Have you ever had a patient who does everything well during PT sessions, but makes little progress outside of the clinic? Have you been frustrated by the fact that some patients feel better when they come to physical therapy, only to report a resurgence of symptoms the next day? These patients are performers. They perform well in physical therapy, but no real motor learning has occurred. Despite sound orthopedic interventions, these patients display little carryover from the clinic to their daily lives. Why? Because we have forgotten about neuroscience.
Drawing on neuroscience can enhance the way we practice as orthopedic physical therapists. The brain drives our movements and is responsible for our ability to learn a new skill. If we only focus on the musculoskeletal system, we are missing a critical piece of the recovery process. Our manual interventions and therapeutic exercise prescription are important, but if we want to enact lasting change on a patient’s faulty movement patterns, we must consider neurological principles of motor learning.
In this guide, we provide motor learning strategies that can be incorporated into our daily treatment sessions to deliver improved patient outcomes.
Choose cues that will promote motor learning
During a treatment session, we need to be cognizant of the effectiveness of our chosen exercises and mindful of how these exercises are explained to patients. While patients are completing exercises, use cues to relay instructions. While it may not seem to make a large difference in the clinic, it will help patients learn and memorize these new movement patterns.
Explicit cues provide patients with instructions according to a precise kinematic strategy. Simply put, explicit cues tell the patient how to move. These types of cues establish what is known as an internal focus of attention because they concentrate on a specific body movement. For example, if a patient is squatting, explicit cues would tell the patient to squeeze his or her glutes and keep the pelvis level. These cues tell the patient exactly what to do and they are focused on their body.
Implicit cues provide the patient with goal-oriented cues. They establish an external focus because they emphasize object movement. If we go back to our squatting example, to give an implicit cue we would have a patient hold a stick horizontally above his or her head and cue to keep the stick level. For the stick to remain level the patient will have to recruit the glutes and also keep the pelvis level, but he or she has to figure this out independently. Cues that are delivered according to outcomes, with an external focus, will allow patients to develop their own kinematic solutions.
What kind of cues do YOU give?
Physical therapy is full of explicit cues with internal focus. While most prefer explicit cues, these instructions are inhibiting carryover outside of the clinic.
Practice promoting the use of implicit cues with an external focus to promote motor learning. We want to direct a patient's attention to the outcomes of movements instead of the specific movements themselves. By setting up a goal instead of providing a specific strategy, we allow our patients to develop their own strategies, which they are more likely to remember. As a result, our patients experience changes on a neurological level.
Should we ever use explicit cues?
To put it shortly, sometimes. Studies show that individuals who are completely novice to a skill may benefit from explicit cues to decrease the neurological demand of learning a brand new skill. Descriptive cues with precise instructions will allow patients to perform complicated movements correctly when they are in the initial stage of learning. However, once the learner has been exposed to the skill he or she is no longer novice and we should begin using implicit cues with an external focus of attention.
Provide feedback based on the complexity of the movement
The amount of feedback we give to our patients plays a considerable role in the motor learning process. Providing feedback 100% of the time will improve performance during the session, but is detrimental to learning. By correcting every little movement, we are helping patients perform well in the clinic, but failing to promote true motor learning.
The type and amount of feedback we give will depend on how complicated the task or exercise is. If the exercise is simple and can be learned in a single session, delay feedback and let patients complete their exercise before correcting them.
For a complex task that requires multiple sessions to master, provide a high frequency of feedback initially. However, once a level of mastery is achieved, reduce the feedback and allow our patients to make errors. Trial and error practice enhances motor learning and allows the patient to learn, which will be more beneficial for them once leaving the clinic.
Repetition and practice are key
Motor learning will not occur without repeated practice, because repetition is a requirement to develop neuroplasticity. Neuroplasticity means that your brain is malleable to change and allows us to learn new languages, change our habits and move differently.
Neuroplasticity is enhanced with continued practice of a skill over time. Repetition and practice of a specific task have been proven to yield the best motor learning results. For example, in a study where basketball players shot baskets from a variety of locations, the greatest success was seen at the foul line even when the lines were obscured. Massive amounts of practice from this distance results in the greatest skill retention.
The same principles apply to our work in the clinic. Once we’ve established an exercise program and have given proper cues and feedback, we need to encourage repeated practice of that movement. Repetition and practice will drive home the motor learning process.
Physical therapists are movement experts - let’s own that domain
No other profession has the knowledge and the skills to change movement patterns the way physical therapists do, and it is our responsibility to harness our knowledge of the body to deliver the best results. When we consider the influence of the brain, we become more effective practitioners and allow our patients to learn new movement patterns.
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