This recent paper by Gabriele Wulf and colleagues investigated the potential factors involved in motor skill learning. Particularly focusing on the influence several variables may have on the learning and performance of specific motor skills as they pertain to the medical field, a review of the literature was performed. Fortunately, the following factors may be applied to a wide range of settings and be of use by those in education, rehabilitation, and sports performance...to name a few. It was suggested that learning can be particularly enhanced when the learner's motivation is optimized.

Learning: "a relatively permanent change in a person's ability to perform a skill"

OBSERVATIONAL LEARNING

• In combination with physical practice, observational practice has been demonstrated to contribute highly to the acquisition of motor skills via mutual activation of the cerebellum, cingulate gyrus, inferior parietal lobe, premotor cortex, and supplementary motor area. The combination of such observational and physical practice is said to provide the opportunity to both extract important information pertaining to coordinated motor patterns as well as evaluate effective strategies that otherwise would be difficult if one were to both prepare and execute simultaneously. Therefore, observation provides the opportunity to "process". Additionally, alternating between observation and physical practice (performing a dyad) allows the learner to observe and apply. This facilitates enhanced motivation.

ATTENTION FOCUS

• This variable pertains specifically to movement in relation to space and time. Ideally, attention should be directed to the induction of an external focus in contrast to one that is internal. Through simple changes in cues utilized, performance and learning can greatly be enhanced. For example, instructing a patient to "thrust his/her pelvis to the ceiling" will performing a glute bridge would be a more effective cue than suggesting he/she "activate the glutes and extend the hips". Similarly, greater gains will likely be witness in a training environment when asking a squatting athlete to "sit back onto a chair" as opposed to "flex your hips keep your tibia vertical". This external focus has been shown to facilitate automaticity of movement  and the use of unconscious processes, therefore reducing unwanted attentional demands.

FEEDBACK

• Commonly pertaining to "knowledge of results" and "knowledge of performance", feedback has been demonstrated to highly influence motivation. Specifically when provided following "good" trials, feedback is said to facilitate more effective learning through positivity. Further, normative feedback, that is, feedback in relation to the performance of others (or the norm), enhances self-efficacy and motivation. This is true even in such instances when feedback was false (i.e. saying "great job" - even though performance was relatively poor). Therefore, rather than providing neutral information, positive feedback in specific situations will enhance self-fulfillment and motivation, thereby affecting learning.

PRACTICE THAT IS SELF-CONTROLLED

• Providing the learner with the opportunity to control their practice conditions has been demonstrated to be an effective method for the learning of motor skills. Allowing the learner to dictate when or when they do not want to receive feedback seems to be of greater importance than frequency of feedback. Additionally, occasionally permitting the individual to decide when they choose to practice facilitates greater active involvement and subsequently, enhanced motivation, self-control and effort. Such practice and learning conditions may also pertain to free play (allowing the athlete to spend extra time in the weightroom, court, or ice) and recreational exercise (performing rehabilitation exercises at home or in the gym).

As you can see, there are no shortage of methods for us as rehabilitation and exercise professionals to become more effective "teachers". In utilizing some of the above principles in the strategies we employ, we may become more effective practitioners and facilitate better means of motor skill acquisition.

Reference: Wulf G, Shea C & Lewthwaite R. (2010). Motor skill learning and performance: a review of influential factors. Medical Education, 44; 75-84 

Study Title: Return-to-Play in Sport: A Decision-Based Model
Authors: DW Creighton, I Shrier, R Shultz, WH Meeuwisse & GO Matheson
Journal: Clinical Journal of Sport Medicine
Date: September 2010

Summary:

• For those of you involved in sport medicine, here is an excellent example of scientific insight into the factors that may influence and determine Return to Play decision making.  This paper, authored by individuals at Stanford University, McGill University and the University of Calgary, details the all important, multifactorial decision making process of allowing an athlete to return to “full participation in sport without restriction”.  Through a literature synthesis, a model that included the Evaluation of Health Status, Evaluation of Participation Risk, and Decision Modification was proposed.  While the authors noted that the ability to quantify several decision elements may be limited, they suggested that decision modification must only be considered once participation risk is determined.

• Although seemingly short and straightforward, this paper provides comprehensive insight into the variables that must be considered by those in a priviledged position to determine whether or not an athlete is permitted, let alone mentally and/or physically capable of, returning to sport.

Complete resolution of symptoms "cannot be considered in isolation” when determining return to play

Creighton DW, Shrier I, Shultz R, Meeuwisse WH & Matheson GO. (2010). Return-to-play in sport: A decision-based model. Clinical Journal of Sport Medicine, 20(5); 379-385

This past week my most recent review was posted on Research Review Service, a site specifically for health care professionals of manual and rehabilitative therapy. The Influence of Reduced Hamstring Length on Patellofemoral Joint Stress During Squatting in Healthy Male Adults by Whyte et al was published earlier this year in Gait Posture.

Here's a brief summary of the study:

Study Purpose:

• To determine the presence of a relationship between hamstring length and PFJ stress at 3 specific knee joint angles of flexion.

Study Population:

• 16 recreationally active males divided into two groups based on knee joint angle-measured hamstring length.

Methodology:

• A biomechanical model incorporating knee joint angle, knee extensor moment, and PFJ contact area was used to quantify PFJ stress.
• MRI and 3D motion analyses were also utilized in this study.
• A one-way ANOVA to determine the variations in PFJ stress between the 2 groups (with and without reduced hamstring length) was used.

Main Findings:

• Patellofemoral Joint stresses differed significantly between the two groups at specific angles of knee flexion.
• No significant differences in hip angles between the two groups.

Clinical Application:

• This study demonstrated that subjects with reduced hamstring lengths have increased PFJ stress during various positions of the squatting movement.  As a result, such a decrease in length MAY contribute to the pathogenesis of various conditions relating to the knee.
• These results enable us to consider another factor when managing those with knee pathology.

For a complete and "evidence-informed" understanding of the study, check out my review. I have obviously left out specifics from this study in this post as Research Review Service is a paid membership site. However, if you would like more information, please do not hesitate to ask.

Here's a brief summary of an excellent paper by Boudreau et al from Manual Therapy. 

The purpose of this paper was to summarize several important aspects of motor-skill training for enhancing musculoskeletal rehabilitation.

Cortical Neuroplasticity: a dynamic feature of life that encompasses functional or morphological change in properties of neurons (connection strength, represenational patterns, neuron reorganization.

• Positive changes: improvements in motor performance
• Negative changes: decreases in performance, such as in the presence of chronic pain (low back pain resulting in decreased cortical spinal drive in lumbar musculature and subsequent shift in somatosensory representation)

It is hypothesized that motor-skill training can influence the direction of change in cortical neuroplasticity.

• That is, the representation of muscles affected by pain in the sensorimotor system.

Potential effects of motor-skill training:

• Improvements in task performance
• Improvements secondary to very short training intervals.
• Improvements occuring in two stages - 1) fast learning (following a single training session); 2) slower learning (across several sessions of practice)
• Improvements with activation of inhibited/delayed musculature via repeated voluntary contractions.

Methods of Optimizing Rehabilitation:

• Skilled training - skilled/precision tasks (vs strength training) should be performed to facilitate neuroplastic changes, and subsequently improvements in motor behaviour.
• Negative effects of the presence of pain during novel motor skill acquisition - since pain alters excitability of the primary motor cortex in a rapid manner, these responses are generally protective and counterintuitive in the motor-learning process. Negative effects are also demonstrated in the presence of low quality sleep, stress, and attention deficits. Therefore, motor-skill learning should be relatively pain free.
• Protective effect of motor-skill training - training prior to acute experimental pain may prevent unwanted cortical neuroplastic changes.
• Cognitive effort - the greater the complexity of a skilled task and its corresponding intent, results in greater cortical representation and changes.
• Quality - since no difference seems to exist with greater repetitions of within-session skill learning tasks, the primary focus of each rehabilitation session should be quality of performance.

The above information was derived from a multitude of studies and demonstrates that motor-skill training may positively influence cortical neuroplasticity in musculoskeletal rehabilitation
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