Learning to Walk Post-Stroke

Kelly DeAngelis

EXSC 351

13 November 2015

1. My patient is Albert, a 65 year-old man suffering from hemiparesis on the left side of his

body following a stroke. Alberts goal is to learn to walk again so that he will be able to

get from one room to another in his home without assistance. Being able to walk again
 will allow Albert to go about his basic daily activities, such as walking to the bathroom,

more easily. Furthermore, by mastering the ability to walk short distances on his own,

he will be able to stay home by himself while his wife runs quick errands. Based on the

learning stage model proposed by Fitts and Posner, Albert is currently is the cognitive

stage of learning. He is in the cognitive stage because his movements involve many

gross errors and his performance of the skill is highly variable. Furthermore, when he

makes a mistake, Albert needs to be told what to do to make improvements because he

does not understand how to fix his mistakes (Magill, 2007). The motor skill of walking

involves lifting one leg while standing, extending it slightly, and then bringing the leg

back down so that the foot is planted on the ground a short distance in front of where it

had previously been. This process is then repeated, alternating the legs so that the

person moves in a forward direction. Walking can be defined as a gross motor skill

because it involves the use of large muscle groups in the legs (Magill, 2007). In Alberts

case, learning to walk again will be a closed skill because he wants to be able to move

about his home, a relatively stable and unchanging environment that he is very familiar

with (Magill, 2007). There will be no object manipulation involved in learning this motor

skill as Albert wants to be able to walk completely on his own, without the assistance of a

walker or a cane (Magill, 2007).

2. A massed practice is defined as having a schedule in which many practices of long

duration are held over a relatively short period with little time for rest between sessions.

In contrast, a distributed practice schedule is one in which shorter practices are held

over a longer amount of time with frequent periods of rest (Shumway-Cook & Woollacott,

1995). For Albert, I will be using a distributed practice schedule. A distributed practice

schedule has been shown to produce better retention of skills over longer periods of

time. In a study performed by Kwon, Kwon, and Lee (2015), it was determined that a

distributed practice schedule led to faster and more accurate execution of a motor

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 response when compared to a massed practice schedule. The purpose of this study

was to determine whether a massed or distributed practice schedule would produce

better results for motor learning. Thirty adults were randomly assigned to either the

massed or the distributed practice group where they underwent three training sessions

to learn a motor skill that involved pressing a key in response to a specific visual cue on

a computer screen. Those in the distributed group had twelve-hour breaks in between

each training session, while those in the massed group only had ten minutes between

each session. Subjects in both groups were tested before the training sessions, once

immediately after the second session, and once immediately after the third session. The

results from this study suggested that individuals in the distributed group had faster and

more accurate responses to visual cues after both the second and third sessions as

compared to those in the massed group (Kwon, Kwon & Lee, 2015). Although the data

from this study support my decision to use a distributed practice schedule for Albert, I

must keep in mind that the learners involved in this study were in the associative stage

of learning while Albert is only in the cognitive stage. The skill they were learning was

also a fine motor skill, unlike the gross motor skill that Albert will relearn. Due to these

limitations, I will have to make sure that I adapt the practice sessions to Alberts specific

situation. To implement my distributed practice schedule, I will have Albert attend one

hour practice sessions twice a week for six months. The period of time between the first

and second session of the week will be two days. There will be three days between the

second practice session of one week and the first session of the following week.
3. The microstructure of a practice refers to whether a blocked or random schedule is used.

A blocked schedule involves completely practicing a particular motor skill before

progressing to practicing a different motor skill (Magill, 2007). In contrast, a random or

variable schedule involves practicing different skills at varying times throughout a

practice session. Contextual interference is related to a random practice schedule and

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results from a motor skill being practiced at the same time that another skill is practiced,

or when the learner quickly switches from practicing one skill to another (Magill, 2007).

This often causes a decline in performance of the skill but leads to improved retention

(Shumway-Cook & Woollacott, 1995). Because I want Albert t be able to retain the

motor skill of walking between practice sessions and after completion of his therapy, I

will be implementing a random practice schedule. A study performed by Paulwels,

Swinnen, and Beets (2014) demonstrated the positive effect of contextual interference.

The purpose of the study was to determine whether or not the contextual interference

effect applied to the learning of a bimanual motor skill. Forty subjects were assigned to

either a blocked practice or random practice group and had to complete a tracking task

on a computer using both hands to rotate a joystick. Subjects had to trace a line with a

cursor by moving the joystick in different directions. Three different frequency ratios

were completed by moving one hand more quickly than the other. Subjects in the

blocked group performed the same frequency ratio multiple times before moving on to

the next one, but those in the random practice group performed the different frequency

ratios in a random order. The participants in the random practice group experienced an

initial decline in performance of the task, but their ultimate retention of the skill was

better than those in the blocked group (Paulwels, Swinnen, & Beets, 2014). Even

though the results from this study support my decision to use a random practice

schedule, there are some key limitations. The motor skill performed by the participants

was a fine motor skill that involved object manipulation. Albert will be learning a gross

motor skill that does not involve object manipulation. Also, the participants of this study

were in the associative stage of learning while Albert is in the cognitive stge. To

implement a variable practice schedule, I will have Albert practice several variations of

the motor skill as he is relearning to walk. For example, he will walk different distances

such as 25 meters and 50 meters. Albert will also be walking a specific distance at

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 different speeds. For example, he will need to walk 25 meters moving at a pace of 0.5

m/s and then again at 1.0 m/s. Another variation I will be implementing into Alberts

practice is his direction of walking. I will have him practice walking to a designated

location in a straight line and by traveling an indirect route that requires him to turn right

and left in a maze-like pattern.

4. I will be using both verbal instructions and demonstration during Alberts practice

sessions. Demonstration is a form of instruction in which the instructor shows the

learner how to do the skill by physically performing it himself. This can be done in

person or through video footage. Verbal instructions tell the learner how to perform the

motor skill in writing or through spoken language (Magill, 2007). Dib and Sturmey (2007)

performed a study that demonstrated the positive effects of incorporating verbal

instruction and demonstration into a practice setting. The objective of the study learn

how verbal instruction and demonstration of proper form would affect the posture of

novice flute players. Three flute players taking beginner-level lessons received

instruction from their teacher in the form of both demonstration and verbal instruction for

3-4 months. The teacher videotaped the flute players during these lessons to see the

progression of the students as they continued with their lessons. Upon completion of the

study, it was determined that the subjects all played the flute with proper form and even

maintained proper form 1-2 months after their lessons had ended. This suggests that

the instructors use of demonstration and verbal instructions combined led to a

successful outcome in improving the students postures (Dib & Sturmey, 2007). The

subjects in this study were similar to Albert in that they were also in the cognitive stage

of learning how to play the flute. However, the motor skill they were learning was a fine

motor skill that involved object manipulation. This poses as a limitation because Albert

will be learning a gross motor skill that involves no object manipulation. To incorporate

both verbal instruction and demonstration into the practice sessions, I will begin by

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 modeling the correct walking form while talking him through it. I might say, See how I

am extending my leg slightly out so that my foot will land in front of the other one when I

plant it on the ground? I will also show him video footage of a person demonstrating

how to walk properly. Then, as Albert begins to practice the motor skill himself, I will

verbally instruct him as he practices walking. For example, I could tell him, Now stand

up straight, lift your right leg off the ground and extend it out so that your knee is bent at

a 45 degree angle. I might also say, Push off the ground with your toes as you are

lifting your leg up.

5. Knowledge of results (KR) is a form of augmented feedback in which the instructor

provides the learner with information about the outcome of a movement. Knowledge of

performance (KP) is feedback about how the movement was performed (Shumway-

Cook & Woollacott, 1995). KP can be given while the skill is being performed or after it

has been performed. KR can only be given after the movement has been completed. I

will be using KP to provide Albert with feedback because he wants to be able to walk

with proper form by executing the movements correctly. In a study performed by Cirstea

and Levin (2007), it was demonstrated that KP led to improved performance of a motor

skill in stroke victims as compared to KR. The purpose of this study was to determine

whether KP or KR would produce better results for stroke victims trying to recover the

motor skill of moving their arm. Twenty-eight stroke patients were chosen as

participants to complete a pointing movement with their affected arm. The subjects were

required to move their arm from the ipsilateral side to a target on the contralateral side

without looking. Half of the subjects received KR after completion of the movement

while the other half received KP while performing the task. The results suggested that

individuals who received KP during the arm movement made greater progress towards

being able to move their arm as well as they had before suffering a stroke when

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 compared to those who received KR (Cirstea & Levin, 2007). This study provides strong

support for my decision to use KP because the motor skill practiced was a gross motor

skill without object manipulation like the one Albert will be learning. However, the

subjects that participated in this study differed from Albert because they were in the

associative stage of learning. Because Albert is in the cognitive stage of learning, he

cannot detect and correct errors in his movements (Magill, 2007). By calling attention to

specific movements as he is performing them, Albert will be able to better understand

how to correct these movements than if I just told him he walked a distance of 25 meters

4 seconds slower than his fastest time. To implement KP during Alberts practice

sessions, I will give him verbal feedback on specific movements, such as gait length

(Your stride was very short during that last exercise.) and foot placement (You placed

your foot almost directly underneath your trunk instead of out in front of it.), as he

practices the different variations of walking I have planned for him.

6. Descriptive augmented feedback (AFB) describes what happened during performance of

the motor skill. This type of AFB may encourage the learner to identify their errors and

decide how they can be corrected (Magill, 2007). Prescriptive AFB is information about

how the movement should be performed in the future in order to avoid repeating the

same mistakes. When this type of AFB is given, the learner is told the mistakes he

made and given advice about how to correct them the next time the skill is performed

(Magill, 2007). I will be providing Albert with prescriptive AFB because he is still in the

cognitive stage of learning and may have difficulty with identifying what he needs to

improve on in order to avoid repeating the same mistakes. In a study performed by

Porte, Xeroulis, Reznick, and Dubrowski (2007) it was demonstrated that prescriptive

feedback led to better results and retention for medical students learning how to suture.

The objective of this study was to determine the efficacy of descriptive feedback from a

computer as compared to prescriptive feedback from an expert. Forty-five medical

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 students were assigned to one of three groups. One group only received feedback from

a computer about the number of movements made during the suturing process. Another

group received the same feedback as the first group, but was also provided with

references of the number of movements it takes for an expert to suture. The third group

received verbal feedback from an expert that included ways to improve suturing

technique in the future. A pre-test was given to assess baseline values. The medical

students then had 18 practice trials of suturing after which a post-test was given. While

students in all three groups showed improvement from pre- to post-test, only those who

received prescriptive feedback from the expert were able to maintain that improvement

one month later (Porte, Xeroulis, Reznick, & Dubrowski, 2007). Although the results of

this study support my decision to use prescriptive feedback, there are some limitations.

For example, the students involved in this study were learning a fine motor skill that

involved object manipulation while Albert will be learning a gross motor skill with no

object manipulation. Another limitation is that the students were in the associative stage

of learning, but Albert is still in the cognitive stage. To implement this type of feedback

into Alberts practice sessions, I will explicitly tell him what he needs to do differently the

next time he performs a specific exercise. For example, I might tell him, You need to lift

your leg higher and swing it out further. I could also tell him, Next time try to walk

keeping your head up instead of looking at the ground.

7. Mastery goals are set for the learner of a motor skill to compare his results only to

himself. These goals focus on making improvements. Performance goals are set to

compare the learner to others. These goals focus on being better than someone else at

a given task (Kavussanu, Morris, and Ring, 2009). Because Albert is not interested in

competing with others and only wants to recover the skill of walking, I will be using

mastery goals to teach him to walk again. The results of a study performed by Xiang,

Bruene, and McBride (2004) support my choice to use mastery goals. The purpose of

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the study was to assess how achievement goals affected the behavior and performance

of students involved in a running program at an elementary school. The running

program required children to run or walk at least once a week during their physical

education classes. One hundred sixteen 4th graders who were involved in the program

were selected to take part in the study. The kids were asked to fill out a questionnaire to

assess whether or not they possessed more mastery goals or performance goals, and to

determine if they felt the running program was focused more on mastery or performance

goals. A week after the questionnaire had be given, the kids took part in a timed one

mile run. The results from this study indicated that the children who possessed more

mastery goals performed better on the one mile run and worked harder during the

practices (Xiang, Bruene, & McBride, 2004). This study is very relevant to my choice to

incorporate mastery goals because the participants were taking part in a gross motor

skill that did not involve object manipulation just like Albert will. However, one of the

limitations to the relevance of this study is that the children were in either the associative

or autonomic stage of learning while Albert is still in the cognitive stage. To help

incorporate mastery goals into Alberts practice sessions, I will time him as he walks 25

meters and then compare his results from one attempt to the next. I will also mark the

farthest distance he is able to walk before needing to stop and take a rest with a strip of

tape on the floor. The next time he attempts to walk as far as he can, his goal will be to

walk further than that piece of tape.

References

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Cirstea, M. C., & Levin, M. F. (2007). Improvement of arm movement patterns and endpoint

control depends on type of feedback during practice in stroke survivors.

Neurorehabilitation and Neural Repair, 21(5), 398-411

Dib, N. E. & Sturmey, P. (2007). The effects of verbal instruction, modeling, rehearsal, and

feedback on correct posture during flute playing. Behavior Modification, 31(4), 382 -388.

Kavussanu, M., Morris, R. L., & Ring, C. (2009). The effects of achievement goals on

performance, enjoyment, and practice of a novel motor task. Journal of Sports Sciences,

27(12), 1281-1292.

Kwon, Y. H., Kwon, J. W., & Lee, M. H. (2015). Effectiveness of motor sequential learning

according to practice schedules in healthy adults; distributed practice versus massed

practice. Journal of Physical Therapy Science, 27, 769-772.

Magill, R., A. (2007). Motor learning and control concepts and applications. Boston, MA:

McGraw Hill.

Pauwels, L, Swinnen, S. P., & Beets, I. A. (2014). Contextual interference in complex bimanual

skill learning leads to better skill persistence. PLoS One, 9(6).

Porte, M. C., Xeroulis, G., Reznick, R. K., & Dubrowski, A. (2007). Verbal feedabck from an

expert is more effective than self-accessed feedback about motion efficiency in learning

new surgical skills. American /journal of Surgery, 193(1), 105-110.

Shumaway-Cook, A., & Woollacott, M. H. (1995). Motor control theory and practical

applications. Baltimore, MD: Williams and Wilkins.

Xiang, P., Bruene, A., & McBride, R. E. (2004). Using achievement goal theory to assess an

elementary physical education running program. Journal of school Health, 74(6), 220-

225.