Winstein and colleagues (Winstein & Kay, 2015; Winstein, Lewthwaite, Blanton, Wolf, & Wishart, 2014) offer support and guidelines for the Accelerated Skill Acquisition Program (ASAP) that put motor learning principles into a conceptual framework that is driven by the fundamental components of the skill of interest, the individual’s capacity to perform the skill, and the individual’s motivation. Their model is both theoretical and practical, and it integrates principles of neurorehabilitation, motor learning, neuroscience, exercise physiology, and behavioral science. Table 4 presents a summary of principles relevant to motor learning and skill acquisition that are important for therapists to consider in creating treatment programs for all clients. In planning practice sessions for optimal motor learning, consideration of the amount of practice, the practice conditions, and the use of feedback to best suit the needs of clients are all important. Regardless of the patient population, it is generally believed that more is better when it comes to practice. Cognitively normal adults may benefit from variable (as opposed to constant) and random (as opposed to blocked) practice sessions because it serves to broaden the motor program and give them the flexibility to adapt to real-life variable situations. For instance, if a cognitively intact client is struggling with sit-to- stand transfers, it makes for good therapy to practice sit-to-stand transfers in variable practice conditions (e.g., from a variety of seating surfaces, heights, types of chairs) and in random practice conditions (e.g., interspersed among other activities that are being practiced). This is not the case for an individual with AD.
Figure 5: Mechanisms of Motor Learning
Note . Content adapted from Shumway-Cook A. and Woollacott M.H. Motor Control: Translating Research into Clinical Practice, 5th ed. (2017). Philadelphia PA: Wolters Kluwer. Baltimore, MD: Lippincott Williams & Wilkins; and Vidoni, E. D., & Boyd, L. A. (2007). Achieving enlightenment: What do we know about the implicit learning system and its interaction with explicit knowledge? Journal of Neurologic Physical Therapy, 31 (3), 145-154. Table 4: Principles Relevant to Enhancing Skill Acquisition What the Learner Needs to Hear Underlying Principles “Just do it!”
“Use it or lose it” is relevant for motor tasks and the brain tissue that supports the tasks. A lack of practice can negatively impact the underlying brain function. Appropriate practice can enhance the underlying brain function. Practice and repetition are key to motor learning and are the most important factors in skill acquisition and underlying neural changes. Intensity is important to motor learning and underlying neural plasticity (similar to the physiological principle of overload in strength training). Solving a motor problem is more useful and meaningful to the learner than being told what to do; it facilitates strengthening of the underlying motor program. Practice activities must be meaningful or salient to the learner for optimal engagement and plasticity; learners should “buy in” to what they are practicing instead of simply doing what they are told to do. There is a challenge threshold for optimal skill acquisition. The task should be challenging to the learner, but it should not exceed the learner’s frustration limits. The level of challenge is too much if performance consistently breaks down. The level of challenge is not enough if the learner is consistently successful. The nature of training influences the nature of neural plasticity. Specificity of training is important for this reason; generally speaking, it is reasonable to train to the task or goal at hand. The transfer of training is possible; learning one skill may have some impact on similar or related skills. Learners benefit from goal-directed tasks and practicing the whole task in context when possible.
“Do it again (and again, and again . . . because practice makes perfect!).”
“Work hard. Play hard.”
“Figure it out.”
“Question authority.”
“How hard is too hard?”
“What is the goal?”
“Do it from start to finish.”
“You can do it! Believe in yourself.” Motivation is important. Promote learner self-confidence. Celebrate success. Note . Table content adapted from Kleim, J. A., & Jones, T. A. (2008). Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research, 5 1(1), S225-S239. https://doi.org/10.1044/1092- 4388(2008/018); and Winstein, C. J., & Kay, D. B. (2015). Translating the science into practice: Shaping rehabilitation practice to enhance recovery after brain damage. Progress in Brain Research, 218 , 331-360. http://dx.doi.org/10.1016/bs.pbr.2015.01.004. Motor learning in Alzheimer’s disease
Individuals with AD often have intact implicit/procedural motor learning capacity (Harrison et al., 2007; Patterson & Wessel, 2002; Ries, 2018; van Halteren-van Tilborg, Scherder, & Hulstijn, 2007; Vidoni & Boyd, 2007). The primary areas implicated in AD (hippocampus and surrounding medial temporal lobe
structures) are responsible for explicit learning and memory; thus, individuals with AD have an impaired ability to use explicit strategies. In contrast, individuals with Parkinson’s disease (who have a more intact hippocampus but significant basal ganglia pathology) may show a more limited ability for implicit motor
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