Motor learning strategies are required when attempting to learn a new skill through a combination of mass practice and experience. Specific strategies for how to assist an individual with learning a new skill are as follows:
Practice skill
Begin skill practice with guided imagery- kinesthetic learning (passive movement)
Initially blocked schedule practice progressing to variable schedule practice to finally progressing random schedule practice as practice repetitions increases and learning improves
Provide effective feedback
Begin with extrinsic feedback
Progress to intrinsic feedback with augmented feedback
The types of augmented feedback are knowledge of results and knowledge of performance
Types of feedback schedules
Feedback given after completion of every task (early stage of learning)
Summed feedback- feedback given after a set number of attempts
Fading feedback- decreasing the amount of feedback given to none as appropriate
Bandwidth feedback- feedback only given if movement is outside of designated range
Transfer specific skill to be generalized in various environments
Skill acquisition leads to the skill being applied in varied situations and environment successfully
This occurs after patient is deemed proficient in original skill
Stages for motor learning
Stages by which motor skill acquisition follows.
Cognitive-”What to do” stage
Learner develops understanding of tasks and how to perform
Movements are slow and inconsistent; there exists an increased amount of trial and error
Extrinsic feedback only
Blocked scheduling
Consistent feedback after each trial of movement
Associative- “How to do” stage
Leaner practices and refines movement
Learner begins to understand errors of movement
50% extrinsic feedback and 50% intrinsic feedback
Continue with blocked scheduling and progressing to variable as skill acquisition occurs
Feedback should progress from summed to faded or decreasing over time.
Autonomous- “How to succeed” stage
Skills performed automatically and with minimal conscious error
Highly skilled and consistent performance
Intrinsic feedback only
Random practice schedule
If any feedback, bandwidth feedback given
Task specific training
Examples of task specific training
Locomotor training
Motorized treadmill training with partial body weight support to promote early gait training
This activity is used to assist with meeting the needs of patient based on their current functional status with goal of returning back to baseline
Constraint-induced movement therapy (CIMT)
Utilized post-stroke to constrain the unaffected upper extremity by use of protective hand mitt
The goal is to constrain the unaffected extremity and force the use of the affected limb to be utilized
Proprioceptive neuromuscular facilitation (PNF)
Rhythmic initiation
A progression of movement from passive → active-assisted → active → resisted. This technique is used to improve the initiation and coordination of movement.
Example:
Patient: A person with Parkinson’s disease.
Application: Therapist helps initiate movement for rolling from supine to sidelying, gradually allowing the patient to take over the movement and eventually providing resistance for strengthening.
Rhythmic rotation
Slow, passive rotational movements around a longitudinal axis are applied to reduce hypertonia (increased muscle tone) and promote relaxation.
Example:
Patient: An individual with spasticity in the trunk.
Application: Therapist slowly rotates the patient’s trunk to assist in relaxing the muscles before initiating trunk flexion activities.
Rhythmic stabilization
This involves isometric contractions of antagonist muscle groups simultaneously to improve joint stability and postural control.
Example:
Patient: A patient sitting unsupported.
Application: Therapist applies multidirectional resistance to the patient’s shoulders, challenging them to maintain their posture and improve trunk stability.
Approximation
Gentle compression of joint surfaces, typically in weight-bearing positions, to stimulate mechanoreceptors and enhance postural stability and muscle activation around the joint.
Example:
Patient: A person in a quadruped position or standing.
Application: Therapist gently compresses the patient’s shoulder joints during weight-bearing to promote co-contraction and stabilize the joint.
Slow reversals
Alternating concentric contractions of agonist and antagonist muscles without relaxation to improve coordination and ensure smooth transitions between movements.
Example:
Patient: A patient with knee weakness.
Application: Therapist resists knee flexion, then extension in a seated position, alternating back and forth to improve functional control and coordination.
Hold-relax
An isometric contraction of a muscle group followed by relaxation and passive stretching. This technique is particularly useful for improving range of motion when pain or tightness is present.
Example:
Patient: A person with hamstring tightness.
Application: The patient performs an isometric contraction of the hamstrings against resistance, followed by passive stretching to improve flexibility.
Contract-relax
An isotonic contraction of the muscle through its available range followed by relaxation and passive movement into an increased range of motion to improve flexibility.
Example:
Patient: A person with limited hip range of motion.
Application: The patient resists the therapist’s push into hip extension and then relaxes, allowing the therapist to stretch the hamstrings and improve flexibility.
Repeated contractions
This involves repeated quick stretches followed by resisted contractions to enhance the initiation and strength of weak muscles.
Example:
Patient: A person with weakness in shoulder flexion.
Application: The therapist provides a quick stretch to the anterior deltoid, followed by resistance to strengthen the muscle and improve range of motion.
PNF patterns are associated with the way in which the joints are moved to perform specific patterns outside of synergy. PNF patterns exist for both the upper and lower extremities. The patterns are as follows for upper extremity:
D1 flexion
D2 flexion
D1 extension
D2 extension
D1 flexion and extension
D2 flexion and extension
The patterns are as follows for lower extremity:
D1 flexion
D2 flexion
D1 extension
D2 extension
Lower extremity PNF
Neurodevelopmental treatment (NDT)
Developmental stages
Each individual with neurological deficits has varied functional deficits.
The aim of the develop[mental stage is to assess what is their current functional status and then aid in getting to the next stage.
Example Stroke patient can sit independently, , next stage would be to work on standing prior to gait
Sensory integration
Providing individuals with neurological deficits require sensory input to assist with understanding their environment and how to respond to it
Postural control
Emphasizing the need for appropriate postural alignment and stability to aid in improving movement patterns
Hands on approach
Therapists provides tactile feedback to given individual knowledge of correct movement patterns
Frenkel exercises
Description:
Frenkel exercises are slow, repetitive, and precise movements performed in supine, sitting, and standing positions.
They emphasize visual control to compensate for loss of proprioception.
Movements are performed actively, and the patient is instructed to watch their limbs while moving.
Exercises are progressed from simple to complex, and from unilateral to bilateral movements.
Rhythm, speed, and range are gradually increased as control improves.
Can be done with or without verbal cues and metronome guidance to aid timing.
Role in neurological rehabilitation:
Improves coordination in patients with sensory ataxia, where proprioceptive feedback is diminished.
Promotes motor control and timing through visual compensation and repetition.
Enhances concentration and motor planning through attention to precise limb movement.
Example exercises:
Treatment strategies for individuals with pusher syndrome
Treatment strategies can include the following;
Do not push/pull to correct posture
Utilize visual cues in the environment to assist with achieving upright position such as door frames or windows
This gives the individual with pusher syndrome a cue as to what is vertical
Stand/sit with non-paretic side against wall to provide support for vertical alignment
Increase weightbearing to paretic side through manual pressure techniques
Place tape on floor to assist with giving visualization of vertical
Distract non-paretic side to avoid pushing by this extremity
Outcome measures
Berg balance scale
Purpose: predict risk for fall and prescription of assistive device
Setting: inpatient rehab, outpatient
Special considerations:
assesses individual in static and dynamic positions in both sitting and standing
score of 45 or less indicates an increased fall risk
Functional gait assessment (FGA)
Purpose: evaluate balance and postural stability during gait
Setting: inpatient rehab, outpatient
Special considerations:
Deviation of the dynamic gait index (DGI) to allow for improved reliability and decrease the ceiling effect (can be used in a diversity of populations)
Score of 22 or less indicates increased risk for fall
Can be used to show change in disease process with a change of 4 or greater indicating significant change in disease process
Dynamic gait index (DGI)
Purpose: measures an individual’s ability to respond to changing demands beyond steady-state walking- specifically for individuals with balance and vestibular deficits
Setting: inpatient rehab, outpatient
Special considerations:
Tests incorporates head turns, stepping over objects, avoiding obstacles as testing components- may be good for high level patents with balance deficits
Score of 19 or less is predictive of falls
Tinetti (POMA)
Purpose: measures balance and gait to determine an individual’s risk for falling
Setting: inpatient rehabilitation, outpatient
Special considerations:
Tests static balance in chair and standing, gait, perception of balance during activities, and fear of falling
Score of 19-23 indicates moderate fall risk, 18 or less indicates high fall risk
Functional reach
Purpose: measure an individual’s balance and stability as related to risk for falling
Setting: acute care, inpatient rehabilitation, outpatient
Special considerations:
Reaching 10 inches or greater indicates low fall risk
Used for individuals who demonstrate difficulty with stepping strategies and reaching outside base of support
Fugl meyer
Purpose: evaluate and quantify motor function recovery in areas of severity of motor impairments, balance, and sensory status post stroke
Setting: inpatient rehabilitation
Special considerations:
Max score is 226 points
Goal is to demonstrate progress with intensive therapy
There is no normal score - the goal is to increase the independence level as therapy interventions are performed
Typically taken at initial evaluation and discharge
Activities- specific balance confidence scale (ABC scale)
Purpose: measure self-reported confidence level in performing without losing balance or feeling unsteady
Setting: outpatient
Special considerations:
This is a self-report survey
Confidence levels is rated by percentages
Score for 80% or higher is high-functioning
50-80% is moderate functioning
50% is low functioning
5 time sit to stand
Purpose: assesses lower limb muscle strength, balance, and functional mobility
Setting: acute care, inpatient rehabilitation
Special considerations:
Norms are established by age
11.4 seconds for 60-69 ages
12.6 seconds for 70-79 ages
14.8 seconds for 80-89 age
Timed up and go (TUG)
Purpose: assess mobility, balanced, and walking while estimating fall risk
Setting: inpatient rehabilitation, outpatient
Special considerations:
Score of 10 seconds or less is considered normal
Functional independence measure (FIM)
Purpose: evaluates an individual’s level of disability and amount of assistance needed to perform mobility and ADLs
Setting: inpatient rehabilitation
Special considerations:
Consists of 18 items that aid in development of goals for patients and give objectivity to level of function
There is no normal score - the goal is to increase the independence level as therapy interventions are performed
Common neuromuscular medications
Levodopa
Mechanism of Action: Replaces dopamine in basal ganglia- use for Parkinson’s disease
