Motor Learning Principles to Alter Gait Deviations

Original Editor - Stacy Schiurring based on the course by Damien Howell

Top Contributors - Stacy Schiurring, Kim Jackson and Jess Bell

Introduction

The development of gait deviations can be a normal part of the aging process. Research has shown that approximately 85% of persons aged 60 years ambulate with "normal gait," however that number decreases to 20% by age 85.. A 2018 systematic review by Herssens et al looked at development of gait deviations across the lifespan. They found as people age, they tend to develop a "cautious gait pattern" which is characterized by (1) decreased walking speed, (2) decreased cadence, (3) decreased step or stride length, and (4) increased step time. Gait deviations can also have a developmental, musculoskeletal, or neurological etiology.

From a rehabilitation perspective, reasons to alter an individual's gait deviation include:

1. To improve pain
2. To improve endurance
3. To improve efficiency
4. To improve performance
5. To improve quality of movements
6. To prevent injury
7. To improve safety
8. To decrease need for assistive devices

Motor Learning

Motor learning differs from symptom modification. A symptom modification procedure can quickly but temporarily alter an individual's performance, often within a single treatment session.

Motor learning can be defined as: "a change in the capability of a person to perform a skill that must be inferred from a relatively permanent improvement in performance as a result of practice or experience." Performance tends to improve as an individual practices a new skill. While these improvements can occur quickly they also tend to be temporary in nature. True learning occurs when practice continues repeatedly. This allows the new skill to be sustained over time. To learn more about motor learning and motor learning theories, please read this article.

The most effective way to progress from performance to learned behaviour is to use scientific principles and theories of motor learning. However, translating theory to clinical practice provides an opportunity for creativity on the part of the rehabilitation professional. The use of language, cues, feedback, and or prompts are particularly powerful tools.

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Putting Theory into Practice

When adapting motor learning theory into clinical practice, it can be helpful to use a framework to shape how learning will occur. Like any rehabilitation plan of care, this framework will be individualised to best meet the needs of the patient, ie the learner. The rehabilitation professional, ie the teacher, can gain insight into the learner's needs during the patient interview and evaluation, and continuously reassess for needed changes or adjustments as therapy progresses.

Considerations for both teacher and learner:

1. Focus of Attention: internal vs external
2. Sensory Preference
3. Analogy
4. Explicit versus implicit learning
5. Exploratory learning
6. Whole vs Part – Segments Sequencing
7. Mindset attitude
8. Autonomy
9. Cueing, prompting, feedback

Focus of Attention

Two types of focus of attention:

1. External focus of attention is directed towards the effect of the movement on the environment.
2. Internal focus of attention is directed towards components of the body's movement

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A 15-year review of literature found that research on focus of attention has consistently shown that an external focus enhances motor performance and learning when compared to internal focus. However, there are some conflicting and contradictory opinions regarding this opinion. Historically, physiotherapists have underutilised the concept of external focus of attention during cueing, prompting, and feedback.

Elmar Kal and colleagues published a series of studies observing interactions between physiotherapists and patients with stroke. Specifically they assessed how the physiotherapists worded their feedback and cues during therapy interventions. They found that only 33% of the therapists were using an external focus of attention, and often after a cue with external focus the feedback would often shift back to an internal focus. For rehabilitation practice, an individualised use of attentional focus instructions may be more effective than an exclusive reliance on external focus instructions, especially if a patients’ motor, sensory, and attentional functioning may be impaired. When used appropriately, both external and internal focus of attention can improve performance and learning.

Alessandro Piccoli et al 2018 looked at focus on attention in patients with neurological central nervous system (CNS) deficits as compared to those with musculoskeletal disorders. When comparing patients with stroke or idiopathic Parkinsons Disease (PD) to healthy subjects, there was conflicting evidence about the use of the optimal attentional strategy. External focus of attention did not always improve motor learnings compared to internal focus of attention due to the pathological motor impairments of stroke and PD. Changes in sensory pathways including vision and proprioception were also found to effect attentional strategy use. This study found that external focus of attention is more effective than internal focus of attention in affecting motor learning in patients with musculoskeletal disorders.

There is research that supports that novice learners are likely to do better with an internal focus of attention, whereas experts do better with external focus of attention. There is evidence that younger learners likely do better with an external focus, whereas older learners can do well with external and or internal.

Rebecca Gose et al 2021 have suggested that the dichotomy between external focus of attention and internal focus of attention functions as a spectrum. They suggest that seeing focus of attention as a binary paradigm overlooks the dynamic and constantly changing interactions between the individual, the task, and the environment. Whether the chosen focus of attention is internal or external, it is an important clinical consideration to use words that are consistent with the patient's preferred sensory learning system.

Sensory Preference

ADD IMAGE OF THREE CIRCLES FROM VIDEO

Three sensory systems involved in mobility:

1. Visual
2. Auditory
3. Kinesthetic

Margeaux Ciraolo et al 2020 found that the majority of people have a preferred sensory system. The visual system was the most commonly preferred sensory system. If a patient's preferred sensory system can be identified, the rehabiliation professional can fine tune their cueing, prompting, and feedback style.

In the clinical setting, a simple way to determine a person's preferred sensory system can be to ask "What three adjectives would you use to describe a day at the beach?"

• If they describe: "It's warm, the sand is between my toes, I feel the breeze on my ear," they tend to be a kinaesthetic learner.
• If they describe: "I hear the waves crashing, the kids are squealing on the beach, and the seagulls are calling out," they tend to be an auditory learner.
• If they describe: "The sky is blue, the sand is brown, I see the waves rolling in," they tend to be a visual learner.
• Some patients may give descriptors for multiple sensory systems
  • for example: a patient can have a kinesio-visual, kinesio-audio, or audio-visual-kinesio sensory preference.

Analogy

• Analogy identifies a target image which connects new information to old information
• The best image will connect to something that is familiar to the learner
• Language used should be consistent with the client's preferred sensory system
• It is preferable to have the image external to the body
• The analogy wording should be short in length, this allows it the be used like a mantra during gait training

Examples of how analogy can be used in gait training:

Desired gait outcome	Analogy
To keep daylight between the knees	"Walk as if you are wearing a full diaper"
A stable pelvis	"Imagine your pelvis is a bucket full of water, don't let it spill out the side"
Forward kneecap/leg alignment	"Keep the kneecap pointing down that road like a headlight. Don't let the headlight veer off to either side"
Proper step or stride length	"Image you are walking along a railroad line, stepping on each railroad tie"
Increased hip and or knee flexion	"Walk as if you are walking in deep snow"

Explicit versus implicit learning

• Explicit learning is at a conscious level whereas implicit is unconscious.
• Implicit learning tends to be more durable
• Some experts argue that if you have an analogy, it's thought to be more implicit, more automatic, you can kind of keep it in the back of your mind.

The dichotomy of implicit learning versus explicit learning can be a spectrum of learning. Both can occur simultaneously, but with increased practice and reinforcement of the new gait pattern more implicit learning will occur.

Examples of implicit learning in physiotherapy:

• Barefoot running
• Backwards walking
• Split treadmill walking
• Constraint therapy
• Robotic gait training
• Metronome or music with a strong beat for altering cadence

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Exploratory learning

Next. I want to talk about compare and contrast or exploratory learning. This is a young lady, 70 years young, a runner and has a chronic left gluteal tendinopathy. And this is her preferred or natural running gait. And my assessment was there's limited daylight between the knees, the left foot tends to cross the midline. So my symptom modification procedure, see something, do something. I showed it to the client and I said, can you now run and have some daylight between your knees? So this is the immediate result within the session. And I think you'll see that now there's more daylight and less of the left foot crossing the midline. So I showed her the deviation, I said, "See that, can you do something different?" When she came back, I queried the patient, the client, what does that feel like? What do you hear? What do you see? Right? And sometimes it requires some prompting, more often, the first comment by the patient is, "It feels weird." And we're going to talk about the side effects of the interventions.

So the next step is I now have the patient run the new way a couple of laps, and then I say, "Run the old way, a couple laps, but I want you to finish with the new way. And then I want you to practice that." It's okay when you go do your walking that you do it the old way sometimes because feeling the contrast, you're going to begin to appreciate the new way may have less pain or no pain. Exploratory learning, contrast.

Whole vs Part – Segments Sequencing

Considerations in terms of sequencing and segmenting whole versus part. Sometimes you need to break it down into parts. Sometimes you can have them practice the whole thing. So how do I decide when to break it down into parts? Well, first off, if it's a spatiotemporal deviation, it's likely better to let them practise the whole thing. If it's not a spatiotemporal component, I tend to break it down into parts and use the dance step to nowhere. The part's better when I break it down into parts or segments it allows me to use this concept of a preferred sensory, so I can do it slow enough and they can listen to it or feel it or begin to see it. I also use the parts method when there's disparate body regions. When I see a trunk rotation is too great and foot crossing the midline that's top and bottom, I break it down into parts so that we can talk about it and the patient can learn.

So this is an example, this young lady is status post right partial knee replacement. Her preferred gait pattern is, despite the joint replacement, is to have excessive out toeing. So she's doing the dance step to nowhere, the right leg is in stance phase. That's status post knee surgery. And I say, I point out to her that she was toed out. I say, toe in, now dance this way back and forth, back and forth. And you can do the compare and contrast. Finish with the new way. I break it down into parts, focusing on stance leg. The next step is when you do the dance step and you got the stance phase correct, is walk this way. Walk away, and then you can do the compare and contrast. Well, while they're walking, let them shift from the old way to the new way and back and forth, breaking it down into parts.

Mindset attitude

Next, I want to talk about choosing the mindset of a positive language versus negative language, the prevailing belief that's, I think developing, is positive is better than negative. Working on strength is probably better than weakness. Both work, both working on weakness and both working on strengths work. But if we can speak in a positive way, engage placebo and minimise nocebic effects it's better. So see that, do that, as opposed to see that don't do that. Hear that, it's quiet. Hear that clomp, don't do that. Feel that, feel that buttock muscle engage to control the pelvis, do that. Feel that it's not engaged, don't do that. Positive would be the new way, negative would be the old way. Positive would be walk with less pain, no pain, negative would be with pain.

Gabriele Wulf et al., the authors of the OPTIMAL theory of motor learning, basically the group profess the importance of external focus of attention, speak to this issue of enhanced expectancies is the best practice to learn, to move better. What's an enhanced expectancy? It's a range of forward-directed anticipatory predictive cognitions or beliefs about what is expected to occur. So, if we provide knowledge of performance and knowledge of results with positive information, it can enhance the learner's expectations that they will have positive results in a similar task in the future. When we provide normative feedback, it suggests that we, kind of, tell a white lie, you're doing better than average. You're doing better than most people. That's going to improve their motivation, improve their self-efficacy, commenting on a peer group performance, such as, "Other people with similar injuries tend to do well when they work on this skill, this can help to increase the patient's or client's expectations that they also will do well. Then the other thing that I think we need to consider is setting easier liberal goals or sub-goals or thresholds or bandwidth. Well, the goals should be challenging, we need to be adjusting them so that the patient is having success.

Autonomy

Next, I want to talk about autonomy and self-choice. It's considered very important to achieve best practice when learning to move in an optimal way. We need to give the learner control of the conditions to enhance their learning, need to give them a choice of their instructional language, sensory preference, positive negative. Give them a choice of practice conditions. Some interesting research on learning to throw darts at a target. Had two groups, one group, they allowed individuals to choose the colour of the darts and the other group they didn't give them a choice of colour. When they were just given a choice of the colour of which darts they were going to throw, they performed better and learned better. It's a funny phenomenon.

So self-control enhances motivation. Interventions need to be designed for the individual characteristics and adjusted based on the individual's response. One size does not fit all. In the reference list for this module, providing an example of a template or a process of taking a specific gait deviation. In this module, we're going to talk about contralateral pelvic drop and list internal focus of attention, cues, prompts, feedback. And for each, I've identified a visual, auditory, and kinaesthetic, and then the template uses external focus of attention, and again, provides vocabulary for visual, auditory, and kinaesthetic. And then we're going to apply that in future modules for other common gait deviations.

Who provides cueing, prompting, feedback

So good cueing, prompting, and feedback. Start with an external focus of attention and try to include an image or an analogy, try to make it in positive placebo language and then adjust it according to the individual's preferred learning sensory system, and then provide them with a choice. So the first time you can start with external focus and then let them practise it and then give them a choice of internal and let them choose between internal and external focus of attention. We need to eventually make those cues and prompts and feedback short, need to try to make it so that they can use contrast and explore on their own and recognise that we want to try to get it to an implicit level.

Resources

• Piccoli A, Rossettini G, Cecchetto S, Viceconti A, Ristori D, Turolla A, Maselli F, Testa M. Effect of attentional focus instructions on motor learning and performance of patients with central nervous system and musculoskeletal disorders: A systematic review. Journal of Functional Morphology and Kinesiology. 2018 Jul 25;3(3):40.