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 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.
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. Integrate errorless learning strategies (eliminate or minimize possible mistakes made by the learner), or structure the environment so errors are less consequential: • Use feed-forward instruction, mnemonics, task modeling, tactile guidance, and cues. • Using excellent observation and movement analysis skills, anticipate errors and intervene before they are made. • Taper guidance and cues as learning occurs. Consider part-to-whole practice by deconstructing mobility or ADL skills as appropriate: • Utilize forward chaining (adding the next component part when learner masters the previous part). • Always put component parts back into the whole task prior to finishing practice session.
de Werd et al., 2013; Kessels & de Haan, 2003; Li & Liu, 2012; Ries, 2018.
Werner et al., 2017; Ries, 2018.
Access to visual feedback may support learning: • Assure appropriate and clean prescription eyewear. • Provide external motivation with visual cues.
Dick et al., 2001; van Halteren- van Tilborg et al., 2007; Ries, 2018. Dawson et al., 2017; Littbrand et al., 2006; Ries et al., 2015; Ries, 2018; Telenius et al., 2015; Toots et al., 2016.
Practice with appropriate level of challenge and intensity: • Patients should be challenged at the highest level possible. • Rest breaks should be offered only when necessary (i.e., the patient truly needs to rest).
Note . From Western Schools, 2020.
Page 16
Book Code: PTNY3622B
EliteLearning.com/Physical-Therapy
Powered by FlippingBook