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- Table 4: Principles Relevant to Enhancing Skill Acquisition What the Learner Needs to Hear Underlying Principles “Just do it!”
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.
“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 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
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