Occupational therapists help patients retrain motor skills through principles of motor learning. Therapists intervene to help patients achieve independence in daily living skills. Ideally skills are taught in the actual environment but clinics are also used. Four factors influence motor learning - the stages of learning, type of task, feedback, and practice. Feedback and practice are especially important for improving performance. Therapists can apply motor learning principles to benefit patient treatment.
Occupational therapists help patients retrain motor skills through principles of motor learning. Therapists intervene to help patients achieve independence in daily living skills. Ideally skills are taught in the actual environment but clinics are also used. Four factors influence motor learning - the stages of learning, type of task, feedback, and practice. Feedback and practice are especially important for improving performance. Therapists can apply motor learning principles to benefit patient treatment.
Occupational therapists help patients retrain motor skills through principles of motor learning. Therapists intervene to help patients achieve independence in daily living skills. Ideally skills are taught in the actual environment but clinics are also used. Four factors influence motor learning - the stages of learning, type of task, feedback, and practice. Feedback and practice are especially important for improving performance. Therapists can apply motor learning principles to benefit patient treatment.
Application of Motor ing and retraining of motor skills and motor
Learning Principles in tasks. The therapist's role is to intervene in the
learning process to assist patients in achieving indepen- dence in the performance of daily living skills. Ideally, Occupational Therapy intervention would be done in the actual environment in which the skill will be performed, such as in the home or on the work site. Because this is not always feasible, Janet L. Poole however, the skills that patients master in the occupation- al therapy clinic are expected to transfer to the patients' home and work environments. Although occupational Key Words: motor activity (physiology) • therapists teach motor skills, most therapists are not motor skills. movement analysis. movement trained as extensively in skill acquisition strategies as are patterns. occupational therapy services physical educators and coaches. Mosey (1986) attributed this lack of attention to the teaching-learning process to therapists' desire to disassociate themselves from the im- age of being teachers. Being a therapist is regarded as The processes under(ying skill acquisition depend on more prestigious than being a teacher. With the excep- the nature of the task and the stage of the learner, In tion of Mosey and Trombly (1989), occupational therapy addition, feedback and practice are two potent learn- textbooks devote little space to motor learning and teach- ing variables when used appropriately in the instruc- ing (Hopkins & Smith, 1988; Pedretti, 1990; Pratt & Allen, tion of motor tasks. Occupational therapists involved 1989). in the training and retraining of motor skills can Some rehabilitation disciplines have already begun benefit }i-om knowledge of instructional methods used by coaches and physical educators, This paper reviews to apply motor learning principles to the functional re- commonly accepted princzples of motor learning and training of patients with neurological impairments (Carr applies these principles to occupational therapy treat- & Shepherd, 1987b; Carr, Shepherd, Gordon, Gentile, & ment. The stage of the learner, type of task, feedback, Held, 1987). Although these principles are in the early practice, and facilitation of skill acquisition are em- stages of validation for patients with pathology, they may phasized. Specific examples of how occupational offer new ideas on how to improve performance. The therapists can use motor learning principles in treat- purpose of the present paper is to describe some of the ment are given. commonly accepted principles of motor learning and to apply these principles to occupational therapy treatment. Specifically, the paper focuses on variables that affect motor learning, such as stages of motor learning, types of tasks, feedback, practice, and, with regard to occupation- al therapy, facilitation of motor skills.
Van abies Affecting Motor Learning
Schmidt (1988) defined motor learning as "a set of pro- cesses associated with practice or experience leading to relatively permanent changes in the capability for re- sponding" (p. 346). The relatively permanent change in behavior is what differentiates learning from temporary improvements in performance. For example, after prac- ticing a transfer several times, a patient may remember how to do it and thus exhibit an improvement in perform- ance. If the patient cannot remember how to execute the transfer the next day, however, the task has nOt been learned. Thus, to estimate learning or relatively perma- Janet L. Poole, MA, OTRJL, is a doctoral student in motor learn- nent changes, performance should be assessed again lat- ing, Department of Health, Physical, and Recreation Educa- er (Schmidt, 1988). tion, and Assistant Professor of Occupational Therapy, School of Health Related Professions, University of Pittsburgh, 116 Four factors influence motor learning: (a) the stages Pennsylvania Hall, Pittsburgh, Pennsylvania 15261. of learning, (b) the type of task, (c) feedback, and (d) practice. Although all of these factors must be considered This article was accepted for publication janumy 24. 1991 by therapists in designing treatment programs, feedback
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and practice are thought to be the two most potent learn- tal)' who has had a stroke begins to feel more comfortable ing variables (Schmidt, 1988). with the new hand placement on the keyboard, and her performance becomes more accurate and consistent. It may take the secretaI)' longer to develop automaticity Stages of Motor Learning than it would a new learner, because the old patterns of Fitts and Posner (1967) defined three sequential stages finger-key aSSignment may be detrimental to new learn- involved in the motor learning process: cognitive, associ- ing (Schmidt, 1988). ative, and autonomous. In the cognitive stage, the learner In the final stage, the autonomous stage, the skill tries to understand the requirements of the motor task. becomes automatic. The skill requires little, if any, cogni- The learner has a vague idea of the task but is unsure of tive processing, so it is less susceptible to interference how to do it. Performance is usually inconsistent because from other ongoing activities or distractions in the envi- the learner is tl)'ing many different strategies to do the ronment. Once control of the prosthesis has become task. Adams (1971) called this the verbal motor stage, automatic, the patient can hold and eat an ice cream cone because learners may need to verbalize the movement and walk down a crowded hall without crushing the cone. strategies. For example, a patient with an above-elbow Instructions in this phase focus on a particular aspect of amputation learning to use a prosthetic arm to grasp the skill. As long as some parts of the skill are automatic, a objects may initially use awkward whole-body positions person can focus on other aspects of performance. The while attempting the task. VerbaliZing the sequence of secretaI)' will be able to look at the material to be typed prepositioning the terminal device, positioning the el- rather than the keyboard, and practice would be focused bow, and locking the elbow joint may be necessal)' to get on increasing speed without sacrificing accuracy. the terminal device in the right position to grasp the object. During this first stage, the learner must begin to Types a/Tasks attend to the relevant information related to the skill (Gentile, 1972). In learning one-handed typing, a secre- Tasks can be classified along a continuum based on the taI)' who has had a stroke understands the task but needs type of environment in which they are performed (Gen- to attend to new finger-key assignments. tile, 1972; Poulton, 1957). The environment may range In the associative stage, or intermediate stage, from stationary for closed tasks to constantly in motion learners begin to refine their skills. Through continu- for open tasks. Critical features of the environment deter- ous practice and repetition, the learner's movements mine the spatial and temporal arrangement of a perform- become more consistent and errors begin to decrease. er's movements. For example, the shape, size, and type of During this stage, the structure of the practice period is handle on a cup will determine the configuration of the an important consideration (Fitts & Posner, 1967). Er- person's hand prior to grasping the cup. Another exam- ror-free practice has been advocated by some theorists ple is how, when attempting to cross a busy street, a so that the learner develops an internal reference of pedestrian's path and speed of movements are con- correctness, or sensol)' feedback of the correct move- strained by the street terrain and by the speed, location, ment (Adams, 1971; Kottke, 1980). Incorrect practice of and number of moving vehicles. a task will require unlearning with interference in sub- In closed tasks, the critical features, such as objects, sequent attempts to respond correctly (Adams, 1971; people, and the terrain, are stationary, and a performer is Lawther, 1977). Learners may use information about constrained by the spatial features of the environment. errors, however, to adjust subsequent movements that Quite different movements would be reqUired to position may increase the ability to generalize to new motor a pencil for writing when the pencil is upright, lead side tasks. Edwards and Lee (1985) showed that subjects down, in a pencil holder than when it is lying flat on a who were allowed to make errors while learning a task desk. Timing is not specified in closed tasks, because they performed better on a novel task than did subjects who are self-paced and the learner deCides the start, finish, had practiced in an errorless learning situation. and duration of the task. Many tasks in the home are Guidance is decreased as the learner begins to form closed. One usually stores grooming and hygiene materi- appropriate associations between the movement plan als in the same location, using consistent movement pat- and the sensol)' consequence, that is, the learner learns terns to perform grooming tasks. The spatial features of what feels right (Winstein, 1987). Feedback should be the environment, however, may vary across trials. Gentile more precise, but it should start to decrease so that the (1987) referred to tasks in which the objects or tools vary learner becomes less dependent on it (Bilodeau & Bilo- in position across time but are stationary during perform- deau, 1958). Learners are encouraged to develop their ance as variable motionless tasks. For example, eating, own error-detection mechanisms (Winstein, 1987). With using the toilet, and some aspects of dressing are often practice, the person with an amputation begins to learn routinely performed in places other than the home envi- what feels right, and the movements to operate the termi- ronment. Thus, one may have to deal with different styles nal device become more subtle and smooth. The secre- of dishes or types of food, different heights of toilets, and
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different articles of clothing and surfaces available to use senses that his body weight is equally distributed over while dressing. both legs while standing or sees that he has missed a cup In open tasks, the supporting surfaces, objects, or with his hand. Conversely, extrinsic feedback is informa- people in the environment are in motion from one trial to tion from an external source that augments the intrinsic the next (Gentile, 1972). The external environment con- feedback. The external source may be a therapist or a trols the spatial and temporal features of the movement device such as a biofeedback machine or a timer. Feed- and makes predictive demands on the performer. If the back is used in early learning to generate or modify each environment is in motion but the motion remains the successive movement pattern. Later feedback helps com- same across trials, the task is referred to as a consistent pare the movement executed to the reference of correct- motion task. Stepping on to an escalator, lifting luggage ness (Adams, 1971; Schmidt, 1975). The more sensory from a conveyer belt, and sealing boxes moving on an channels through which feedback is provided, the stron- assembly line are examples of consistent motion tasks. ger the reference of correctness will be (Adams, 1971; These tasks require mechanical devices that control a Mulder & Hulstijn, 1985). constant rate of motion in the environment. In a true In the patient with impaired sensation, extrinsic open task, the changes are not predictable, as in catching feedback can be used to augment the absent or impaired a fly ball, walking down a crowded hall, and driving a car. intrinsic feedback. Studies have shown that motor learn- Successful performance of open tasks is determined by ing can occur in the absence of intrinsic feedback. In the the performer's ability to adapt quickly to the changing classic study by Rothwell et al. (1982), the deafferented environment. subject learned new motor tasks while receiving extrinsic Routine homemaking tasks may have an open ele- visual feedback through the use of an oscilloscope. When ment to them. For example, the presence of animals or the visual feedback was removed, the subject could per- young children in motion within the home could force form the tasks, but his performance decayed over time. predictive demands on the performer. The performer The authors concluded that feedback was needed at may have to anticipate the location of the children or some later point in time to update the central nervous animals to avoid tripping over them or, in some instances, system about the success and overall accuracy of the the performer may have to catch the moving object. Many movement. occupations, such as driver, crane operator, and food Two kinds of extrinsic feedback can be provided to service worker, involve open tasks. Moving cars, trucks, learners: knowledge of results and knowledge of per- and people and shifting loads make ongoing attentionaJ formance. Knowledge ofresults is verbal augmented feed- demands on the performer. back about movement outcome that is given after a move- The multitude of tasks that a person engages in dur- ment (Schmidt, 1988). Knowledge of results provides ing any given day vary along a continuum from open to information about errors, thus providing the learner with closed. Outside the home, for example, in the workplace, information on how to modify the movement on the next school, or community environment, continual monitor- attempt. Examples used by therapists may be, "You land- ing of the environment of both stationary and moving ed too near the edge of the bed," "Your shirt is on back- objects is necessary. The therapist's responsibility is to wards," and "You put your left leg in your right pant leg." train the person to do the task in the environment most Knowledge ofperformance is verbal feedback about appropriate to that task. For closed and consistent mo- the nature of the movement that is given after a response tion tasks, practice should occur under fIxed environmen- (Schmidt, 1988) Winstein (1987) suggested that thera- tal conditions to develop movement consistency in attain- pists use knowledge of performance more often than ment of the goal. Exposure to all possible sets of knowledge of results to proVide information that the per- environmental conditions that one may encounter in real former may not be aware of and that is directed toward life is necessary to improve the performance of open and correcting the movemem pattern rather than just the variable motionless tasks (Gentile, 1987; Spaeth-Arnold, movement outcome. Examples of knowledge of perform- 1981) ance are, "You need to shift your weight more to your right leg," "Your hand did not open soon enough," and "Bend your knees and keep your back straight." Feedback Feedback of either type helps to facilitate and accel- Feedback, along with practice, is considered to be a po- erate the learning process. Carr and Shepherd (1987a) tent learning variable (Bilodeau & Bilodeau, 1958; Sal- and Gentile (1987) believed that therapists have not moni, Schmidt, & Walter, 1984; Schmidt, 1988). Feedback placed enough emphasis on verbal feedback for knowl- may be intrinsic or extrinsic. Intrinsic feedback is inher- edge of performance and visual feedback for knowledge ent sensory information from receptors in the muscles, of results. Vision has been reported to play an important joints, tendons, and skin as well as receptors in the visual role in the acquisition and control of movement (Keele & and auditory systems. Intrinsic feedback may occur dur- Posner, 1968; Zelaznik, Hawkins, & Kisselburgh, 1983). ing or after movement production. For example, a patient Furthermore, when visual and verbal feedback were
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eliminated, movement accuracy was impaired, even constant practice. Feeding oneself different textures of though augmented proprioceptive feedback, in the form foods with different utensils, rising from different chair of resistance, was provided (Williams & Stelmach, 1968). heights, and putting on different styles of front-opening The amount and frequency of feedback is determined by upper extremity garments are examples of variable prac- the type of task the performer is engaged in and [he 5[age lice, whereas keeping the food, utensils, chair height, and of learning. style of garment the same across trials are examples of constant practice. Practicing under variable conditions has been shown to increase generalizability to novel situa- Practice tions (Shapiro & Schmidt, 1982). Because it is impossible Practice is a second important variable in motor learning for patients to practice every task they may encounter (Schmidt, 1988). Skill has been shown to increase directly after discharge, variable practice may help with adapta- in relation to the amount of practice (Newell & Rosen- tion to a new situation. bloom, 1981). In the clinic, practice of motor skills is The amount of a skill practiced can range from a limited to time spent in the treatment session, which may subset of components constituting a task, called part be only 1 hr daily or less. Yet studies of skill learning show practice, to practicing the task in its entirety, called whole that it takes many trials to develop skill (Crossman, 1959; practice. The logic behind part practice is that learning Kottke, 1980). Practice, however, involves more than can proceed more efficiently, especially when the task is mere repetition of a movement. It also means the formu- complex (Schmidt, 1988; Singer, 1980). The learner can lation of "new plans of action to solve motor problems spend less time on the parts of the task that were already posed by the environment" (Whiting, 1980, p. 545). mastered. Examples of part practice include practice with Motor learning researchers have devoted consider- only one article of clothing, buttoning buttons on a button able effort to determining the best way to structure prac- board, practicing shoe tying one step at a time, practicing tice (for a review, see Schmidt, 1988). One can manipu- typing with one hand in isolation of the other hand, and late the scheduling of rest periods, the order of the using simulators for driving and work-related tasks. Pall movements or skills practiced, the conditions of the task, practice appears to be effective when the task can be or the amount of the task that is practiced. broken down into steps that are not temporally coordi- Rest periods can be scheduled such that the rest nated with each other (Wightman & Lintern, 1985). For time is less than the practice time, called massed prac- example, the timing of the steps in tying a shoe or putting tice, or greater than the practice time, called distributed on a shirt is not crucial to performance of the task, where- practice. Massed practice is probably not appropriate in as in walking or steering a car, many of the steps that can acute rehabilitation for patients who fatigue easily or who be isolated interact and are performed simultaneously. can control the pace of their daily schedule. Massed prac- At the heart of practice is the issue of transfer. Do the tice, however, may be appropriate in industrial or voca- skills that patients learn in the cliniC transfer to the home tional rehabilitation, specifically, for the injured worker and work environments? For example, do patients actual- who will be returning to a work environment that de- ly use joint protection or body mechanics principles out- mands task repetition or task performance over a certain side the clinic? Is the patient who is independent and safe time period. getting into and out of the bathtub in the clinic also safe The order of the tasks practiced can remain the and independent at home? Stallings (1982) defined trans- same, called blocked practice, or differ, called random fer as "the effect previous practice has on subsequent practice, across trials. In blocked practice, a patient learning or performance" (p. 203). In this respect, trans- might practice grasping styrofoam cups for several tri- fer involves not only transfer from practice in the clinic to als, then pick up coins for several trials; this pattern is performance in the home or on the job, but also transfer then repeated. Random practice, which might require from one motor skill to another and from limb to limb. the grasping of a styrofoam cup, followed by the grasp- For transfer to occur, the learner must have adequate ing of a coin, a coffee mug, and a pencil, requires the experience with the original task and conditions sur- learner to be more alert, because the object grasped on rounding learning a movement. Practice must simulate each trial is different. The advantage of blocked trials is the real-life performance situation as closely as possible that performance improves faster than with random (Stallings, 1982). This implies specificity of training or practice. The disadvantage is that the learner may not practice of the task under the same conditions under attend to the task because he or she knows what to which the task will be performed. Therefore, if patients expect (Lee & Magill, 1983; Shea & Morgan, 1979). are to use correct body mechanics on the job, they should Moreover, learning and recall have been found to im- practice the techniques while actually doing the task. prove more with random practice than with blocked Thus, the use of an activity requiring prolonged tool use practice (Shea & Morgan, 1979). and overhead reaching to simulate an auto mechanic's The conditions of the task may vary across trials, job may not necessarily enable the person to return to his called variable practice, or may remain the same, called or her job.
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For most sports, the practice of drills or parts of a head to the side before commencing a task. The patient whole task in isolation does not transfer to the real game with an amputation may be instructed to look for the flat situation (Stammers, 1982; Wightman & Lintern, 1985). surface of objects before deciding how to pre-position the Likewise, the practice of isolated exercises for increasing terminal device on the prosthesis. For all tasks, relevant weight bearing on a hemiplegic lower extremity did not features of the environment could be enhanced with the result in more equal weight distribution during actual gait use of color, markings, or a contrasting background. (Winstein, Gardner, McNeal, Barto, & Nicholson, 1989), Typewriter keys could be color coded according to which and electromyographic biofeedback training on specific finger is assigned to which key for the beginning one- movements of the hemiplegic upper and lower extremity handed typist. In addition, with open tasks, as the instruc- did not improve functional use of the extremity (Mulder tor identifies the relevant cues, the learner could observe & Hulstijn, 1988; Wolf & Binder-Macleod, 1983). Newell the motion in the environment before attempting a task (1981) suggested that some breakdown of tasks, in which (Gentile, 1987; Spaeth-Arnold, 1981). For example, a per- there are natural subtasks and in which timing is not son learning to steer an electric wheelchair might observe crucial, may be appropriate for persons with brain dam- the events in a crowded hallway as the therapist points age. He recommended that part practice be used only to out people's walking speeds, door locations, and inter- acquire the most basic component of a task and should be sections where moving people may suddenly stop, turn, followed by whole practice in which the person concen- or emerge. trates on the component. When practicing only part of a In initial learning, constant and blocked practice may task, the learner may have difficulty integrating the ele- be indicated to increase performance. The learner needs ments and timing in the whole task. These findings sug- to practice the same movement a few times to get the gest the need for treatment programs to be more specific idea of it. For example, transfers to the same chair can be in terms of the environmental conditions and underlying practiced before proceeding to different heights or types. processes. Ideally, therapy would be done in the work or When training a confused patient, the therapist may also home environment. A recent study by McCauley (1990) prefer to use a constant schedule. For example, dressing incorporated individualized on-the-job instruction in training might start with only one style of shirt, pants, and body mechanics with traditional lecture instruction. The shoes. Nter a few days of practice with one particular subjects did improve in their use of body mechanics over style of clothing, the patient would need to practice with a 4-week period. other styles. Mental practice, or imagining task performance with- Through trial and error and numerous attempts to out any overt action, is another practice technique. Re- complete the task, the learner begins to develop success- search indicates that mental practice is better than no ful movement patterns. To facilitate learning, the move- practice at all but is not as effective as actual practice ments should be practiced in whole rather than part, so (Feltz & Landers, 1983; Weinberg, 1979). This type of that the movements are practiced in the context of the practice has been found to activate cortical areas associat- entire task (Schmidt, 1988). If learners accomplish the ed with the particular movement (Decety, Philippon, & goal or execute the desired movement, they are encour- Ingvar, 1988; Ingvar & Philipson, 1977; Roland, Larsen, aged to repeat the same performance. If the learner is Lassen, & Skinhoj, 1980). Carr and Shepherd (1987b) unsuccessful, then feedback from the therapist regarding suggested that mental practice may be beneficial follow- the general features of the movement should be given. In ing a stroke, at which time the patient has very little early learning, feedback should be given frequently so muscular activity. Mental practice allows persons to prac- that the learner develops a reference of correctness in- tice on their own even before active muscle contractions stead of incorrect or compensatory movement patterns can be activated. (Adams, 1971; Gentile, 1987; Kottke, 1980; Schmidt, 1975). Feedback should be delayed a few seconds after the movement is made so that the learner can process Facilnation of MOLOr kill Acquisiti n intrinsic feedback (Gentile, 1987). In the initial stages of learning, it is extremely important Practice in the later stages of learning becomes more that the learner understand the goal. The therapist can task dependent. Specificity of training and a constant use verbal instruction, demonstration, or manual guid- practice format are often advocated for closed and consis- ance to give the patient an idea of the movement. Video- tent motion tasks in which the environment is stable and tapes or photographs can clarify understanding. The predictable. However, motor learning research shows therapist's instructions, however, should focus on the that even for closed tasks, variable practice schedules important perceptual cues and essential aspects of the improve learning and transfer (McCracken & Stelmach, skills. In teaching correct lifting techniques, the therapist 1977; Shapiro & Schmidt, 1982). Feedback in the later may instruct the patient to test the load and to assess the stages of learning should be precise but should become path and destination of the load before beginning the lift. less frequent so that the learner becomes less dependent A patient with a visual-field deficit may be cued to turn the on feedback (Salmoni et aI., 1984). For closed and consis-
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tent motion tasks, knowledge of performance is more tional methods using verbal instructions to teach joint appropriate, because the goal is successful goal attain- protection, body mechanics, or assistive device usage will ment with the use of a consistent movement response probably not result in carryover to the home or work (Gentile, 1987). For example, when training keyboard environment. Persons should be trained in the environ- operators to reduce forceful, repetitive finger exertions, ment most appropriate to the type of task and to where the therapist might provide feedback to not lift the finger the task will be performed in the real world. RecogniZing so high off the keyboard. that this suggestion is not always feasible to implement, In later stages of learning for open and variable mo- therapists can use random and variable practice condi- tionless tasks, variable practice schedules under diverse tions in which the task or environment changes on each environmental conditions are indicated (Siegel & Davis, trial. These two conditions allow patients to practice and 1980). The learner must develop flexibility and a reper- solve a wide variety of motor problems to facilitate gener- toire of strategies to match changing and often novel alization and transfer of motor skills to the home or work environmental conditions. Therefore, the instructor must environment... systematically change environmental conditions during practice to encompass all possible sets of constraints Acknowledgmen t. (Spaeth-Arnold, 1981). For example, mObility training I wish to thank Joan C. Rogers, PhD, William D. Stofer, PhD, should be done in empty hallways and sidewalks as well George E. Carvell, PhD, and Carol A. Wood, PhD, for their many as in crowded hallways and sidewalks. Dressing should be helpful suggestions during the preparation of this paper. done with all styles of clothing that the person normally Rt:ferences wears, and patients should practice lifting objects of var- ious sizes, shapes, and weights to and from different Adams,]. A. (1971). Aclosed-loop theory of motor learning. heights. For practice to be effective, Gentile (1987) rec- Journal of Motor Behavior, 3, 111-149. Bilodeau, E. A., & Bilodeau, I. M. (1958). Variable frequency ommended that the therapist change conditions after knowledge of results and the learning of simple skill.Journal of every two trials rather than after every trial. The second Experimental Psychology, 55, 379-383. trial allows the learner to correct errors immediately. Carr, ]. H., & Shepherd, R. B. (1987a). A motor learning Feedback for variable motionless and open tasks should model for rehabilitation. In]. H. Carr, R. B. Shepherd,]. Gor- focus on how well the performer anticipated the environ- don, A. M. Gentile, &]. M. Held (Eds.), Movement science: Foundations for physical therapy in rehabilitation (pp. 31- ment and selected the movement pattern. Feedback 91). Rockville, MD: Aspen about the prior movement is not valuable, because a new Carr,]. H., & Shepherd, R. B. (1987b).A motor relearning movement may need to be generated on the next trial. program for stroke. Rockville, MD: Aspen. Automaticity is not possible with open and variable mo- Carr,]. H., Shepherd, R. B., Gordon,]., Gentile, A. M., & tionless tasks because there is always an element of un- Held,]. M. (Eds.). (1987). Movement science: Foundationsfor physical therapy in rehabilitation. Rockville, MD: Aspen. certainty that must be monitored continually. Crossman, E. R. F. W. (1959). Theory of acquisition of speed-skill. Ergonomics, 2, 153-166. Decety,j., Philippon, B., & Ingvar, D. H. (1988). rCBF land- ummary scapes during motor performance and motor ideation of a Principles of motor learning have much to offer occupa- graphic gesture: European Archives of Psychiatry and Neuro- tional therapists in designing treatment programs aimed logical Sciences, 238, 33-38. Edwards, R. V., & Lee, A. M. (1985). The relationship of toward the learning or relearning of motor skills. Feed- cognitive style and instructional strategy 10 learning and transfer back, necessary for both the acquisition and the reacqui- of mOlOr skills Research Quarterly for Exercise and Sport, 56, sition of motor skills, depends on the stage of the learner. 286-290 More feedback is needed in the early stages of learning Feltz, D., & Landers, D. M. (1983). The effects of mental practice on motor skill learning and performance: A meta-analy- than in the later stages. During the later stages, feedback sis. Journal of Sport Psychology, 5, 25-57. should be more precise and should decrease in frequen- Fitts, P. M., & Posner, M. r. (1%7). Learning and skilled cy. In addition, extrinsic feedback in the form of knowl- performance in human performance. Belmont, CA: Brooks/ edge of performance or knowledge of results can be used Cole. to augment intrinsic sensory feedback. By providing in- Gentile, A. M. (1972). A working model of skill acquisition with applications to teaching. Quest, 17, 3-23. formation about how movements are executed (i.e, Gentile, A. M. (1987). Skill acquisition: Action, movement, knowledge of performance) as well as the movement and neuromotor processes. In ]. H. Carr, R. B. Shepherd, ]. outcome (i.e., knowledge of results), the therapist gives Gordon, A. M. Gentile, &]. M. Held (Eds.), Movement science: the learner information about how to correct the move- Foundations for physical therapy in rehabilitation (pp. 93- ment pattern on the next attempt. 154). Rockville, MD: Aspen. Hopkins, H., & Smith, H. (Eds.). (1988). Willard and The findings from research on motor learning also Spackman's occupational therapy (7th ed.). Philadelphia: support a functional approach to treatment in which Lippincott. movement patterns and components of tasks should pri- Ingvar, D. H., & Philipson, L. (1977). Distribution of cere- marily be practiced in relation to functional tasks. Tradi- brat blood flow in the dominant hemisphere during motor
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