Motor Learning - Back to the Basics

Original Editor - Jess Bell Top Contributors - Jess Bell and Kim Jackson

Introduction

There is increasing evidence that motor learning principles can have a positive effect on skill acquisition.[1][2] However, while there is a general acknowledgement in research that motor learning is a valuable addition to physiotherapy interventions, it has been found to only have a limited impact in actual clinical practice.[3]

Learning has been defined by Magill (2010, cited by Sattelmayer) as: “A change in the capability of a person to perform a skill that must be inferred from a relatively permanent improvement in performance as a result of practice."[2]

Motor learning has been defined by Shumway-Cook and Woollacott (2017, cited by Bisson) as the process of the acquisition and / or modification of skilled action.[1] In essence, it is the process of learning how to do something well.[1]

Learning is a dynamic process, which takes place over time and in different environments.[1] There are various factors associated with motor learning that are well recognised, such as the amount of practice, types of practice and style of feedback and practice schedules.[4] However, the best method to enable learning to occur in a physiotherapy setting will depend upon clinical context.[1]

Learning vs Performance

When considering learning, it is important to be able to distinguish between performance and learning. Performance tends to improve after an individual practices a skill. These improvements often occur quickly and can be quite significant. However, they also tend to be temporary and may be affected by factors such as fatigue, anxiety, mood and motivation.[1] When practice continues over time, true learning occurs - i.e. the individual retains the skill. She or he can remember what to do and is able to do it effectively. These changes are sustainable over time.[1]

[5]

The three key phases or motor performance and learning are:[6]

  • Acquisition
  • Retention
  • Transfer

When applying learning theory in clinical practice, the aim of a physiotherapy intervention is to ensure that a patient moves from skill acquisition to retention. Ultimately, the goal of therapy will be for patients to continue to practice and reach the transfer stage, so that they can apply the acquired skill in other situations, environments and tasks.[1]

Types of Learning

Learning is typically divided into ‘explicit learning’ and ‘implicit learning'.

Explicit Learning

Explicit learning has been defined as “learning which generates verbal knowledge of movement performance (e.g., facts and rules), involves cognitive stages within the learning process and is dependent on working memory involvement”.[7] It is usually associated declarative knowledge, where the learner is able to state, or say out loud, what the technicalities of the movement are (i.e. they can list the steps of a specific task like tying a shoelace). Thus, it is more cognitive and verbal than implicit learning.[1] Over time, the learner tends to progress and the performance becomes more automatic (i.e. she / he is able to perform the task without having to think about each step).[1]

Implicit Learning

Implicit learning is procedural learning. It has been defined as a type of learning which “progresses with no or minimal increase in verbal knowledge of movement performance (e.g., facts and rules) and without awareness. Implicitly learned skills are (unconsciously) retrieved from implicit memory.”[7] Thus, with implicit learning it is not easy to verbalise or declare the specific steps of a task, but the skill is learned more inherently. Implicit learning can often lead to greater automaticity than explicit learning.[1][8] This means that the individual can perform an action without having to think about it slightly faster than with explicit learning.[1]

While there is debate in the literature about which type of learning may be better, mastering many tasks often requires elements of both.[1]

[9]

Stages of Learning

Fitts and Posner proposed a three stage model of skill acquisition in the 1960s. They named the three stages as follows:[10]

  • The cognitive stage
  • The associative stage
  • The autonomous stage

The Cognitive Stage

The cognitive stage is the period during which the goals of the task and the appropriate movement sequence to achieve these goals are determined.[10] At this stage, the  learner is a novice (i.e. she / he is new to the skill and task at hand) and makes a conscious effort to develop an understanding of what to do.[1][11] Learning tends to be explicit in this stage.[10]

There is often a high degree of error when entering the cognitive stage and a lot of attention is required to learn.[1] For example, when a child is learning to ride a bike, there are many aspects to consider, such as balancing, pedalling and steering. She / he also needs to consider the environment, including the surface and any traffic in the area. Because this task requires a lot of attention, the learner’s performance will likely be inconsistent and include mistakes. A facilitator nearby (i.e. therapist, parent, friend, sibling) may be able to provide assistance, guidance or hands-on help to ensure safety and enable the child to continue to learn.[1]

There tends to be a large improvement in performance in a short period of time during the cognitive stage, particularly when the skill is repeated.[1]

The Associative Stage

The cognitive stage is followed by the associative stage. During this stage, the learner has established the movement sequence and is able to refine his / her strategies.[10][1] She / he does not need to rely so heavily on external instructions and is better able to respond to the context / environment.[11] For example, when riding a bike, the child will learn how to go different speeds and navigate the environment. During this phase, there tends to be fewer errors, greater consistency and improved performance. Less feedback is required, but improvement occurs more slowly.[1]

The Autonomous Stage

The final stage is the autonomous stage. This phase involves further practice of the skill in order to enhance performance, so that it becomes automatic.[10]  The learner has internalised the skill and is able to perform it with minimal cognitive monitoring.[11][1] This means that the learner can pay more attention to other things, including other aspects of the task or environmental features. The performance tends to be free of errors and adaptable, with less feedback required.[1]

When compared to the three phases of motor performance and learning, the acquisition phase of performance tends to correlate with the cognitive stage. The retention phase aligns more with the associative phase and the transfer phase tends to relate to the autonomous stage.[1]

[12]

Practice Schedules

It is important to consider how learning sessions (i.e. physiotherapy sessions, sports practices) can be used to maximise learning. Various practice schedules are discussed in the research and while they tend to be compared to each other, it can be helpful to consider them as existing on a continuum with some elements better suited for some tasks and others better suited to other tasks.[1]

Massed and Distributed Practice

Massed practice occurs when there is minimal rest between trials or practice sessions (i.e. lots of practice is followed by a short rest, followed again by a lot of practice and then a short rest).[4] Distributed practice is the opposite. The practice sessions are more spaced out (hours or days) and longer rest periods are included in the schedule.[4]

Massed practice may be more beneficial for rapid skill acquisition, but distributed practice tends to be better for skill retention and long-term learning. In general, it has been found that motor skills are learned more effectively when there is a long break between training sessions (which is known as the spacing effect),[4] but both massed and distributed practice can have their place in clinical practice:[1]

  • When working with a discrete, simple, short-duration task, massed practice may work very well
  • Distributed practice may work better for more continuous and complex tasks
  • An individual who fatigues quickly may benefit from a more distributed practice schedule

NB: Discrete tasks have a definable start and stop (e.g. sit to stand, stepping onto a curb) whereas continuous tasks do not have a definable stop or start (e.g. walking, cycling, swimming).[1]

Constant Practice vs Variable Practice

Constant practice occurs when an individual practices the same task under the same conditions over and over again (e.g. repeating sit to stand from the same couch, under the same conditions). Variable practice involves variability (e.g. sit to stand from a couch, an office chair, toilet seat etc).[1]

Constant practice tends to help with the acquisition of skills early on whereas variable practice increases the adaptability, or the generalisation of a skill, which increases its transferability.[1] However, again both of these methods can be utilised depending on the skill being learned and the general context. When learning a closed skill, the aim is to focus on specific movement characteristics, but when learning an open skill, variability in a movement pattern is important.[13] A recent study by Czyż and colleagues found that the relative timing of skills obtained during constant and variable practice conditions is actually the same, but that constant practice resulted in a shorter movement time when compared to skills practiced in variable conditions.[13]

In a clinical context, variable practice tends to be indicated for dynamic tasks that need to be performed under variable conditions.  For example, the VIEWs study from 2016 examined walking training in constant versus variable conditions in stroke patients.[14] The group who were given a more variable step training programme demonstrated greater improvements in walking at the end of the trial period.[14] However, constant practice tends to be useful in situations where the task is simple and requires minimal variability. Similarly, constant practice can be beneficial for patients with dementia because it may increase their chance of holding onto and retraining the skill. Once they have acquired the skill, it may be possible to move onto variable training for these patients.[1]

Blocked and Random Practice

Blocked practice is when the same task or task variation is repeated without interruption (e.g. repeated stair climbing). Random practice involves variability. Thus, in a random practice session, the therapist might get the patient to do some stair climbing, followed by walking and then cycling rather than repeating the same task over and over again. Again, while there is variability in research findings about which type of practice may be more beneficial, blocked practice tends to be better early on for skill acquisition whereas random practice will be better for the transfer of skills over time.[15][16][1] Random practice also helps the learner to generalise the skill to other environments.[1]

Thus, early on when a learner is unfamiliar with a task, blocked practice may be beneficial at the start of learning. It may also be beneficial when a learner does not have the cognition / intellectual capabilities to learn from a more random set up. Random practice is indicated for skills that require different movement patterns. Again, the key to choosing practice type is to consider what phase of learning the individual is in, as well as his / her individual capabilities and the type of task.[1]

Guidance and Discovery Practice

Guidance practice is when the teacher / therapist helps to guide the learner (physically, verbally or both) through the task.[1]

Discovery learning refers to practice where the learner is able to discover solutions for himself / herself without guidance or feedback from another person.[7]

Guidance practice has been found to be no more effective than scenarios where no guidance is provided, but providing this kind of feedback may be beneficial for early skill acquisition. Discovery learning tends to be less effective in the acquisition phase, but more effective for retention and transfer to other environments.[1]

Error-Driven and Errorless Learning

Error-driven and errorless learning are commonly discussed in speech therapy research, but can be used across different rehabilitation specialities.[1] Error-driven (sometimes called error-correction schedules) basically involve trial and error - i.e. the learner tries something, which may or may not be successful. If the attempt is not successful, the instructor can provide information to help make the next attempt better. In contrast to this, during errorless learning, the environment is constrained in order to prevent where possible any or many errors from occurring.[1][7]

Error-driven learning can work well for individuals who are able to learn explicitly (i.e. declarative learning). If the individual is not able to learn explicitly (i.e. if she / he has dementia or cognitive impairment, low motor ability), an errorless approach can be more useful as it means that the learner is practising the correct way of doing a task every time.[1][17] For example, when getting into a bath, it is important that a patient with dementia does not do this in an unsafe manner. Thus, correct practice of this skill is important. With errorless training, if the therapist notices an error, she / he would stop the patient and start the task again at the beginning, guiding the patient through the correct steps and continuing with this process until the task can be performed error-free without guidance.[1]

Whole Practice and Part Practice

Whole practice refers to practising the whole task from beginning to end.[2] This tends to work well for continuous tasks (walking, bike riding).[1] Part practice is possible when a task can be broken down into discrete components and each part practised separately (e.g. tennis). Once the learner has mastered each segment, she / he is then able to put them together to complete the full task.[2] When using part practice, it is very important to ensure that the learner does return to whole practice as this will enable him / her to make physical and cognitive connections about where the part belongs in the sequence of the whole task.[1]

Augmented Feedback

Augmented feedback (or extrinsic feedback) is often used to enhance performance during skill acquisition.[18] Augmented feedback occurs when extrinsic feedback (e.g. verbal) is provided by an outside source (e.g. a therapist) in addition to the learner’s intrinsic feedback (e.g. proprioception, vision, touch, pressure etc ).[18][19] Extrinsic feedback can be categorised as either:[19]

  1. Knowledge of results
  2. Knowledge of performance

While it is possible to learn without augmented feedback, it has been found that there is improved retention of a skill when feedback is provided.[19] Different types of feedback can be beneficial depending on the situation. Feedback must be specific to the learner and the stage of learning.[1] If a learner is early on in skill acquisition, feedback might be given quite differently to when she / he is in an autonomous phase. A key aim of motor learning is to help a patient reach a stage where she / he no longer relies on feedback to perform a task - the learner will have developed his / her own sense of the correct or most effective way of performing a task. She / he will have an internal representation of what a movement can and should look like and will, ideally, over time develop the muscle memory to perform the task independently.[1]

Verbal Feedback

Verbal feedback is very common in physiotherapy. It may include words to reinforce or instruct, give knowledge of results or knowledge of performance (i.e. about the quality of the movement). In general, research suggests that feedback is more useful when it reinforces good performance rather than correcting mistakes.[1]

Tactile Cueing or Visual Feedback

Tactile cueing or tactile feedback refers to the use of the therapist's hands (i.e assisting a movement, providing tactile cues for postural alignment / muscle activation). Visual feedback may be given through gestures, mirrors, objects or signs or even in virtual reality games.[1]

Timing of Feedback

There are different ways to time feedback. Concurrent feedback means that the feedback is given during the task.[1][20] For instance, if a therapist notes that a patient is dragging his / her toe during gait, the therapist may provide a cue to try to correct this pattern. This type of feedback has been found to have good correlation with fast acquisition of a skill. Concurrent feedback may not, however, be as good for retention and learning over time.[1]

In contrast to concurrent feedback, terminal or summary feedback have been found to be more effective for long-term learning. There is limited evidence to suggest that terminal feedback may be more beneficial than concurrent feedback on transfer tests (i.e. a test which requires the participant to perform a newly acquired skill in a new situation).[2]

Terminal feedback refers to feedback that is given at the end of each repetition of an action. The patient completes a task and is then given feedback by the therapist. Summary feedback occurs after the patient has completed several repetitions of a task. Thus, summary feedback happens less frequently than terminal feedback.[1]

It is believed that these methods of feedback may help with long-term learning as they allow the learner to independently reflect on how well they have performed a task.  This reflection can then be consolidated alongside the feedback provided by the instructor / therapist. Thus, while concurrent feedback can be useful during therapy sessions, it is important to also consider using summary and terminal feedback for long-term retention.[1]

Faded Feedback

Faded feedback is defined as feedback that is given less and less frequently over time as the performance changes or improves.[21] This type of feedback tends to be better for learning than constant feedback. Thus, the therapist may begin by providing concurrent feedback, but as the performance improves, she / he will provide less feedback and see if the patient can maintain performance.[1]

Bandwidth Feedback

Bandwidth feedback is defined as feedback which is given when a learner’s performance falls outside a certain acceptable level of error.[22] The wider the bandwidth, the more error allowed. Over time as performance improves and learning is evident, the bandwidth is reduced and the feedback becomes more specific and focused.[1] This type of feedback has been found to be beneficial when learning simple motor skills during physical and observational practice.[22] In a clinical context, it may be useful for patients who are able to learn explicitly from their errors, but may not be as advantageous for patients with dementia because it allows error to occur.[1]

Summary

  • There are three key stages of learning and each stage is suited to different practice schedules and style of feedback
  • Learning style is also impacted by the learner’s characteristic and the features of the skill
  • While the factors discussed above are likely important in skill acquisition, it has also become evident in the research that other motivational factors (such as social-cognitive and affective) in connection with practice conditions also have an impact on learning[23]

References

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