Purpose—The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke. Methods—Writing group members were nominated by th...

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association

It is generally accepted that augmented feedback, provided by a human expert or a technical display, effectively enhances motor learning. However, discussion of the way to most effectively provide augmented feedback has been controversial. Related studies have focused primarily on simple or artificial tasks enhanced by visual feedback. Recently, technical advances have made it possible also to investigate more complex, realistic motor tasks and to implement not only visual, but also auditory, haptic, or multimodal augmented feedback. The aim of this review is to address the potential of augmented unimodal and multimodal feedback in the framework of motor learning theories. The review addresses the reasons for the different impacts of feedback strategies within or between the visual, auditory, and haptic modalities and the challenges that need to be overcome to provide appropriate feedback in these modalities, either in isolation or in combination. Accordingly, the design criteria for successful visual, auditory, haptic, and multimodal feedback are elaborated.

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Augmented visual, auditory, haptic, and multimodal feedback in motor learning: A review

Over the past 15 years, research on focus of attention has consistently demonstrated that an external focus (i.e., on the movement effect) enhances motor performance and learning relative to an internal focus (i.e., on body movements). This article provides a comprehensive review of the extant literature. Findings show that the performance and learning advantages through instructions or feedback inducing an external focus extend across different types of tasks, skill levels, and age groups. Benefits are seen in movement effectiveness (e.g., accuracy, consistency, balance) as well as efficiency (e.g., muscular activity, force production, cardiovascular responses). Methodological issues that have arisen in the literature are discussed. Finally, our current understanding of the underlying mechanisms of the attentional focus effect is outlined, and directions for future research are suggested.

https://golfsciencelab.com/wp-content/uploads/2015/10/Wulf_AF_review_IRSEP_2013.pdf

Attentional focus and motor learning: a review of 15 years

Objectives Findings from the contemporary psychological and movement science literature that appear to have implications for medical training are reviewed. Specifically, the review focuses on four factors that have been shown to enhance the learning of motor skills: observational practice; the learner’s focus of attention; feedback, and self-controlled practice.

Observational Practice  Observation of others, particularly when it is combined with physical practice, can make important contributions to learning. This includes dyad practice (i.e. practice in pairs), which is not only cost-effective, but can also enhance learning.

Focus of Attention  Studies examining the role of the performer’s focus of attention have consistently demonstrated that instructions inducing an external focus (directed at the movement effect) are more effective than those promoting an internal focus (directed at the performer’s body movements). An external focus facilitates automaticity in motor control and promotes movement efficiency.

Feedback  Feedback not only has an informational function, but also has motivational properties that have an important influence on learning. For example, feedback after successful trials and social-comparative (normative) feedback indicating better than average performance have been shown to have a beneficial effect on learning.

Self-Controlled Practice  Self-controlled practice, including feedback and model demonstrations controlled by the learner, has been found to be more effective than externally controlled practice conditions.

Conclusions  All factors reviewed in this article appear to have both informational and motivational influences on learning. The findings seem to reflect general learning principles and are assumed to have relatively broad applicability. Therefore, the consideration of these factors in designing procedures for medical training has the potential to enhance the effectiveness and efficiency of training.

Medical Education 2010: 44: 75–84

https://www.onlinelibrary.wiley.com/doi/epdf/10.1111/j.1365-2923.2009.03421.x

Motor skill learning and performance: a review of influential factors.

Effective motor performance is important for surviving and thriving, and skilled movement is critical in many activities. Much theorizing over the past few decades has focused on how certain practice conditions affect the processing of task-related information to affect learning. Yet, existing theoretical perspectives do not accommodate significant recent lines of evidence demonstrating motivational and attentional effects on performance and learning. These include research on (a) conditions that enhance expectancies for future performance, (b) variables that influence learners' autonomy, and (c) an external focus of attention on the intended movement effect. We propose the OPTIMAL (Optimizing Performance through Intrinsic Motivation and Attention for Learning) theory of motor learning. We suggest that motivational and attentional factors contribute to performance and learning by strengthening the coupling of goals to actions. We provide explanations for the performance and learning advantages of these variables on psychological and neuroscientific grounds. We describe a plausible mechanism for expectancy effects rooted in responses of dopamine to the anticipation of positive experience and temporally associated with skill practice. Learner autonomy acts perhaps largely through an enhanced expectancy pathway. Furthermore, we consider the influence of an external focus for the establishment of efficient functional connections across brain networks that subserve skilled movement. We speculate that enhanced expectancies and an external focus propel performers' cognitive and motor systems in productive "forward" directions and prevent "backsliding" into self- and non-task focused states. Expected success presumably breeds further success and helps consolidate memories. We discuss practical implications and future research directions.

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Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning

Purpose. There is little guidance on using extrinsic feedback to enhance motor learning after stroke. This narrative review synthesises research findings and identifies questions remaining to be answered. Method. A summary is given relating to the use of extrinsic feedback in healthy subjects. Then, research concerning content of feedback, feedback scheduling, and attentional focus is discussed in relation to patients with stroke. Results. Though research is scarce, preliminary key findings were as follows: Patients’ balance performance can improve from receiving visual feedback about weight distribution during practice; auditory feedback of force production may improve performance of sit-to-stand; providing feedback on less than 100% of trials, and giving summary or average feedback may enhance learning; instructions or feedback inducing an external focus may be more effective than those with an internal focus. Further research is needed concerning the relative benefits of verbal, visual, video and kinematic feedback; reduced feedback frequencies and summary feedback schedules; feedback delays, error estimation, and self-controlled feedback; and attentional focus of feedback. Conclusions. Although there are some indications that feedback might enhance motor learning after stroke, there are many areas as yet not examined and there is clearly a need for considerable research in this area.

/pdf/extrinsic-feedback-for-motor-learning-after-stroke-what-is-4bmsyie16q.pdf

Extrinsic feedback for motor learning after stroke: What is the evidence?

Recent studies (Chiviacowsky & Wulf, 2002, 2005) have shown that learners prefer to receive feedback after they believe they had a “good” rather than “poor”trial. The present study followed up on this finding and examined whether learning would benefit if individuals received feedback after good relative to poor trials. Participants practiced a task that required them to throw beanbags at a target with their nondominant arm. Vision was prevented during and after the throws. All participants received knowledge of results (KR) on three trials in each 6-trial block. While one group (KR good) received KR for the three most effective trials in each block, another (KR poor) received feedback for the three least effective trials in each block. There were no group differences in practice. However, the KR good group showed learning advantages on a delayed retention test (without KR). These results demonstrated that learning is facilitated if feedback is provided after good rather than poor trials. The findings are...

Feedback After Good Trials Enhances Learning

Performing and learning motor skills has been shown to be enhanced if the performer adopts an external relative to internal focus (or no focus) of attention (Wulf, 2007). The present study examined the generalizability of this effect to top-level performers (balance acrobats). Participants performed a balance task (standing on an inflated rubber disk) under each of three attentional focus conditions: (a) external focus (i.e., minimize movements of the disk), (b) internal focus (i.e., minimize movements of the feet), and (c) control conditions (no focus instructions). While there were no differences between conditions in the amount of postural sway, the frequency of movement adjustments was higher in the control condition, relative to both external and internal focus conditions. This suggests that movement automaticity and postural stability were greatest when the balance experts were free to adopt their “normal” focus of attention. The finding implies that there may be a limit to the performance-enhancing...

Attentional Focus Effects in Balance Acrobats

This study investigated the influence of normative feedback on learning a sequential timing task. In addition to feedback about their performance per trial, two groups of participants received bogus normative feedback about a peer group's average block-to-block improvement after each block of 10 trials. Scores indicated either greater (better group) or less (worse group) than the average improvement, respectively. On the transfer test 1 day later, which required producing novel absolute movement times, the better group demonstrated more effective learning than the worse group. These findings add to the mounting evidence that motivational factors affect motor skill learning.

Normative Feedback Effects on Learning a Timing Task

It has been shown that practice in dyads, as compared to individual practice, can enhance motor learning and increase the efficiency of practice (as two participants can be trained at the same time; Shea, Wulf, & Whitacre, 1999). The dyad practice protocol used by Shea et al. included both observation and dialogue between partners. Thus, it was not clear whether the learning benefits of dyad practice were due to observation, dialogue, or both. The present study examined the individual and interactive effects of observation and dialogue. The task used was speed cup stacking. Participants practiced under one of four conditions: observation/dialogue, observation/no dialogue, no observation/dialogue, and no observation/no dialogue. The two conditions that included observational practice were more effective (i.e., produced faster movement times) than the two conditions without it, both during practice and on a retention test performed under individual performance conditions. This suggests that the learning advantages of dyad practice are primarily due to the opportunity to observe another learner.

Gabrielle Wulf

Papers

Extrinsic feedback for motor learning after stroke: What is the evidence?

Feedback After Good Trials Enhances Learning

Attentional Focus Effects in Balance Acrobats

Normative Feedback Effects on Learning a Timing Task

Enhancing motor learning through dyad practice: contributions of observation and dialogue.