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Transitioning from Wheelchair to Walker

Lily Gullion
Exsc 351 Spring 2015
4/10/2015

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1. My learner is a 70 year old man, Ron, who has Parkinson’s disease. I am teaching
him how to transition from a sitting position in his wheelchair to a standing position using
a walker. He needs to master this skill to maintain activities of daily living that require
standing (brushing teeth over a sink, reaching for a cup from a cabinet.) He has recently
been prescribed therapy and is struggling with transitions because of his disease
(Zijlistra et al., 2012). According to the Fitts and Posner model, the client is in the
second stage of learning, which is the associative phase. He is in the second stage
because some of his movements are conscious and require cognitive activity, but some
of the action is done with automaticity (Shmidt, 2008). The transition from wheelchair to
walker includes holding the wheelchair’s arm rests, planting feet on the ground, leaning
forward, pushing off the chair, grasping the walker with one hand at a time, and standing
upright. Ron’s goal is a gross motor skill because it involves large muscle groups. It is
also discrete, meaning it has a clear beginning and end and is a specific skill. According
to Gentile’s 2D taxonomy, the environment does not change during the activity (low
regulatory variability) and does not change between trials of the activity (low context
variability). It will be practiced in a closed environment; it is self-paced, predictable, and
the client knows what to expect. There is also object manipulation, because the client
will be interacting with the walker directly (Shmidt, 2008).
2. I will focus the lesson on mastery goals. Mastery goals are focused on self-learning
and improvement. Mastery goals are best when the learner wants to increase their
knowledge about a new skill (Seel, 2012). Performance goals are often measured by
comparing the learner to others, and the focus is more on winning. This type of goal is
best when the learner already has experience with the skill and is now trying to perform
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for other people (Shmidt, 2008). Ron’s goal, which is to transfer from sitting in a
wheelchair to standing with a walker without assistance, is best classified as mastery. I
reviewed a study which’s purpose was to implement the mastery goal of movement
amplitude as a way to improve the subjects’ large muscle movements. The researchers
worked with participants who had Parkinson’s to teach a new method of therapy,
focusing on the improvement on the learner’s knowledge of the skill. One group of
participants was instructed to focus on mastery goals by making exaggerated and large
movements, and one group, the control, was just told to reach and walk like normal. The
results of the study were that patients who were taught to focus on mastery goals and
make big movements improved in both reaching and walking activities compared to
those who were practicing without mastery goals (Farley & Koshland 2005). We will
implement this mastery goal in Ron by teaching him to lean his body forward over his
toes; now he’s just leaning over his knees when trying to stand up. The strengths of this
source are that it studied a similar population (Parkinson’s), at a similar stage of
learning (associative stage), and the movement of walking and reaching are both
related to sit to stand. The weaknesses of this source are that the subjects were not
required to perform the sit to stand task, which is different than walking or reaching
alone. Ron’s task is gross motor with object manipulation, but walking is classified as
gross motor and reaching is object manipulation. This study is relevant to Ron because
it gives a therapeutic method which supports the implementation of his mastery goals.
3. I will provide verbal instructions to my client. Verbal instructions are frequent cues
which are spoken to facilitate learning and direct attention. Demonstration, which is
often used with verbal instruction, is modeling a desired movement pattern.
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Demonstration has more of an impact when the subject is learning a new skill, and
verbal instructions are better when the subject already has experience (Haibach, Redi,
& Collier 1977). I will implement the verbal instructions before the action by reminding
Ron to lean forward and lift off from the wheelchair, (“lean forward, lift off the
wheelchair.”) I will also use verbal cues during the transition to remind him to keep lifting
up (“up, up up!”) To justify this type of instruction, I used a source that studied the
effectiveness of verbal cues in walking with Parkinson’s patients. In this study, patients
were divided into two groups; one group got verbal instructions during their treatment,
which consisted of walking 1800 feet every day for 10 days, and one group had did not
get the verbal instructions. The results proved that verbal instructions are successful in
improving the walking movement in patients (Lehman, Toole, Lofald, & Hirsch, 2005).
The limitations are that the patients were trained in walking activities and Ron is
learning sit to stand, but the learners were at the same stage (associative stage). The
classification of walking is gross, continual, and without object manipulation, which is
different from Ron’s transition, which is gross, discrete, and with object manipulation.
4. I will use Knowledge of Performance (KP) as my main way to provide augmented
feedback. Knowledge of Performance tells the subject specific aspects of the quality of
action, while Knowledge of Results (KR) focuses on the actual outcome. For example,
KP provides feedback like “you didn’t shift your weight forward enough” while KR would
provide “you stood up 2 seconds slower than last time” (Haibach et all, 1977). KP is a
great type of feedback for Ron because I want him to focus on the specific movements
that make up his transition so he can accomplish the task with proper form. I will
implement KP when working with Ron by identifying errors in the elements of his
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performance. To justify this implementation, I reviewed a research study which taught
older adults how to throw a free throw with a basketball using varying amounts of KP. In
the background section of the article, the authors explain that elderly people do better
with KP than KR because they remember information for shorter periods of time and
need to be reminded about specific movement patterns. In the study, sixty people
between 60-69 years old were divided into 4 groups to learn the new basketball skill.
One group was not given feedback, one was given KP feedback 33% of the time, one
66% of the time, and one group received 100% KP, which occurred after every practice
shot. The results were that those who received KP after 66% of their shots learned the
best. This shows that implementing KP is better than not having augmented feedback
(Nunes et al. 2014). One limitation of this study is that the participants were in the first
stage of learning (cognitive stage), unlike Ron, who is in the second stage (associative
stage). Strengths of the study are that it used participants who were near my patient’s
age, and both skills are gross motor with object manipulation. The study is relevant to
Ron because it proves the usefulness of using KP in an elderly population.
5. I will provide prescriptive feedback to my client as he stands. Descriptive feedback
restates what the client just did (“you stood up in 5 seconds”). Prescriptive feedback
provides suggestions about what the client should change or how to correct errors
(Schmidt, 2008). I will do this by telling him explicitly “You need to lean forward until your
nose is above your toes before you stand.” To justify using prescriptive feedback, I
reviewed a study which researched the effects of computer based descriptive feedback
or prescriptive feedback on undergrad students learning surgical techniques. This study
used 45 premed students in 3 groups and taught them suturing skills. One group
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received computer generated descriptive feedback, one received motion analysis
feedback, and one group received expert prescriptive feedback. They had 19 practice
trials, and skill retention was retested after 1 month. The results were that everyone
increased in skill performance, but only those which received prescriptive feedback
retained the information after 1 month (Porte, Xeroulis, Reznick, & Dubrowski, 2007).
The strengths of this study are that the participants were in the second stage of learning
like Ron, and the goal was discrete. The limitations are that the participants were
younger than Ron, and the skill was fine motor instead of gross motor. The results of
this study show that prescriptive feedback helps the patient retain the information, which
is exactly what Ron needs.
6. Massed practice is when there are long periods of performance and short periods of
rest. Distributed practice is when the rest between performance trials is longer than the
amount of time spent practicing (Schmidt & Lee, 2011). I will implement a massed
practice schedule by having Ron perform the action on 5 times with 30 seconds of rest
during therapy sessions. To justify this schedule, I reviewed a study which researched
practice schedules on performance of a discrete sports skill. The handball pass was
taught to inexperienced participants who were broken into massed and distributed
practice groups. The massed groups only had 1 second between trials and the
distributed group had 30 seconds between trials, and the ball was passed 50 times in
each group. The results were that both groups performed equally well immediately after
the practices, but the massed practice group retained the information after 2 weeks
(Panchuk, Spittle, Johnson, & Spittle, 2013). The strengths of this study are that the skill
taught was a discrete, gross motor skill, just like Ron’s. The limitations are that the
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participants were in the first stage of learning, and they were not elderly. This study is
relevant to Ron because it shows that using massed practice helps patients retain
discrete motor skills.
7. I will be using a random practice schedule for my client. Blocked practice is when
patients perform one technique over and over before continuing onto the next skill.
Random practice is when tasks are randomly performed, and the same skill is not
repeated twice in a row (Schmidt, 2008) I will implement a random practice schedule by
practicing sit to stand among other activities during a therapeutic session. For example,
we will do a sit to stand transition, a fine motor task, a walking task, and then sit to stand
again. To justify this schedule, I reviewed a research article which looked at the skill
retention of elderly adults after blocked or random practice. Forty people between 60
and 80 years old learned and practiced how to use an ATM machine and were divided
into two groups, blocked and random practice groups. In the blocked group, the
participants made five of the same action (withdrawal) between moving onto a different
action (deposit cash). In the random group, participants performed the five types of
actions (withdrawal, deposit, transfer, fast cash, account information) randomly. The
results show that those who were in the random practice group performed with better
accuracy and speed (Jamieson & Rogers, 2000). The strengths of this study are that
the participants were in the same age range as Ron and the skill performed was
discrete. The limitations are that the skill performed was fine motor (Ron’s is gross
motor), and the participants were in the cognitive stage while Ron is in the associative
stage. This study is relevant to Ron because it shows that random practice is helpful in
retaining discrete skills in elderly people.
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Works Cited
Farley B.G. and Koshland G.F. (2005). Training BIG to move faster: the application of
the speed–amplitude relation as a rehabilitation strategy for people with
Parkinson’s disease. Experimental Brain Research, 167(3), 462-467.
Haibach P., Reid G., & Collier D. (1977). Motor Learning and Development.
Harvey R.L., Macko R.F., Stein J., Zorowitz R.D., & Winstein C.J. (2009). Stroke
Recovery and Rehabilitiation.
Jamieson B.A. and Rogers W.A. (2000). Age-Related Effects of Blocked and Random
Practice Schedules on Learning a New Technology. Journal of Gerontology,
55(6), 343-353.
Lehman D.A., Toole T., Lofald D., & Hirsch M.A. (2005). Training with verbal instructional
cues results in near-term improvement of gait in people with Parkinson disease.
Journal of Neurological Physical Therapy, 29, 2-8.
Nunes M.E., Souza M.G., Basso L., Carlos B.M., Correa U.C., & Santos S. (2014).
Frequency of provision of knowledge of performance on skill acquisition in older
persons. Frontiers in Psychology.
Panchuk D., Spittle M., Johnson N., Spittle S. (2013). Effect of Practice Distribution and
Experience on the Performance and Retention of a Discrete Sport Skill.
Perceptual and Motor Skills, 116, 750-760.

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Portess M.C., Xeroulis G., Reznick R.K., & Dubrowski A. (2007). Verbal feedback from
an expert is more effective than self-accessed feedback about motion efficiency
in learning new surgical skills. Elsevier, 1, 105-110.
Schmidt R.A. (2008). Motor Learning and Performance: A Situation Based Learning
Approach. 4th ed.
Schmidt R.A. and Lee T. (2011). Motor Control and Learning, 5th ed.
Seal N.M. (2012). Encyclopedia of the Sciences of Learning.
Zijlistra A., Mancini M., Lindemann U., Chiari L., & Zijlstra W. (2012). Sit-stand and
stand-sit transitions in older adults and patients with Parkinson’s disease: event
detection based on motion sensors versus force plates. Journal of
Neuroengineering and Rehabilitation, 9, 75.

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