (See Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A71) for more insights from the authors.

Self-Controlled Learning: The Importance of Protecting Perceptions of Competence

Recent studies examining the role of self-controlled feedback have shown that learners ask for feedback after what they believe was a “good” rather than “poor” trial. Also, trials on which participants request feedback are often more accurate than those without feedback. The present study examined whether manipulating participants’ perception of “good” performance would have differential effects on learning. All participants practiced a coincident-anticipation timing task with a self-controlled feedback schedule during practice. Specifically, they were able to ask for feedback after 3 trials in each of three 10-trial practice blocks. While one group (Self-30) was told that an error of 30 ms or less would be considered good performance, another group (Self-4) was informed that an error of 4 ms or less would be considered a good trial. A third, self-control group (Self) did not receive any information about what constituted good performance. The results showed that participants of all groups asked for feedback primarily after relatively good trials. At the end of practice, both the Self-30 and Self groups demonstrated greater perceived competence and self-efficacy than the Self-4 group. The Self-30 and Self groups also performed with greater accuracy and less variability in retention and transfer (non-dominant hand) 1 day later. The present findings indicated that the typical learning benefits of self-controlled practice can be thwarted by depriving learners of the opportunity of experiencing competence through good performance. They add to the accumulating evidence of motivational influences on motor learning.