this motor task strengthens this internal motor program and minimizes the chance of errant hand position in the future. In designing practice sessions for individuals with typical cognition, the goal is to expand the motor program so that the individual has motor flexibility and can adapt to real-life situations. This is done through variable, random practice. In AD, there is evidence to support that motor learning is more likely when practice is constant (versus variable) and blocked (versus random) (Dick, Hsieh, Dick-Muehlke, Davis, & Cotman, 2000; Dick et al., 1996; Dick, Hsieh, Bricker, & Dick-Muehlke, 2003); and limited transfer of training should be expected (Dick et al., 2003; Patterson & Wessel, 2002; Ries, 2018; van Halteren- van Tilborg et al., 2007). In effect, the goal in motor learning/ relearning in dementia is to narrow/focus the motor program so that the individual develops consistency in their ability to perform the specific functional task. Consider this in the context of relearning an ADL or in learning how to use a walker after a fall that resulted in a hip fracture – the therapeutic environment and task should be thoughtfully designed to elicit the desired motor response from the patient. When a task has component parts that the therapist feels would be useful to repetitively practice, it may be reasonable to utilize part-to-whole practice with forward chaining (i.e., adding the next component part when the learner masters the previous part). A recent RCT demonstrated that a dementia-specific training strategy for sit- to-stand that integrated errorless learning (using demonstration, fading guidance, and tactile cues) and part-to-whole practice (using forward chaining) was effective in creating sustainable improvement in task performance (Werner et al., 2017). Little is known about the optimal use of feedback for learning in individuals with AD. Cognitively intact adults generally benefit from strategic use of extrinsic feedback (summary versus constant feedback that fades over time, to encourage more reliance on intrinsic processes of the learner), but the cognitive abilities of individuals with AD may not support the ability to internalize feedback. One small study compared the ability of individuals with AD to learn a novel computer-based task with 33% versus 100% knowledge of results feedback and determined the lesser amount of feedback to be superior in skill retention (Rice, Fertig, Maitra, & Miller, 2008). Constant visual feedback may be useful in learning motor skills (Dick et al., 2001; Ries, 2018; van Halteren-van Tilborg et al., 2007), and feedback can be used to motivate and encourage participation. Finally, successful motor learning requires the appropriate level of challenge and intensity of training (Dawson, Judge, & Gerhart, 2017; Littbrand et al., 2006; Ries, Hutson, Maralit, & Brown, 2015; Telenius, Engedal, & Bergland, 2015; Toots et al., 2016). Table 5 presents a summary of the characteristics of successful motor learning interventions for this population. Therapists are encouraged to integrate as many components of the available evidence as possible to create the most effective interventions for individuals with AD.
learning (van Tilborg & Hulstijn, 2010); this finding justifies assumptions that neuroanatomical regions are associated with different types of learning. Therapists of patients with AD are cautioned not to totally discount explicit learning strategies, particularly in early stages of dementia, because some small studies have demonstrated success with declarative learning of motor and functional skills (van Tilborg, Kessels, & Hulstijn, 2011a, b). If rehabilitation professionals devote conscious attention to structuring practice sessions to facilitate implicit learning, they stand the best opportunity for success. A dementia care model presented by Harrison and colleagues (2007) integrated individuals’ preserved implicit memory into interventions using motor skill learning and perceptual priming to improve and maintain performance on self-care tasks. Individuals with AD may be able to process information about an object’s physical features, such as shape, color, and size (perceptual priming), even if they are unable to process information about an object’s meaning and associated representations (conceptual priming). Though not well tested, this model suggests that repetitive perceptual priming (interaction with relevant objects and environments) and constant practice of the task may improve (or delay the loss of) function. For instance, an ADL task such as oral care may be optimally maintained if the conditions under which it is practiced are familiar and consistent (e.g., smell and taste of toothpaste, feel of the toothbrush, sound of the morning news playing on the radio). Another relatively recent addition to the motor learning literature related to AD, although evident in cognitive rehabilitation literature, is the concept of errorless learning, which utilizes strategies directed at eliminating errors when learning or relearning skills. Individuals with AD are not able to self-monitor their errors or learn from their mistakes like their cognitively intact peers, so minimizing or eliminating mistakes improves the chances of strengthening the optimal motor program for the task at hand. While there is some support for errorless learning strategies in dementia (de Werd, Boelen, Rikkert, & Kessels, 2013; Kessels & de Haan, 2003; Li & Liu, 2012), a recent randomized controlled trial (RCT) demonstrated equivocal results in comparing errorless learning to trial and error learning when retraining relevant ADL tasks – both strategies were equally effective (Voigt-Radloff et al., 2017). Errorless learning strategies include feed-forward instruction, task modeling, mnemonics, and tapered guidance of the task. Errorless learning strategies require the therapist to rely on their powers of observation, anticipation, and movement expertise, as the goal is to avoid any and all motor errors when learning or relearning a skill. For example, an individual new to walker use being trained for optimal hand placement during sit-to- stand transitions would be carefully instructed and monitored to push from the chair with one or both hands for standing (versus positioning both hands on the walker). Consistently encouraging the proper hand positioning while the individual is learning
Table 5: Characteristics of Successful Motor Learning Interventions Characteristics and Strategies Exploit implicit memory and learning in design of treatment sessions: • Learning by doing is the goal. • Treatment environment and task should elicit the desired response. • Functional context is desirable.
References
Harrison et al., 2007; Patterson & Wessel, 2002; Ries, 2018; van Halteren-van Tilborg et al., 2007; Vidoni & Boyd, 2007. Dick et al., 1996; Dick et al., 2000; Dick, et al., 2003; Harrison et al., 2007; Patterson & Wessel, 2002; Ries, 2018; van Halteren-van Tilborg et al., 2007. Dick et al., 2000; Patterson & Wessel, 2002; Ries, 2018; van Halteren-van Tilborg et al., 2007.
Utilize constant (versus variable) and blocked (versus random) practice sessions to facilitate task learning and relearning; consistency in task practice is key: • Practice the specific needs of the anticipated living environment and goal task. • Repetitive and consistent practice facilitates learning. • Finish each component of treatment before moving on to the next. Be mindful of specificity of training; train to the specific desired task or tasks: • Expect limited to no transfer of training. • Highlight functional (versus abstract) tasks. • Treatment in the living environment (e.g., home care, skilled nursing facility) is ideal for specificity of training.
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