Strategies to Improve Motor

Learning

Tabigue, Ralfh Uriel M.

Motor skill learning is based on the brain’s capacity for
recovery through mechanisms of reorganization and adaptation.
An effective rehabilitation plan capitalizes on this potential
and encourages active participation.
Activities are selected that are meaningful and important to the
patient. Optimal motor learning can be promoted through
attention to a number of factors, most importantly, strategy
development, feedback, and practice.
Strategy Development
The therapist first assists the patient in learning the desired
task (cognitive stage).
The desired task is demonstrated at the ideal performance
speeds. If the task has a number of interrelated steps, practice
of component parts may precede practice of the whole task.
It is important, however, not to delay practice of the
integrated task because this may interfere with effective
transfer of learning.
The therapist should give clear, simple verbal instructions and
not overload the patient with excessive or wordy instructions.
Some evidence to suggest that providing excessive information
about the task can be disruptive to learning, especially for
patients with MCA stroke involving the sensorimotor cortex.
This interference may block formation of the implicit motor
plan. Correct performance should be reinforced and intervention
provided when movement errors become consistent
Active participation is essential for learning; there is no
learning with passive movements. Practicing the movements on the
less affected side first can yield important transfer effects.
Mental practice or mental rehearsal is the systematic
application of imagery techniques for improving performance and
learning.
The patient is instructed to visualize the movement and imagine
himself or herself functionally using the affected limb.
As practice progresses, the patient is asked to self examine
performance and identify problems, specifically, what
difficulties exist, what can be done to correct the
difficulties, and what movements can be eliminated or refined.
If a complex task is practiced, the patient is asked to identify
if the correct components were performed, how the individual
components fit together, and if they were appropriately
sequenced.
If the patient is unable to provide an accurate assessment of
problems, the therapist can prompt the patient in decision
making using guiding questions and utilize demonstration to help
identify problems.
Feedback
Feedback can be intrinsic (naturally occurring as part of the
movement response) or extrinsic (provided by the Therapist)
During early motor learning the therapist provides extrinsic
feedback (e.g., verbal cueing, manual cueing), and manual
guidance to shape performance. It is important to monitor
performance carefully and provide accurate feedback. The
patient’s attention should be directed to naturally occurring
intrinsic feedback
During later learning (associative phase), proprioception
becomes important for movement refinement. This can be
encouraged by early and carefully reinforced weight-bearing
(approximation) on the more affected side during upright
activities.
Additional proprioceptive inputs (manual contacts, tapping,
stretch, light tracking resistance, antigravity postures) can be
used to improve feedback and stimulate learning. The patient
should be encouraged to “feel the movement” while learning to
distinguish correct movement responses from incorrect ones.
Surface EMG biofeedback can be used to provide augmented
feedback.
Exteroceptive inputs (light rubbing, stroking) may be used to
provide additional sources of sensory inputs, particularly where
distortions of proprioception exist.
The use of a mirror can be an effective adjunct for some
patients to improve motor function using visual feedback.
Mirror therapy (MT) is a therapeutic intervention that focuses
on moving the less impaired limb while watching its mirror
reflection. A mirror is placed in the patient’s midsagittal
plane, presenting the patient with the mirror image of his or
her less affected limb as if it were the hemiparetic limb.

It is important to note that use of mirrors is contraindicated

in patients with marked visuospatial perceptual impairments.
Practice
Practice, practice, and more practice is essential for motor
skill learning and recovery. The therapist needs to organize the
patient’s therapy session to ensure optimal practice.
Blocked practice (constant repetition of a single task) is used
to improve initial performance and motivation, especially for
patients with disorganized movements.
The patient should be encouraged to self-monitor practice
sessions and recognize when fatigue may be setting in and rest
is required.
Motivation is key to successful learning. The patient should be
fully involved in collaborative goalsetting from the beginning
and continually reminded of the goal, the task, what progress
has been made, and the expected outcomes. Treatment sessions
should include positive experiences, ensuring the patient
experiences success in therapy and instilling selfconfidence.
Interventions to Improve
Sensory Function
Patients who have significant sensory impairments may
demonstrate impaired or absent spontaneous movement.
The more the patient can be encouraged to use the affected side,
the greater the chance of increased awareness and function.
Multiple interventions for UE sensory impairment after stroke
have been described. These can be categorized into sensory
retraining or sensory stimulation approaches.
Sensory retraining programs include use of:
Mirror therapy

Repetitive sensory discrimination activities,

Bilateral simultaneous movements,

Repetitive task practice (e.g., sensorimotor integrative treatment with its

focus on normalizing tone, practice of functional activity, and use of
augmented sensory cues).
Sensory stimulation intervention includes:
Compression techniques (weight-bearing, manual compression, inflatable pressure
splints, intermittent pneumatic compression)
Mobilizations

Electrical stimulation

Thermal stimulation

Magnetic stimulation
A safety education program should be instituted early for
patients, family, and caregivers to improve awareness of sensory
impairments and ensure protection of anesthetic limbs. This is
particularly important for preventing UE trauma during transfer
and wheelchair activities.