Motor Learning/Control

Question 1

If deficient, improving __ and __ will help improve stair climbing and fast gait speed. Additionally ___ is associated with FIM scores, particularly with items of locomotion and stairs. What else can impact?

Answer 1

If deficient, improving LE STRENGTH & POWER will help improve stair climbing and fast gait speed. Additionally BALANCE is associated with FIM scores, particularly with items of locomotion and stairs.
- Are they depressed?

If you can improve any of the above, you might expect to see improved fast walking & stairs, and ultimately community mobility!

Question 2

Community mobility involves multiple domains! Name a few…

Answer 2

Traffic level
Minimum distance
Time constraints
Ambient condition
Terrain characteristics
External physical load
Attentional demands
Postural transitions (e.g. getting in/out of a car, on/off a bus)

Question 3

Sleep after motor skill practice results in performing the task [faster/slower], with [more/fewer] errors and [more/less] efficiently compared to after a similar time spent awake. This is especially true of tasks that were taught [implicitly / explicitly], [discrete/continuous] tasks, and of [simple / complex] tasks. How much sleep is needed? When? How about older adults? How about post-CVA?

Answer 3

Sleep after motor skill practice results in performing the task FASTER with FEWER errors and MORE efficiently compared to after a similar time spent awake. This is especially true of tasks that were taught EXPLICITLY (e.g. with a lot of instruction/cues), DISCRETE (more so than continuous) tasks, and of COMPLEX (more so than simple) tasks. Research is VARIABLE re: amount of sleep needed (many hours vs 45 min nap) and when sleep occurs.
Older healthy adults do NOT benefit from sleep as much, perhaps d/t age-related sleep changes.
After CVA, you can see sleep alterations in up to 50% of people post chronic CVA. They benefit from sleep for discrete more so than continuous tasks, and for implicit more than explicit (instructions) tasks. You should be screening for sleep disorders & encourage sleep after practice!

Question 4

Feedback from errors drives the formation of internal ___, which allow feed[forward/back] control and are important in learning stemming from [what part of the brain?]. Reduction of errors has been shown to [aide / hinder] learning. How does physical guidance fit in??

Answer 4

Feedback from errors drives the formation of internal MODEL, which allow feedFORWARD control and are important in learning stemming from CEREBELLUM. Reduction of errors has been shown to HINDER learning.

Physical guidance may be necessary when the task is very difficult since errors would be so large that they would difficult from the actual task (e.g. falling over when trying to walk, inability to move leg to step) but does not allow for any error detection/correction.

Question 5

Errorless learning was developed for treating individuals with impaired __ and __ function. The rationale is that [implicit / explicit ] memory is responsible for recognizing and correcting errors - with certain cognitive deficits, these errors may not be recognized, so they’re not corrected. Instead, these are implicitly consolidated into long term memory via ___ practice. For errorless learning, task is divided into [many small / one continuous ] step(s) so errors can be corrected immediately.

Answer 5

Errorless learning was developed for treating individuals with impaired MEMORY and EXECUTIVE FXN. The rationale is that EXPLICIT memory is responsible for recognizing and correcting errors - with certain cognitive deficits, these errors may not be recognized, so they’re not corrected. Instead, these are implicitly consolidated into long term memory via LOTS OF practice. For errorless learning, task is divided into MANY SMALL step(s) so errors can be corrected immediately.

Question 6

How does mental practice help? What populations does this not work in vs may work well for?

Answer 6

Increases cortical excitability, scores on Wolf Motor Fxn test and Fugl Meyer

Need sufficient cognition to comprehend/carry-out. Helpful in that it is non-fatiguing. Does best if someone has prior experience with mental practice.

Parietal lobe damage PREVENT MP ability.
Frontal lobe and BG damage IMPAIR MP ability
Some evidence suggests that MP may be helpful in PD & Cerebellar disorders!

MP cannot be used in and of itself - used in conjunction w/other therapies! Unsure what the optimal regimen is.

Question 7

What parts of the brain are most responsible for procedural motor learning, including the acquisition and retention of automaticity?

What part of the brain is most responsible from learning from errors?

Answer 7

Basal ganglia and cortical connections are most responsible for proecdural learning

Cerebellum is most responsible for learning from errors

Question 8

Circuits involved with reward-based and goal-directed learning are the [rostral/caudal] regions of the ____ and the ___ cortex. What neurotransmitter is involved? This type of learning tends to occur [initially / later] and is most responsible for [ improved performance / retention]

Answer 8

Circuits involved with reward-based and goal-directed learning are the ROSTRAL (ASSOCIATIVE) regions of the BASAL GANGLIA and the PRE-FRONTAL cortex. DOPAMINE and D1/D2 receptors are involved. This type of learning tends to occur INITIALLY and is most responsible for IMPROVED PERFORMANCE

Question 9

Circuits involved with learning via extended practice are the [rostral/caudal] regions of the ____ and the ___ cortex. What neurotransmitter is involved?
This type of learning tends to occur [initially / later] and is most responsible for [ improved performance / retention]

Answer 9

Circuits involved with learning via extended practice are the CAUDAL (SENSORIMOTOR) regions of the BASAL GANGLIA and the SENSORIMOTOR cortex. DOPAMINE and D1/D2 receptors are involved.
This type of learning tends to occur LATER and is most responsible for RETENTION

Question 10

Depletion of [neurotransmitter?] in caudal basal ganglia results in abnormal [performance / retention] therefore loss of automatic motor control. In mild to mod PD, they might have [faster/slower] learning rates, so efficiency of learning changes. How does this change practice needs?

Answer 10

Depletion of DOPAMINE in caudal basal ganglia results in abnormal RETENTION therefore loss of automatic motor control. In mild to mod PD, they might have SLOWER learning rates, so efficiency of learning changes. Needs greater than normal amounts of practice; start early in the disease process as it takes more time for learning/automaticity. Important to match learning environment to daily functional situations!

Question 11

Learning in PD

In mild to mod PD, they might have [faster/slower] learning rates, so efficiency of learning changes.

• How does this change practice needs?
• Role of sensory cueing?
• Dual task training?

Answer 11

In mild to mod PD, they might have SLOWER learning rates, so efficiency of learning changes, but they CAN learn. Needs greater than normal amounts of practice; start early in the disease process as it takes more time for learning/automaticity. Important to match learning environment to daily functional situations! With high-demand/challenge practice conditions, motor learning was preserved ONLY when retention test used matched the same practice conditions! This highlights the difficulty with “task switching” in PD

• Sensory cueing: use of auditory/ visual /somatosensory cues improves speed and step length after 9 x 30 min sessions for 3 weeks, with retention at 6 wks! Improves automaticity of walking. Be sure to wean cue to reduce dependence on them.
• Dual task training: 1 x 20 min session fo walking dual task training improves walking step length & speed in 3-6 different dual task! Practicing (via gait training, cog strategies, external cueing) reduces the attentional demands of walking -> greater automaticity

Question 12

How does the presence of freezing of gait in PD affect learning? Can you train protective stepping in these indivudals?

Answer 12

In PD, those with freezing of gait (FOG) have more difficulty with implicit learning than those without freezing!

Those with +FOG did not improve as much and did not retain as well following training of protective stepping. Suggests that motor learning is impaired in those with +FOG, but it is not absent! They CAN learn! They may need more training.

Question 13

The following are considered “goal-based exercise” and can be helpful to improve performance via principles of ___. What do each of the following specifically help to improve?

• Treadmill training
• Amplitude training
• Tai chi
• Dancing
• Boxing

Answer 13

The following are considered “goal-based exercise” and can be helpful to improve performance via principles of NEUROPLASTICITY (think: intensity, repetition, specificity, difficulty, and complexity of practice). What do each of the following specifically help to improve?

• Treadmill training: improves gait parameters
• Amplitude training: verbal feedback and attention strategies, improves movement speed and amplitude
• Tai chi: cognition/balance, decreases falls
• Dancing: challenges cognition/balance with partner, external cues w/music -> improves balance and gait
• Boxing: improves balance and gait

Question 14

Benefit of aerobic exercise in neuro populations?
Aim for sustained/vigorous exercise at __-__% HRMax!

• Increases in __ and changes in the brain environment which may enhance neuroplasticity and improve ___.
• Evidence for combination fo goal-based + aerobic exercising (e.g. adding TM training to a cycling routine)
• May improve __ function and have other effects

Answer 14

Benefit of aerobic exercise in neuro populations?
Aim for sustained/vigorous exercise at 60-80% HRMax!

• Increases in BLOOD FLOW and changes in the brain environment which may enhance neuroplasticity and improve MOTOR LEARNING.
• Evidence for combination fo goal-based + aerobic exercising (e.g. adding TM training to a cycling routine)
• May improve COGNITIVE function and have other effects

Question 15

Motor learning in Cerebellar dysfunction:
- Damage to Cb generally leads to impairments in ability to learn from movement __. Training/learning [can / cannot] occur, though evidence is limited and imprecise.

Small study (Keller and Bastain 2014) N=14 in degenerative Cb dz did a 6-wk HEP without a control group, HEP involved static and dynamci sitting and standing, not much gait due to safety concerns. Resulted in improved walking speed, some gait parameters, TUG, DGI, all maintained at 1 month post (except TUG)!. Found that increases in walking speed were affected by the level of ___.

Answer 15

Motor learning in Cerebellar dysfunction:
- Damage to Cb generally leads to impairments in ability to learn from movement ERRORS. Training/learning CAN occur, though evidence is limited and imprecise.

Small study (Keller and Bastain 2014) N=14 in degenerative Cb dz did a 6-wk HEP without a control group, HEP involved static and dynamci sitting and standing, not much gait due to safety concerns. Resulted in improved walking speed, some gait parameters, TUG, DGI, all maintained at 1 month post (except TUG)!. Found that increases in walking speed were affected by the level of BALANCE CHALLENGE. Aim for DIFFICULT BUT DOABLE!

Question 16

Motor learning principles in Cerebellar Dysfunction
What to practice:
- Patient-focused adaptability (what do you need to be able to do in what environments?)
- Practice tasks in the contexts they need to do! (as they have difficulty adjusting to internal and external forces)
- Address gait ataxia by addressing [ coordination and accuracy exercises / balance activities such as stability during standing and gait]. Recall, deficits in [balance / coordination] yield gait ataxia!
- Reduce dual task demands at first, then gradually reintroduce, moving from feed [back/fwd] to feed[back/fwd].

How to practice:

• [ Easy / work at edge of ability]
• Practice [a little / a LOT] can result in plasticity
• May benefit from [explicit / implicit] cues to compensate for lack of [explicit / implicit] processes
• Move [quickly / slowly] - why??

Answer 16

Motor learning principles in Cerebellar Dysfunction
What to practice:
- Patient-focused adaptability (what do you need to be able to do in what environments?)
- Practice tasks in the contexts they need to do! (as they have difficulty adjusting to internal and external forces)
- Address gait ataxia by addressing BALANCE activities such as stability during standing and gait. Recall, deficits in BALANCE (not LE coordination!) yield gait ataxia!
- Reduce dual task demands at first, then gradually reintroduce, moving from feedBACK to feedFORWARD

How to practice:

• WORK AT EDGE OF ABILITY
• Practice PRACTICE PRACTICE can result in plasticity
• May benefit from EXPLICIT cues to compensate for lack of IMPLICIT processes (they lack implicit prediction / feed forward! Visual feedback is GOOD since feedforward isn’t working as well!
• Move SLOWLY! They have difficulty with predicting internal and external forces on limbs (F=MA), so moving more quickly is harder and increases dysmetria; moving more slowly lets them use more visual feedback mechanisms. But recall some individuals with Cb lesions also have oculomotor problems (saccades, sm pursuit etc) so vision may or may not be helpful for them

Question 17

Motor learning in Alzheimer’s:
- Faulty [implicit / explicit] learning, therefore they do not recognize or correct errors in movement, so instead those errors are consolidated into learning.

So, aim for ___ learning! Principles include:

• [long task sequences / break tasks into small steps]
• [Delayed feedback / correct errors immediately with verbal cues]
• Set up exercise/activity so errors are [more / less] likely to occur
• Provide demonstration and verbally guide individual through task
• [Keep / fade] verbal cues when steps are performed correctly
• [ high / low] # of reps, ideally engage __ to help with carryover
• In mild to moderate dementia, this learning can preserve for weeks to months - they [can / cannot] acquire new or regain forgotten skills! Keep tasks ___

Answer 17

Motor learning in Alzheimer’s:
- Faulty EXPLICIT learning, therefore they do not recognize or correct errors in movement, so instead those errors are consolidated into learning.
So, aim for ERRORLESS learning! Principles include:
- BREAK TASK INTO SMALL STEPS
- CORRECT ERRORS IMMEDIATELY WITH VERBAL CUES
- Set up exercise/activity so errors are LESS likely to occur
- Provide demonstration and verbally guide individual through task
- FADE verbal cues when steps are performed CORRECTLY
- HIGH # of reps, ideally engage CAREGIVERS/FAMILY to help with carryover

• In mild to moderate dementia, this errorless learning can preserve for weeks to months - they CAN acquire new or regain forgotten skills! Keep tasks MEANINGFUL (using a phone, coffee maker; remembering family names)

Question 18

Motor learning in TBI:

• Evidence is [robust / limited]
• Learning is likely influenced by site/severity of brain lesion
• Consider cognitive effects: if pt has impaired explicit memory, focus training on [implicit / explicit] tasks; impact of impaired attention
• Some evidence indicates impaired learning to adapt to novel environments. Aim for training to increase the __ and __ of practice!

Answer 18

Motor learning in TBI:

• Evidence is LIMITED
• Learning is likely influenced by site/severity of brain lesion
• Consider cognitive effects: if pt has impaired explicit memory, focus training on IMPLICIT tasks; impact of impaired attention
• Some evidence indicates impaired learning to adapt to novel environments (e.g. community mobility). Aim for training to increase the AMOUNT and VARIABILITY of practice!

Question 19

Motor Learning with Cerebral Palsy

• Feedback schedules: 100% feedback had less error than reduced feedback (similar to typically-developing peers). Also had less accuracy and consistency vs typically-developing kids w/discrete arm movement task.
• Random vs blocked practice?
• Learning rate [may be delayed / is normal]
• Intensity maters: needs perhaps __-__x more practice than peers
• Role of errors vs errorless learning?
• Task specificity?

Answer 19

Motor Learning with Cerebral Palsy

• Feedback schedules: 100% feedback had less error than reduced feedback (similar to typically-developing peers). Also had less accuracy and consistency vs typically-developing kids w/discrete arm movement task.
• Random vs blocked practice? No clear advantage of one over the other, though random resembles naturalistic setting
• Learning rate MAY BE DELAYED
• Intensity maters: needs perhaps 2-3x more practice than peers
• Role of errors vs errorless learning? Able to learn with errorless or while making errors! However fewer errors = more learning occurs ABLE TO LEARN.
• Some evidence that making errors BIGGER (e.g. putting weights on weaker leg w/gait training) were helpful in learning
• Task specificity? Aim for challenging, progressively more demanding, and active participation. Meaningful tasks, appropriate environment.

Question 20

Individuals with developmental coordination disorder demonstrate substantially [more/less] skill with daily activities which require motor coordination compared to their peers. Motor disturbance significantly interferes with __ and __. This [is / not] attributable to ___ [disease state?]

Answer 20

Individuals with developmental coordination disorder demonstrate substantially LESS skill with daily activities which require motor coordination compared to their peers. Motor disturbance significantly interferes with ACADEMIC ACHIEVEMENT or ADLs. NOT DUE TO a general medical condition (eg. CP).

Question 21

Motor Learning in individuals with Developmental Coordination Disorder

• Impaired ___, with resultant difficulty seeing similarities between tasks and transferring skills, generalizing from one situation to another, or modifying movement to meet changes in task/environment.
• Rely predominantly on ___ information (indicating they’re stuck in the early stages of motor learning)
• Most impaired, but heterogenous population

Answer 21

Motor Learning in individuals with Developmental Coordination Disorder

• Impaired ADAPTABILITY, with resultant difficulty seeing similarities between tasks and transferring skills (e.g. walking balance beam vs curb), generalizing from one situation to another, or modifying movement to meet changes in task/environment (e.g. throwing a ball in a different direction, throwing a heavy ball vs lighter)
• Rely predominantly on VISUAL information (indicating they’re stuck in the early stages of motor learning)
• Most impaired, but heterogenous population

Question 22

Factors influencing motor learning in Developmental Coordination Disorder:
- Impaired __ recognition. These individuals show large variability in performance normally, which impacts what their body/brain perceives as an ___. I.e. errors in response to task changes were considered normal, so they weren’t recognized or corrected. They use [implicit/ explicit] system for error recognition, but it might be impaired

• Task difficulty: they can learn simple task as rapidly/accurately as peers, but are slower and less accurate with a more complex task.
• Explicit vs implicit learning and teaching?
• Comorbidity - this is often found in developmental disorders e.g. dyslexia, reading disabilities, and ADHD - they need a lot of ___
• Affect of motivation?

Answer 22

Factors influencing motor learning in Developmental Coordination Disorder:
- Impaired ERROR recognition. These individuals show large variability in performance normally, which impacts what their body/brain perceives as an ERROR. I.e. errors in response to task changes were considered normal, so they weren’t recognized or corrected. They use EXPLICIT system for error recognition, but it might be impaired

• Task difficulty: they can learn simple task (e.g. visual motor task) as rapidly/accurately as peers, but are slower and less accurate with a more complex task (think about that optimal challenge point for them!)
• Explicit vs implicit learning and teaching? Explicit training is used frequently, but they can also learn implicitly! (though the literature is conflicting)
• Comorbidity - this is often found in developmental disorders e.g. dyslexia, reading disabilities, and ADHD - they need a lot of PRACTICE
• Affect of motivation? Persistent failure/difficulty often leads to these kiddos avoiding motor tasks, adopting a sedentary lifestyle, eventually spending significantly less time participating in physical activity, etc.

Question 23

In developmental coordination disorder, motor learning is [absent / impaired but not absent]. Needs lots of ___ during PT and at home. Enhance ___ - let kid select goals, consider ecological validity, practice games they’ll enjoy! Assist in monitoring performance and detecting __ .

• Use [ implicit / explicit / a mix of both] for teaching and learning
• Provide opportunities to solve motor problems
• What kind of instruction/positioning / handling?
• Practice and feedback schedule?
• Practice environments?

Answer 23

In developmental coordination disorder, motor learning is IMPAIRED BUT NOT ABSENT Needs lots of PRACTICE during PT and at home. Enhance MOTIVATION - let kid select goals, consider ecological validity, practice games they’ll enjoy! Assist in monitoring performance and detecting ERRORS

• Use A MIX OF IMPLICIT AND EXPLICIT teaching and learning
• Provide opportunities to solve motor problems
• VERBAL instruction, as well as positioning, handling, opportunities for visual and observational learning; physical demo and modeling (do along w/the kiddo)
• Practice and feedback schedule? FREQUENT practice and CONSISTENT feedback
• Practice in a variety of environments to optimize transfer and generalization!