applying principles of motor learning

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Journal List HHS Author Manuscripts PMC3773509

J Hand Ther Author manuscript available in PMC 2014 Apr1Published in f inal edited form as

J Hand Ther 2013 Apr-Jun 26(2) 94ndash103doi 101016jjht201212007

PMCID PMC3773509NIHMSID NIHMS502120

Applying principles of motor learning and controlto upper extremity rehabilitationLisa M Muratori PT EdD Eric M Lamberg PT EdD CPed Lori QuinnPT EdD and Susan V Duff PT OT EdD CHT

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The publishers f inal edited version of this article is available at J Hand TherSee other articles in PMC that cite the published article

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Go toAbstract

The purpose of this article is to provide a brief review of the principles ofmotor control and learning Different models of motor control fromhistorical to contemporary are presented with emphasis on the systemsmodel Concepts of motor learning including skill acquisitionmeasurement of learning and methods to promote skill acquisition byexamining the many facets of practice scheduling and use of feedback areprovided A fictional client case is introduced and threaded throughout thearticle to facilitate understanding of these concepts and how they can beapplied to clinical practice

Keywords Motor Learning Motor Control Hand Upper extremityRehabilitation

The challenge of achieving hand and arm skill given neurological diseaseor injury may be met by weaving key concepts of motor learning andcontrol into treatment protocols However in order to effectively integratethese concepts into hand rehabilitation programs motor learning andmotor control strategies need to be better understood The purpose ofthis review is to outline key principles of motor learning and motor controlthat can be used to foster skill acquisition in upper extremity (UE)rehabilitation To illustrate the application of these principles for individualswith neurological conditions we will consider the case of ldquoJoanrdquo a 38year old female who sustained a traumatic brain injury that led to left UEhemiplegia (see Table 1)

See reviews

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skills in stroke concepts on reacquisition ofmotor control and therapist guidelines for

[J Neuroeng Rehabil 2009]

Rapid feedback responses correlate withreach adaptation and properties of novelupper limb loads

[J Neurosci 2013]

Nature of spatial coupling in children withand without developmental coordinationdisorder in ball catching

[Adapt Phys Activ Q 2013]

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Applying principles of motor learningand control to upper extremityrehabilitat


Go to

Table 1Case Study - Joan

MOTOR LEARNING AND CONTROL

The attainment of motor skills involves a process of motor learningwhose principles integrate information from psychology neurologyphysical education and rehabilitation research Together these disciplinesshape our understanding of how individuals progress from novice toskilled motor performance throughout the lifespan Infants learning toreach and grasp use the perceptions they have of their own body andabilities to secure objects of various shapes and sizes Older adults mustoften accommodate to the gradual loss of strength and sensory changesthat occur with aging to modify how they perform manipulation tasksIndividuals with neurological conditions that affect UE function may needto relearn previously acquired motor skills with an altered number andquality of resources available to them

Systems Model

Motor control theories provide a framework to guide the interpretation ofhow learning or re-learning movement occurs Perspectives in motorcontrol are based on evolving models of the nervous system and representthe paradigm shifts that have taken place throughout history Historicallywhen the concepts of an existing paradigm begin to limit the way

1

2

Review Motor skill acquisition[Annu Rev Psychol 1991]

Flexion-reflex of the limb crossedextension-reflex and reflex stepping andstanding

[J Physiol 1910]


movement and behavior are interpreted new paradigms are developedFor example in the early 1900s voluntary movement was thought tooccur through reflex linkages This paradigm led to numerous theories ofmotor control that have been replaced as knowledge of the nervoussystem expands Although the assumptions associated with varied motorcontrol theories differ most current theories have incorporated a Systemsview of distributed control of the nervous system A Systems modelsuggests that movement results from the interaction of multiple systemsworking in synchrony to solve a motor problem The advantage of theSystems model is that it can account for the flexibility and adaptability ofmotor behavior in a variety of environmental conditions Functional goalsas well as environmental and task constraints play a major role indetermining movement This frame of reference provides a foundation fordeveloping intervention strategies based on task goals that are aimed atimproving motor skills

To exemplify how movement problem are solved consider our caseJoan as she attempts to don a shirt while sitting at the edge of the bedTo be successful she must learn how to solve this motor problem with theconstraints imposed by her brain injury A Systems model of controlsuggests multiple factors both internal and external to Joan needconsideration when she performs this functional movement Internalfactors may include strength flexibility coordination pain levelmotivation cognition autonomic function and sitting balance at aminimum External factors may include the type of shirt firmness of thebed the type of floor surface the availability of assistive devices and

2

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4

5


outside distractions In order to complete the task of upper body dressingall available systems must work together to produce a single strategy

Degrees of Freedom Problem

Producing a single optimal strategy for movement presents a significantproblem to the nervous system Nikolai Bernstein a nineteenth centuryRussian neurophysiologist who challenged the contemporary reflextheories of movement that dominated his field pioneered the concept ofmultiple systems working together to create movement He argued that toperform smooth and efficient voluntary movement one must overcome thedegrees of freedom problem Bernstein recognized that when multiplesystems interact there are vast movement options (degrees of freedom)available to perform the same action For example Joan could reachfor a cup on a table in front of her by flexing her shoulder and extendingher elbow or she could keep her arm close to her body and flex at thetrunk to bring her hand to the cup This redundancy takes place atmultiple levels within the CNS For example muscles can fire in differentways to control particular movement patterns or joint motions Inaddition many different kinematicmovement patterns can be executed toaccomplish one specific outcome or action A healthy individual can don ashirt by initiating the action with one arm or the other or even both arms atoncendash each strategy accomplishes the same dressing goal

Bernstein has suggested that a key function of the CNS is to controlredundancy by minimizing the degrees of freedom or the number ofindependent movement elements employed The resolution to the degrees

4

4


of freedom problem will vary depending on the characteristics of thelearner as well as the components of the task and environment For Joanshoulder pain may increase the likelihood of co-contraction to stabilize herbody against undesired movement as she attempt to don the shirt Herimpulsivity and lack of insight might make her less likely to appropriatelyrestrain the degrees of freedom during her initial attempts at dressingThus during the early stages of learning how to dress her upper bodyJoan may produce very simple movements and limit the amount of jointmotion by holding some joints stiffly via muscle co-contraction Thisaction decreases the degrees of freedom allowing for greater success Asthe task is learned Joans muscle co-activation may decrease As herskill improves she may exhibit greater fluidity reflecting the ability of theCNS to use multiple motor resources to accomplish select tasks

Dominant Theories

The question of how specific movement patterns are selected out of thevast number of options available has a major influence on how therapistsintervene Many theories have developed describing how multiple systemsmight come together to produce a functional movement However twodistinct classes of theory have dominated the discussion for more thanforty years The first focuses on central control of movement instructions(eg Motor Program Theory [MPT]) and the second on dynamic self-organization of multiple sub-systems around a meaningful goal (egDynamic Pattern or Dynamical Systems Theory [DST])

Motor Program Theory initially suggested that some form of neural

6

7


storage of motor plans took place and that these motor plans wereretrieved as needed to achieve motor goals Three major issues arosearound the ability of MPT to adequately explain voluntary movement astorage problem a novelty problem and the problem of motorequivalence The storage problem is the result of the huge repertoire ofhuman movements Where are the motor plans for the movements storedIt would seem there would need to be an infinite storage capacity in thenervous system to contain all the plans necessary for the variety ofmovement available The second issue the novelty problem addressesthe ability to plan new actions How is there a program for a movementthat has never been performed before Finally there is the issue of motorequivalence --the same action can be accomplished using differentpatterns of coordination How is this possible if the action is the result of aprogram

Some of the issues outlined above in MPT have been addressed with thegeneralized motor program (GMP) theory proposed by Schmidt In hiswork Schmidt argues that motor programs do not have to be specifiedfor every action Rather there are generalized programs that contain rulesfor a large class of similar actions This minimizes the storage needsaccounts for novelty (new actions are merely versions of other actionspreviously performed and therefore part of an existing class ofmovements) and explains motor equivalence by arguing that rules of aGMP are not muscle specific rather there are invariant features that theprogram specifies including timing and force coordination Theseinvariants help define classes of movement and minimize the absolute

7

89Review Motor schema theory after 27years reflections and implications for anew theory

[Res Q Exerc Sport 2003]


amount of information that must be stored

Conversely DST proposes that rather than a sequence of motor stepsthat are ldquostoredrdquo movement is an emergent property occurring as theneuromuscular system interacts with the environment an online adaptationspecific to the task at hand In DST physical movement is constrainedby characteristics of the individual (size cognition motivation etc)environment (light gravity etc) and task (goals rules etc) Althoughthe CNS is still necessary for initiating movement and monitoring ongoingmovement for error it is just one subsystem responsible for the eventualmotor output An assumption of DST is that while certain movementpatterns are preferred they are not obligatory and therefore new patternsof movement can emerge when there is a shift somewhere in thesystem This is an attractive idea when working with patients as changesin their body structure (eg hemiparesis of one arm) would represent aldquoshift in a sub-systemrdquo allowing for a new adaptive motor pattern toemerge Providing opportunities in clinic and home programs for theemergence of new patterns would exemplify use of the DST perspective

It is not clear whether one theory will prevail or a compromise of thesetwo theories will evolve that better answers how movement occursBernstein suggested that the outcome of a movement is represented in amotor plan (eg aiming a ball toward a target) and distributed at differentlevels of the CNS This is a concept that many theories have adoptedAlthough the specific organization of motor plans is not known flexibleneural representations of the dynamic and distributed processes through

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13

4

14ndash16

Hidden skills a dynamic systemsanalysis of treadmill stepping during thefirst year

[Monogr Soc Res Child Dev 1991]

Dynamic pattern theory--someimplications for therapeutics[Phys Ther 1990]

Implications of a dynamical systemsapproach to understanding infant kickingbehavior

[Phys Ther 1991]

Is the organisation of goal-directed actionmodality specific A common temporalstructure

[Neuropsychologia 2000]


Go to

which the nervous system can solve motor problems seem to existA motor program has evolved into an abstract representation of amovement that centrally organizes and controls the degrees of freedomLearning comes from an interaction and strengthening among multiplesystems and there may be strong neural connections between relatedsystems that can be crudely viewed as representations This internalrepresentation needs to be matched to the external environment andfunctional movement likely emerges as a result of this interaction

SKILL ACQUISITION

Skilled actions are those that demonstrate consistency flexibility andefficiency Consistency refers to the repeatability of performance ndash is theindividual able to perform the task consistently over a period of trialsconducted over a number of sessions For example can Joan sit for asustained period repeatedly Flexibility (transferability) refers to theability to adapt and modify task performance based on changingenvironments or conditions For instance can Joan maintain her sittingbalance on various surfaces when buttoning her shirt Efficiency usuallypertains to the capabilities of the cardiovascular and musculoskeletalsystems Can Joan maintain a sustained sitting position without becomingexhausted or does an extended period of sitting limit her activity for therest of the day It is important to realize that performance of an activityindicates that one has attained that skill however within any motor taskpeople can possess various levels of skill

Stages of Skill Acquisition

14ndash16

17


In the early part of Joans recovery her movements may be poorlycontrolled and her movement goals may be simple and limited Forexample Joan may knock over cups when attempting to grasp or mayneed to focus on donning a pullover shirt rather than one that requiresfastening As she begins to recover Joan may exhibit a larger repertoireof movements and move with less effort or greater efficiency Theseattributes exemplify Joans progression through stages of skill acquisitionAs clinicians we must determine where individuals are struggling along thelearning continuum so we can target our interventions appropriatelyAlthough various stages of learning have been proposed a two-stagemodel proposed by Gentile introduces key components for clinicians toconsider when designing intervention strategies

In Gentiles model there are two objectives for the initial stage oflearning (1) to learn the basic movement pattern needed to achieve thegoal and (2) to identify components of the environment important to thetask Gentile further classifies environmental characteristics into regulatoryand non-regulatory features Regulatory features of the environmentinclude all aspects necessary for successful performance of the task Thuswhen donning a shirt while sitting at the edge of the bed Joan mustconsider the texture of the shirt the size of the openings for the arms andthe head the buttons and button holes the firmness of the bed the heightof the bed the surface of the floor and presence or absence of bed railsto use for support Non-regulatory features are those aspects of theenvironment that are present ndash and may even be distracting ndash but are not

18


integral to performance of the task In our example the color of the shirtpresence of a roommate and sound in the hallway are all non-regulatoryfeatures Even though the features may alter the way the movementultimately is produced Joan does not need to attend to thesecharacteristics to put on her shirt

When they are in the initial stage of learning individuals should beencouraged to actively explore the environment through trial and errorThis stage is a period in which the basic dynamics of movements areexperienced and new strategies are tested within the limits of patientsafety It is often considered a cognitive stage as performers must solve aseries of problems experienced as they try various movements It isimportant to note that even those with cognitive deficits should beprovided with opportunities to strategize ways to complete a movementwithout over instruction Therapists can aide learning by structuring theenvironment to maximize regulatory features and minimize non-regulatoryfeatures as individuals actively search for appropriate movementstrategies

Once a coordinative pattern develops that allows for some degree ofsuccess and the performer is able to distinguish between regulatory andnon-regulatory features of the environment the later stage of learningbegins During this phase of refinement the focus switches from ldquowhat todordquo to ldquohow to dordquo the movement better Thus this later stage oflearning is characterized by a less cognitive process of consolidation inorder to improve motor efficiency and movement flexibility (eg the abilityto perform the task under different conditions)

17


to perform the task under different conditions)

It is important to remember that learning is not linear Instead motorperformance follows the `power law of learning with large improvementsnoted during early practice and smaller rates of improvement displayed aspractice continues We often see periods of great improvementfollowed by plateaus or even regression in our patients During theseperiods it is possible that while performance appears worse learning isstill occurring During the off periods individuals may be fatigued or havedecreased attention or they may be attempting new strategies to performthe task However evidence suggests that memory consolidation for long-term storage continues during performance plateaus and plateaus arefollowed by new periods of observable improvement

Explicit vs Implicit Learning Processes

Gentile has suggested that motor skill learning involves two parallel yetdistinct learning processes explicit and implicit complementing thestages of learning discussed above Although these two processes changeat different rates and appear to take place in different stages theyoverlap during skill learning During explicit learning the performersfocus is on attainment of the goal as in the initial stage of learning In anattempt at early success the performer develops a ldquomaprdquo between theirbody structure and the conditions within the environment

Initially Joan must understand the movements she can make with herlimited ROM and strength to determine how her body can achieve thegoal of sitting in bed or transitioning from sit to stand She must attend to

19

20

21

Neural correlates of motor memoryconsolidation [Science 1997]


changes in her movements shapestructure and its relationship to externalconditions and demands as she attempts to problem-solve through tasksThe therapist may need to provide simple relevant cues to assist withproblem solving due to Joans attention deficits Whenever movementpatterns can be consciously adapted by the performer they areconsidered to be regulated by explicit processes However success atachieving a task goal does not necessarily imply that movementperformance is efficient

During extended practice in the later stages of learning Joans motorcontrol strategies should be refined indicating the predominance ofimplicit processes Implicit learning will occur over a gradual period oftime as she learns to unconsciously merge successive movements couplesimultaneous components and regulate intersegmental force dynamicsinherent in specific tasks Intersegmental force dynamics incorporateactive forces produced through muscle contraction and passive forcessuch as motion-dependent torques (joint movement obtained withoutmuscle contraction) that occur naturally in the environment or as a resultof movement The variability typically observed in young children andnovel performers as they learn particular motor skills allows them todevelop a range of force production patterns Although explicitprocesses dominate the early stages and implicit processes in the laterstages it is important to understand that both processes are presentthroughout (re)learning Joan may not able to perform the most basiccomponent of dressing without some change in force dynamics andgradation Likewise as her skill improves new conditions will be

22

21

21


confronted and conscious attention will be allocated as necessary

Measurement of Motor Learning

Motor learning is measured by analyzing performance in three distinctways acquisition retention and transfer of skills Acquisition is theinitial practice or performance of a new skill (or new control aspect of apreviously learned motor skill) For Joan this means the practice ofreaching with her left hemiparetic arm toward an object of interest as sheincorporates the components of sequencing balance control strengthand movement efficiency Retention is the ability to demonstrateattainment of the goal or improvement in some aspect following a short orlong time delay in which the task is not practiced This means that Joanwould be able to reach to grasp objects while sitting at the edge of thebed at the end of one treatment session and again at the beginning of anew session on a different day without further practice or cueing If she issuccessful she demonstrates that she has retained the ability to reach tograsp objects from a static sitting position Transfer requires theperformance of a task similar in movement yet different from the originaltask practiced in the acquisition phase (eg altered force or timing) Forexample Joan would display transfer if she could reach to grasp objectsplaced at different parts of the workspace at a quick pace from a seatedposition on chairs of different height Acceptable performance of a motorskill within a single session (or series of sessions) does not demonstratethat the skill has been learned A skill is not considered truly learned untilretention andor transfer of that particular skill is demonstrated It is

23


imperative when determining a clients level of independence that weconsider whether we have measured performance at a point in time orlearning of the skill so that it can be performed in the environments andunder the conditions necessary for the client to be successful

Classification of Motor Skills

Three useful classification systems for motor skills include defining the

Fine and gross motor skills are familiar to therapists Fine motor skills arethose that use small muscles of the hands and mouth for manipulation andspeech Gross motor skills use the larger muscles of the trunk andextremities Both small and large muscles may be included in variousupper extremity tasks for Joan such as stabilizing the trunk while reachingin standing

Movements classified as discrete or continuous may be controlled bydifferent mechanisms Discrete movements have a defined beginningand end point Common examples are turning on a light pushing a buttonraising your hand in class slipping on a shoe and goal-directed reachingContinuous or rhythmic motions are those with no clear start or endWalking playing the drums swimming and driving all represent

size of the movement ndash gross or fine motor skills(1)beginning and end points ndash discrete or continuous and(2)characterizing the stability of the environment in which the task isbeing performed ndash open or closed These three classificationschemes can be used to organize and plan task practice

(3)

24 On rhythmic and discrete movementsreflections definitions and implications formotor control

[Exp Brain Res 2007]


Go to

continuous tasks The distinction between these classes of movements isoften difficult to discern Is continuous motion a series of discretemovements or conversely are rhythmic movements functional units whilediscrete are merely abbreviated rhythmic motions As movements fallalong a continuum between these classes the term serial movements hasbeen proposed to account for movements that are continuous but withclear discrete components Piano playing keyboard typing andbuttoning a blouse could be considered serial movements

Finally skills can be classified as open or closed based on the temporaland spatial features of the environment where a task is performed Aclosed skill is one in which the performer can start and stop at any timebecause the regulatory features of the environment remain constantExamples include sitting on a chair in a quiet room while performing handexercises dressing and many activities of daily living Open skills requirethe performer to conform to changes in the environment for successPredictive abilities are essential For example catching a ball requires youto move your hands in time with the movement of the ball to makecontact Similarly when reaching out to shake someones hand ndash youmust conform to the other persons speed and hand position to besuccessful As clinicians we frequently start with closed skills because weare working in a patients room therapy gym or clinic but we must moveto environments that are progressively more open to provide a challengeand optimize an individuals independence

PROMOTING SKILL ACQUISITION

25

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22


Practice

We know that to gain expertise a skill must be rehearsed repeatedlyHowever there are many variables to consider when structuring the waypractice should ensue including the amount the type and the schedule Aspresented above the best practice design should not simply promoteimmediate performance effects but ensure long-term learning bypromoting retention and transfer of skill

Amount of Practice

It is well supported that the best way to improve at any skill is to practicepractice and do more practice The more time devoted on task the moreopportunity an individual has to improve their capabilities This is readilyobserved by thinking about the development of reaching abilities inchildren It takes a number of years for a child to be able to perform areach to grasp that is similar to how it is performed in adults Duringthose years many movements are made as the child initially tries to get ahand to the mouth or bat at a toy and eventually attempts to pick up a cupof water to drink or throw a ball During practice not all of the attemptsand combinations of movements are successful but each attempt providesthe child with information about both what to do and what not to do inorder to achieve the goal

In rehabilitation the underlying principle more practice is better is readilyobserved when interpreting the literature on constraint-induced movementtherapy (CIMT) In this rehabilitation paradigm initially designed for

23

2627

The development of coordination for reach-to-grasp movements in children[Exp Brain Res 2002]

Structuring of early reaching movementsa longitudinal study [J Mot Behav 1991]

An application of upper-extremityconstraint-induced movement therapy in apatient with subacute stroke

[Phys Ther 1999]


adults post-stroke the unaffected arm is restrained requiring theindividual to use the affected arm to complete numerous repetitions ofvarious tasks that challenge the system Results from this type ofrehabilitation program have been promising showing that intensestructured practice leads to improvements in function quality ofmovement timing and even changes in the neuro substrates of thebrain which correspond to improved movement capabilities

Whole vs Part Practice

Should a motor task be practiced in its entirety (whole) or should it bebroken into separate parts The answer is not an easy one and is multi-factorial involving an in-depth understanding of the movement in questionTo decide if part practice may be beneficial the task must be analyzedbased on the number of segments as well as the degree that thosesegments are interdependent on one another In continuous motortasks the current portion of a movement is dependent on the movementjust completed and therefore these tasks are best practiced in theirentirety Sequences of movements that will be coupled such as a danceroutine or reaching to grasp a cup and lifting it to drink may lendthemselves to be divided practiced and then combined for wholepractice since there are segments that are clearly separated from oneanother This part practice can be beneficial if used properly since alearner can perform pieces of the movement and have some degree ofsuccess providing increased motivation to learn the skill Howeverdeciding how to divide a task is often a difficult decision for a therapist

28ndash34

35

36ndash39 40

17

See more

Forced use of hemiplegic upperextremities to reverse the effect of learnednonuse among chronic stroke and head-

[Exp Neurol 1989]

Improvement after constraint-inducedmovement therapy recovery of normalmotor control or task-specific

[Neurorehabil Neural Repair 2013]

Association of activity changes in theprimary sensory cortex with successfulmotor rehabilitation of the hand following


The timing of natural prehensionmovements [J Mot Behav 1984]


For example it may be easy to see how Joan can practice the reach tograsp of the cup then separately practice the movement of bringing thecup to her mouth however it is more difficult to separate the reach fromthe grasp since there is a temporal relationship between reach andgrasp Artificially breaking apart a task that does not lend itself to partpractice may not benefit motor learning and may even hinder the process

While it appears clear that more practice is better how practice sessionsshould be structured to ensure optimal learning is less clear Should a lotof practice be performed at once (massed) or should rest breaks besprinkled throughout (distributed) Should only one task be practiced(constant) or should different tasks or variations of the singular task beintroduced (variable)

The concepts of massed and distributed practice define different waysthat practice can be undertaken For example if you wanted to work withJoan on left hand control you may decide to perform 30 trials of insertinga key into a lock and turning during the treatment session but shouldJoan practice all 30 trials at once Massed practice requires all the trialsto be performed in a manner that minimizes the amount of rest betweentrials so there is more time on task than there is spent during restDistributed practice divides repetitions into smaller chunks to allow forrest between trials (eg 5 trials now 5 in 10 minutes etc) Clinicallythere is no empirical evidence to support that either of these scheduleslead to superior motor skill learning however depending on the goal ofthe practice session and the individuals capabilities (strength endurance

41

23


cognition ability to focus on task) incorporating either a massed ordistributed schedule may lead to better learning and should be taken intoaccount when designing a treatment intervention

Constant vs Variable Practice

Performance of only one task exactly the same way time after time istermed constant practice Using our earlier example this would involveJoan inserting the same key into the same lock from the same startposition every attempt While this may improve Joans ability to performthis particular task the literature to date has found there may be areduced ability to retain and transfer a skill following constantpractice For transfer of skill to occur study results have suggestedthat variable practice may be more effective Variable practice involvesperforming variations of the task or completely different tasks throughouta treatment session For Joan this would mean using different keys whichrequire varying degrees of force to undo a lock Variability could also beintroduced by placing locks in different locations which would requirechanges in the starting hand posture What is not clearly understood ishow much variation should be present to encourage optimal learning

Three categories are used to describe variability and practice order --blocked random and serial In the key and lock example theintervention is designed so that Joan will engage in 30 practice trialsinserting three different shaped keys with slightly different fingertip forcedemands (Key A Key B and Key C) into the same lock A blockedschedule would require that all practice be completed under one condition

42ndash45

46

Variability of Practice and ContextualInterference in Motor Skill Learning[J Mot Behav 1995]

Contextual interference effects insequence learning for young and olderadults

[Psychol Aging 2010]


before moving on to the next For example 10 trials are performedconsecutively with Key A then 10 with Key B and finally 10 with Key CA random schedule maximizes variability As with blocked Joan willcomplete 30 trials ensuring 10 trials with each key but each key ispracticed in a random order If blocked and random practice schedulesare considered as the anchors on a continuum a serial schedule issomewhere in between A serial schedule requires a sequence to befollowed until all 30 trials (10 on each condition) are completed (egABC ABC ABC hellip10 times)

The ability to predict what task will be performed from trial to trial differsdepending upon the type of practice schedule with blocked having thehighest and random the lowest degree of predictability The effect ofdifferent practice schedules on learning is termed contextualinterference Briefly during blocked practice there is low interferenceor disruption in memory as a person practices multiple trials repeatedlyHowever in random practice there is high interference because trials areinterrupted by other tasks Study results have shown that while highercontextual interference (random practice) may lead to poor performanceit frequently leads to better learning (as measured with retention andtransfer tests) compared to blocked practice This may occur becausein random practice the skill must be reconstructed on each attemptallowing an individual to practice a variety of strategies This benefitappears to be lost when learning very complex tasks or in individuals withsignificant neurological impairments For example Joans difficulty withmulti-step commands and trouble focusing on tasks may make random

47

48

49

Contextual interference and augmentedfeedback is there an additive effect formotor learning

[Hum Mov Sci 2011]

Contextual interference effect elaborativeprocessing or forgetting-reconstruction Apost hoc analysis of transcranial magnetic

[J Mot Behav 2008]


practice ineffective Furthermore blocked practice may best because ofthe increased chance for success during practice providing motivation tocontinue with practice

The Role of Mental Practice

Mental practice involves cognitive rehearsal and imagining of a motoraction with the goal of improving performance but without the productionof overt physical movement Research has demonstrated thatdepending on the task improvements in motor skill can occur with mentalpractice alone however when mental practice is combined with physicalpractice the improvement in skill is magnified It is hypothesized thatmental practice is successful in helping improve skill because whenperformed the neural processes involved in imagining the movement arevery similar to those required for physical performance Furtheralthough there is no overt movement with mental practice EMG studieshave demonstrated that low level muscle activity (submovement activity)occurs Thus if Joan was to use mental practice to work on dressing sheshould be instructed that it is not relaxing meditation Instead Joan shouldvisualize herself going through the steps are dressing concentrating on themovements required and ldquofeelingrdquo how their imagined body is moving

Specificity and Location of Practice

Task-specific or task-oriented practice is an approach to rehabilitationthat focuses on performance of functional tasks that are meaningful to theindividual In order for this type of practice to be successful a therapist

2350ndash52

5152

4153ndash55

56

Review Mental practice for relearninglocomotor skills [Phys Ther 2010]

Review The effects of mental practice instroke rehabilitation a systematic review[Arch Phys Med Rehabil 2006]

Review Motor imagery in physicaltherapist practice [Phys Ther 2007]


Modulation of muscle responses evokedby transcranial magnetic stimulationduring the acquisition of new fine motor

[J Neurophysiol 1995]

Possible involvement of primary motorcortex in mentally simulated movement afunctional magnetic resonance imaging

[Neuroreport 1996]

Task-related training improvesperformance of seated reaching tasks[Stroke 1997]


must be able to accurately assess their patient and identify their limitationsand deficits It becomes the job of the therapist to accurately arrange theenvironment to provide the proper affordances so that the task or amodified version of the task can successfully be completed by theperformer An affordance is the reciprocal relationship or ldquofitrdquo between aperformer and the environment and can drive the composition of themovement For example when working on reach to grasp with Joan ifthe goal for the session is to have her modulate the force of her graspthen following principles of task-oriented practice Joan might be askedto reach and grasp a Styrofoam cup instead of a glass This task-orientedregiment differs from a therapeutic approach that is typically moreimpairment based whereas the latter regiment may use therapeuticexercise (ie repetitive squeezing activity) out of the reach to graspcontext as a means to achieve the goal

While task oriented treatments may appear simple setting theenvironment to target the movements you desire your patient to practice isquite difficult and time consuming If your environment is not set properlythe performer may not be successful and thus may become frustrated andnot have the drive to want to continue to practice Further it is importantto ensure the activity performed is challenging and meaningful to theindividual as to not be perceived as boring or useless Lastly it isimportant to note that task-specific practice may be only one portion ofyour therapeutic intervention Therapeutic exercise and other modes oftreatment may also be required such as range-of-motion activities or jointmobilization to allow the patient to have the tools available to successfully

57

performance of seated reaching tasksafter stroke A randomized controlled trial

[Stroke 1997]


Go to

complete a particular task-oriented activity

Practice which leads to optimal learning depends on the task beinglearned and the characteristics of the learner (eg age stage of learning)The best practice design will not simply promote immediate performanceeffects but more importantly will promote long-term learning

THE ROLE OF FEEDBACK

Feedback refers to information an individual receives pertaining to theperformance of a task It is generated from two sources The first isreferred to as internal or task-intrinsic which is information about themovement gained through interpretation of sensory visual and auditoryexperiences The second is external feedback commonly referred toas augmented feedback since this information is primarily used to enhancetask-intrinsic feedback However sometimes external feedback mayhave a more important role and serve as a replacement if impairment ispresent in a sensory system Augmented task-related feedback can comein many forms such as verbal visual (demonstration) or physical (manualguidance) Use of augmented feedback can greatly enhance a personsability to learn a task but when and how should it be provided Here wewill explore the types of augmented feedback available and discuss thecontent timing and frequency of this feedback and its role in enhancinglearning (see Table 2)

Table 2Factors Associated with Delivery of

1723

1723


Verbal Augmented Feedback (KR orKP)

Types of Augmented Feedback

Verbal augmented feedback is provided as either knowledge of results orknowledge of performance Knowledge of results is information relatedto the outcome and in most cases is redundant information because by thetime a task is completed the performer is usually aware if they weresuccessful Knowledge of performance pertains to information regardingexecution of the task and typically relates to the type or quality of themovement Although it is usually redundant information knowledge ofresults may be useful at any time during the learning process but isparticularly useful in the earlier stages because it can serve as a motivator(eg great job you opened your hand) Knowledge of performance isbest used in the later stages after the goal of the movement is realized andnow the information provided about varying aspects of the movement canbe more readily understood by the performer

Composition of the Augmented Feedback

Feedback can be delivered many ways With regards to knowledge ofperformance the therapist can provide descriptive information regardingthe past movement (eg you moved your hand too soon) or prescriptiveinformation offering a possible solution to be used for the next attempt(eg next time move your hand as you extend your elbow) If used in thetraditional sense these are both passive methods of providing information

17

58


(the learner is being told what happened or what to do next) A betterway to use these tools may be to engage the patient-learner in a dialogueby asking leading questions so that they become an active participant intrying to solve the movement problem (eg what do you think happenedon the last attempt What will you do differently on the next attempt)Active learning is thought to be crucial because it emphasizes the processof continuing to solve new and different motor problems as they ariserather than just being provided with the solution For example whenworking with Joan to improve her dressing abilities we may ask her howshe intends to get her left arm through the shirtsleeve This approachwould require Joan to assess the situation and her ability to ultimatelyformulate and execute a motor plan rather than just being provided with asolution

In addition depending on the learner and the stage of learning he or she isin the therapist must decide what type of feedback to provide such as

whether the information given should be general (about themovement itself) or specific (about a particular portion of amovement)

1)

qualitative (that was faster than last time) or quantitative (thatwas 3 seconds faster than last time)

2)

comprised of information related to an internal focus ofattention (lift your arm to shoulder height and extend yourelbow) or external focus of attention (reach to turn on the lightswitch) and

3)

whether information should be provided regarding the4)


Overall it appears that individuals in the early stage of learning such asJoan in the early phase of rehabilitation would do better with prescriptiveor active-engaging feedback that is more general and qualitative in naturewith an external focus on what was done correctly

Frequency of Augmented Feedback

Feedback can be provided concurrently during a task or it can beprovided after a task is performed (terminal) While the goal of concurrentfeedback is to have an immediate effect on the movement beingperformed studies have suggested that concurrent feedback may actuallyhinder retention and transfer because the performer or the individualperforming the task becomes reliant on that feedback to complete thetask successfully This is an important consideration for hand therapistsSo how much feedback should be provided

Studies in healthy populations are suggesting that less feedback is bestThis does not suggest that no feedback should be provided Augmentedfeedback can enhance learning but it has also been found that too muchcan hinder learning Our patients naturally become dependent onfeedback when it is provided to them Feedback that is more frequentencourages passive rather than active participation and can reduce thepatients ability to perform those skills Thus the amount of feedbackshould be reduced as therapy progresses This can be done by (1) usingan intermittent schedule of when feedback is given that consists of

whether information should be provided regarding thecorrectness of the movement or on the errors

4)1759

60

61

Effects of physical guidance andknowledge of results on motor learningsupport for the guidance hypothesis


Interaction of feedback frequency and taskdifficulty in childrens motor skill learning[Phys Ther 2012]


summary or average information regarding a selection of previousattempts (2) using a faded schedule that initially provides a lot and then isreduced as practice continues (3) setting up boundaries (bandwidth)where feedback will be given only if an error is too large or too small or(4) allowing the performer to have some control and decision-makingover when and what type of assistance is provided during task practiceThe frequency of feedback is dependent on the stage of the learner andthe learner themselves

Before Task Performance ndash Modeling

Modeling ldquorefers to the process of reproducing actions that have beenexecuted by another individualrdquo These demonstrations are powerfulsources of information given prior to task performance that provide theobserver with the general movement pattern and the goal of the movementas well as information about the way submovements are coordinated andrelated to one another that are otherwise difficult to put into wordsStudies indicate that the learner readily adopts the demonstrated strategies(whether effective or ineffective) for use to perform a motor skillThus the model that will demonstrate the movement must be carefullychosen

The type of model used has been found to influence motivation andtherefore subsequent learning While mastery or expert models provideimportant strategies for the learner these strategies may be so advancedthat they are unusable for the learner In these cases a less skilled modelor even better a less-skilled peer model (someone with similar physical

17

62

6364

Review Modeling considerations in motorskill acquisition and performance anintegrated approach

[Exerc Sport Sci Rev 1989]

Modeling effects on motor performance[Res Q 1976]


characteristics) maybe more beneficial because the learner can noticecorrect and incorrect aspects of the movement and strategies the modelused to correct for errors Thus in the case of Joan the therapist servingas the model for how to put a shirt on may not provide Joan with themost useful information it may be best to have a peer (such as anotherpatient) perform this activity for Joan to watch and problem solvethrough

Manual Guidance

Manual guidance is when a therapist passively moves a patient-learner inan effort to provide more appropriate proprioceptive feedback but isthis the best way to teach an individual how to perform a task It goeswithout argument that when safety is a concern then it is important that atherapist is close by or has their ldquohand-onrdquo the learner but what aboutwhen learning or relearning a skill It has been suggested that manualguidance is in a way concurrent feedback Thus the guidance that atherapist provides becomes part of the regulatory features of the task andthe participant becomes dependent on that feedback to complete the tasksuccessfully Thus while performance may improve learning (asmeasured through retention and transfer) may be slowed since duringpractice the learner did not need to actively solve the motor problem overand over So when working with Joan as she tries to regain the ability tomove independently from sit to stand should the therapist practice in amanner that is always hands-off Well not exactly First as mentionedabove safety is of the utmost importance Barring that there are other

65

A comparison of manual guidance andknowledge of results in the learning of aweight-bearing skill

[J Neurol Phys Ther 2008]


Go to

times when manual guidance may be needed For example we may keepour hands on Joan in order to take her through the movement she will beasked to perform to give her an idea of the movement we would like herto produce Yet if manual guidance is used the therapist should attempt toremove the physical assistance as soon as possible so the patient does notbecome dependent on this guidance

SPECIAL CONSIDERATIONS FOR THEINDIVIDUAL WITH NEUROLOGICAL IMPAIRMENT

An often overlooked component of motor re-learning in our patients is theso-called slow component of learning This aspect of learning is notexperience dependent but rather sleep dependent It involves thebiochemical and structural changes that occur in the nervous systemduring different periods of sleep and is present in both sensory-perceptualand motor learning Because many patients with neurologicalconditions have sleep disturbances it is likely that some of the deficits inlong-term skill learning arise from inadequate processing of practice

The capacity of the brain to modify its structure or function in response tolearning or brain damage is termed plasticity As concepts of neuralplasticity have gained acceptance the functional changes seen duringlearning and following recovery from brain damage are being interpretedwithin a Systems Theory framework The brains attempt to recover frominjury may initially involve resolution from shock as noted by a reductionin edema However the majority of recovery is due to neuralreorganization The extensive research on plasticity provides strong

66

6768

69

Functional MRI evidence for adult motorcortex plasticity during motor skilllearning

[Nature 1995]

The time course of learning a visual skill[Nature 1993]

Review How much brain does a mindneed Scientific clinical and educationalimplications of ecological plasticity

[Dev Med Child Neurol 1998]


Go to

Go to

justification to enhance motor learning and re-learning across all ages andskill levels

FootnotesPublishers Disclaimer This is a PDF file of an unedited manuscript thathas been accepted for publication As a service to our customers we areproviding this early version of the manuscript The manuscript will undergocopyediting typesetting and review of the resulting proof before it ispublished in its final citable form Please note that during the productionprocess errors may be discovered which could affect the content and alllegal disclaimers that apply to the journal pertain

References

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2 Kuhn TS The Structure of Scientific Revolutions 2nd ed University ofChicago Press Chicago 1970

3 Sherrington C Flexion-reflex of the limb crossed extension-reflex andreflex stepping and standing J Physiol 191040(1ndash2)28ndash121[PMC free article] [PubMed]

4 Bernstein NA The Coordination and regulation of MovementsPergamon Press Oxford 1967

5 Horak F Assumptions underlying motor control for neurologicrehabilitation Alexandria VA 1991


6 Gordon J Assumptions underlying physical therapy intervention InCarr JA Shepard RB editors Movement Science Foundations forPhysical Therapy in Rehabilitation Aspen Publishers Inc Rockville MD1987

7 Keele SW Movement control in skilled motor performancePsychological Bulletin 196870(6)387ndash403

8 Schmidt RA A schema theory of discrete motor skill learningPsychological review 197582(4)225ndash260

9 Schmidt RA Motor schema theory after 27 years reflections andimplications for a new theory Research quarterly for exercise and sport2003 Dec74(4)366ndash375 [PubMed]

10 Thelen E Ulrich BD Hidden skills a dynamic systems analysis oftreadmill stepping during the first year Monogr Soc Res Child Dev199156(1)1ndash98 discussion 99ndash104 [PubMed]

11 Scholz JP Dynamic pattern theory--some implications fortherapeutics Physical therapy 1990 Dec70(12)827ndash843 [PubMed]

12 Newell KM Constraints on the development of coordination InWade MG Whiting HTA editors Motor development in childrenAspects of coordination and control Nijhoff Amsterdam 1986

13 Heriza CB Implications of a dynamical systems approach tounderstanding infant kicking behavior Physical therapy 1991Mar71(3)222ndash235 [PubMed]


14 Gordon J Current status of the motor program - invited commentaryPhysical therapy 1994 Aug74(8)748ndash752

15 Morris ME Summers JJ Matyas TA Iansek R Current status of themotor program Physical therapy 1994 Aug74(8)738ndash748 discussion748ndash752 [PubMed]

16 Weiss PH Jeannerod M Paulignan Y Freund HJ Is the organisationof goal-directed action modality specific A common temporal structureNeuropsychologia 200038(8)1136ndash1147 [PubMed]

17 Schmidt RA Lee TD Motor control and learning A behavioralemphasis Human Kinetics Publishers 2005

18 Gentile AM A working model of skill acquisition with application toteaching Quest 197217(1)3ndash23

19 Newell A Rosenbloom PS Mechanisms of skill acquisition and thelaw of practice Cognitive skills and their acquisition 19811ndash55

20 Shadmehr R Holcomb HH Neural correlates of motor memoryconsolidation Science 1997 Aug 8277(5327)821ndash825 [PubMed]

21 Gentile A Movement science Implicit and explicit processes duringacquisition of functional skills Scandinavian Journal of OccupationalTherapy 19985(1)7ndash16

22 Gentile A Skill acquisition Action movement and neuromotorprocesses In Carr JA Shephard RB editors Movement science


Foundations for physical therapy in rehabilitation Aspen PublishersRockville MD 2000 pp 111ndash187

23 Magill RA Motor learning and control Concepts and Applications9th ed McGraw Hill 2011

24 Huys R Jirsa V Studenka B Rheaume N Zelaznik H Humantrajectory formation Taxonomy of movement based on phase flowtopology Coordination Neural behavioral and social dynamics200877ndash92

25 Hogan N Sternad D On rhythmic and discrete movementsreflections definitions and implications for motor control Exp Brain Res2007 Jul181(1)13ndash30 [PubMed]

26 Schneiberg S Sveistrup H McFadyen B McKinley P Levin MFThe development of coordination for reach-to-grasp movements inchildren Exp Brain Res 2002 Sep146(2)142ndash154 [PubMed]

27 von Hofsten C Structuring of early reaching movements alongitudinal study J Mot Behav 1991 Dec23(4)280ndash292 [PubMed]

28 Blanton S Wolf SL An application of upper-extremity constraint-induced movement therapy in a patient with subacute stroke Physicaltherapy 1999 Sep79(9)847ndash853 [PubMed]

29 Charles J Lavinder G Gordon AM Effects of constraint-inducedtherapy on hand function in children with hemiplegic cerebral palsyPediatr Phys Ther 2001 Summer13(2)68ndash76 [PubMed]


30 Crocker MD MacKay-Lyons M McDonnell E Forced use of theupper extremity in cerebral palsy a single-case design The AmericanJournal of Occupational Therapy 199751(10)824ndash833 [PubMed]

31 Ostendorf CG Wolf SL Effect of forced use of the upper extremityof a hemiplegic patient on changes in function A single-case designPhysical therapy 1981 Jul61(7)1022ndash1028 [PubMed]

32 Taub E Miller N Novack T et al Technique to improve chronicmotor deficit after stroke Archives of physical medicine andrehabilitation 199374(4)347 [PubMed]

33 Taub E Wolf SL Constraint-Induced (CI) movement techniques tofacilitate upper extremity use in stroke patients Top Stroke Rehabil1997338ndash61

34 Wolf SL Lecraw DE Barton LA Jann BB Forced use ofhemiplegic upper extremities to reverse the effect of learned nonuseamong chronic stroke and head-injured patients Experimental neurology1989104(2)125ndash132 [PubMed]

35 Kitago T Liang J Huang VS et al Improvement After Constraint-Induced Movement Therapy Recovery of Normal Motor Control orTask-Specific Compensation Neurorehabilitation and Neural Repair2012 [PubMed]

36 Laible M Grieshammer S Seidel G Rijntjes M Weiller C HamzeiF Association of Activity Changes in the Primary Sensory Cortex With


Successful Motor Rehabilitation of the Hand Following StrokeNeurorehabilitation and Neural Repair 201226(7)881ndash888 [PubMed]

37 Liepert J Bauder H Miltner WHR Taub E Weiller C Treatment-induced cortical reorganization after stroke in humans Stroke200031(6)1210ndash1216 [PubMed]

38 Liepert J Miltner W Bauder H et al Motor cortex plasticity duringconstraint-induced movement therapy in stroke patients Neuroscienceletters 1998250(1)5ndash8 [PubMed]

39 Treger I Aidinof L Lehrer H Kalichman L Constraint-InducedMovement Therapy Alters Cerebral Blood Flow in Subacute Post-StrokePatients American Journal of Physical Medicine amp Rehabilitation201291(9)804ndash809 [PubMed]

40 Taub E Uswatte G Bowman MH et al Constraint-InducedMovement Therapy Combined With Conventional NeurorehabilitationTechniques in Chronic Stroke Patients With Plegic Hands A Case SeriesArch Phys Med Rehabil 2012 Aug 21 [PMC free article] [PubMed]

41 Jeannerod M The timing of natural prehension movements Journal ofmotor behavior 1984 [PubMed]

42 Hall KG Magill RA Variability of Practice and ContextualInterference in Motor Skill Learning J Mot Behav 1995 Dec27(4)299ndash309 [PubMed]

43 Hanlon RE Motor learning following unilateral stroke Archives of


physical medicine and rehabilitation 199677(8)811ndash815 [PubMed]

44 Kruisselbrink LD Van Gyn GH Task characteristics and thecontextual interference effect Percept Mot Skills 2011 Aug113(1)19ndash37 [PubMed]

45 Lin CH Wu AD Udompholkul P Knowlton BJ Contextualinterference effects in sequence learning for young and older adultsPsychol Aging 2010 Dec25(4)929ndash939 [PubMed]

46 Shea JB Morgan RL Contextual interference effects on theacquisition retention and transfer of a motor skill Journal ofExperimental Psychology Human Learning and Memory 19795(2)179

47 Lee TD Wulf G Schmidt RA Contextual interference in motorlearning Dissociated effects due to the nature of task variations TheQuarterly Journal of Experimental Psychology 199244(4)627ndash644

48 Wu WF Young DE Schandler SL et al Contextual interference andaugmented feedback is there an additive effect for motor learning HumMov Sci 2011 Dec30(6)1092ndash1101 [PubMed]

49 Lin CH Fisher BE Winstein CJ Wu AD Gordon J Contextualinterference effect elaborative processing or forgetting-reconstruction Apost hoc analysis of transcranial magnetic stimulation-induced effects onmotor learning J Mot Behav 2008 Nov40(6)578ndash586 [PubMed]

50 Malouin F Richards CL Mental practice for relearning locomotorskills Physical therapy 201090(2)240ndash251 [PubMed]


51 Dickstein R Deutsch JE Motor imagery in physical therapistpractice Physical therapy 2007 Jul87(7)942ndash953 [PubMed]

52 Braun SM Beurskens AJ Borm PJ Schack T Wade DT Theeffects of mental practice in stroke rehabilitation a systematic reviewArchives of physical medicine and rehabilitation 200687(6)842ndash852[PubMed]

53 Pascual-Leone A Nguyet D Cohen LG Brasil-Neto JPCammarota A Hallett M Modulation of muscle responses evoked bytranscranial magnetic stimulation during the acquisition of new fine motorskills Journal of Neurophysiology 199574(3)1037ndash1045 [PubMed]

54 Roland PE Larsen B Lassen N Skinhoj E Supplementary motorarea and other cortical areas in organization of voluntary movements inman Journal of Neurophysiology 198043(1)118ndash136 [PubMed]

55 Roth M Decety J Raybaudi M et al Possible involvement ofprimary motor cortex in mentally simulated movement a functionalmagnetic resonance imaging study Neuroreport 19967(7)1280[PubMed]

56 Dean CM Shepherd RB Task-Related Training ImprovesPerformance of Seated Reaching Tasks After Stroke A RandomizedControlled Trial Stroke 199728(4)722ndash728 [PubMed]

57 Gibson JJ The ecological approach to visual perception LawrenceErlbaum 1986


58 Shumway-Cook A Woollacott MH Motor control translatingresearch into clinical practice Lippincott Williams amp Wilkins 2006

59 Wulf G Chiviacowsky S Schiller E Aacutevila LTG Frequent externalfocus feedback enhances motor learning Frontiers in Psychology 2010Nov 111 2010 [PMC free article] [PubMed]

60 Winstein CJ Pohl PS Lewthwaite R Effects of physical guidanceand knowledge of results on motor learning support for the guidancehypothesis Research quarterly for exercise and sport 1994Dec65(4)316ndash323 [PubMed]

61 Sidaway B Bates J Occhiogrosso B Schlagenhaufer J Wilkes DInteraction of feedback frequency and task difficulty in childrens motorskill learning Physical therapy 2012 Jul92(7)948ndash957 [PubMed]

62 McCullagh P Weiss MR Ross D Modeling considerations in motorskill acquisition and performance An integrated approach In PandofKB editor Exercise and Sport Sciences Reviews Vol 17 1989 pp475ndash513 [PubMed]

63 Martens R Burwitz L Zuckerman J Modeling effects on motorperformance Research Quarterly 1976 [PubMed]

64 McCullagh P Model similarity effects on motor performance Journalof Sport Psychology 1987

65 Sidaway B Ahn S Boldeau P Griffin S Noyes B Pelletier K Acomparison of manual guidance and knowledge of results in the learning


NLM NIH DHHS

of a weight-bearing skill Journal of Neurologic Physical Therapy200832(1)32 [PubMed]

66 Carr JA Shepard RB editors Movement science Foundations forphysical therapy in rehabilitation 2nd ed Aspen Publishers 2000

67 Karni A Meyer G Jezzard P Adams MM Turner R UngerleiderLG Functional MRI evidence for adult motor cortex plasticity duringmotor skill learning Nature 1995 Sep 14377(6545)155ndash158[PubMed]

68 Karni A Sagi D The time course of learning a visual skill Nature1993 Sep 16365(6443)250ndash252 [PubMed]

69 Lebeer J How much brain does a mind need Scientific clinical andeducational implications of ecological plasticity Dev Med Child Neurol1998 May40(5)352ndash357 [PubMed]

Copyright | Disclaimer | Privacy | Browsers | Accessibility | ContactNational Center for Biotechnology Information US National Library of Medicine8600 Rockville Pike Bethesda MD 20894 USA

You are here NCBI gt Literature gt PubMed Central (PMC) Write to the Help Desk


Go toAbstract

The purpose of this article is to provide a brief review of the principles ofmotor control and learning Different models of motor control fromhistorical to contemporary are presented with emphasis on the systemsmodel Concepts of motor learning including skill acquisitionmeasurement of learning and methods to promote skill acquisition byexamining the many facets of practice scheduling and use of feedback areprovided A fictional client case is introduced and threaded throughout thearticle to facilitate understanding of these concepts and how they can beapplied to clinical practice

Keywords Motor Learning Motor Control Hand Upper extremityRehabilitation

The challenge of achieving hand and arm skill given neurological diseaseor injury may be met by weaving key concepts of motor learning andcontrol into treatment protocols However in order to effectively integratethese concepts into hand rehabilitation programs motor learning andmotor control strategies need to be better understood The purpose ofthis review is to outline key principles of motor learning and motor controlthat can be used to foster skill acquisition in upper extremity (UE)rehabilitation To illustrate the application of these principles for individualswith neurological conditions we will consider the case of ldquoJoanrdquo a 38year old female who sustained a traumatic brain injury that led to left UEhemiplegia (see Table 1)

See reviews

See all

skills in stroke concepts on reacquisition ofmotor control and therapist guidelines for

[J Neuroeng Rehabil 2009]

Rapid feedback responses correlate withreach adaptation and properties of novelupper limb loads

[J Neurosci 2013]

Nature of spatial coupling in children withand without developmental coordinationdisorder in ball catching

[Adapt Phys Activ Q 2013]

Cited by other articles in PMC

See all

Design considerations for a theory-drivenexergame-based rehabilitation program toimprove walking of persons with stroke

[European Review of Aging and P]

Usability and Effects of an Exergame-BasedBalance Training Program[Games For Health Journal 2014]

LinksPubMed

Recent ActivityClearTurn Off

See more

Applying principles of motor learningand control to upper extremityrehabilitat


Go to




Systems Model


1

2



[J Physiol 1910]




2

3

4

5






4

4



Dominant Theories



6

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13

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14ndash16





[Phys Ther 1991]




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SKILL ACQUISITION



14ndash16

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(3)




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[Phys Ther 1999]





28ndash34

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36ndash39 40

17

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[Exp Neurol 1989]










41

23






42ndash45

46







47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

5152

4153ndash55

56








[Neuroreport 1996]





57


[Stroke 1997]


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1723

1723







17

58





1)


2)


3)








4)1759

60

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17

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6364






Manual Guidance


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66

6768

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[Nature 1995]





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Go to



References














































































NLM NIH DHHS









Go to




Systems Model


1

2



[J Physiol 1910]




2

3

4

5






4

4



Dominant Theories



6

7




7







10

11

12

13

4

14ndash16





[Phys Ther 1991]




Go to


SKILL ACQUISITION



14ndash16

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17







19

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(3)




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25

17

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Practice


Amount of Practice



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2627




[Phys Ther 1999]





28ndash34

35

36ndash39 40

17

See more


[Exp Neurol 1989]










41

23






42ndash45

46







47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

5152

4153ndash55

56








[Neuroreport 1996]





57


[Stroke 1997]


Go to






1723

1723







17

58





1)


2)


3)








4)1759

60

61









17

62

6364






Manual Guidance


65




Go to





66

6768

69


[Nature 1995]





Go to

Go to



References














































































NLM NIH DHHS











2

3

4

5






4

4



Dominant Theories



6

7




7







10

11

12

13

4

14ndash16





[Phys Ther 1991]




Go to


SKILL ACQUISITION



14ndash16

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18





17







19

20

21





22

21

21





23








(3)




Go to




25

17

22


Practice


Amount of Practice



23

2627




[Phys Ther 1999]





28ndash34

35

36ndash39 40

17

See more


[Exp Neurol 1989]










41

23






42ndash45

46







47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

5152

4153ndash55

56








[Neuroreport 1996]





57


[Stroke 1997]


Go to






1723

1723







17

58





1)


2)


3)








4)1759

60

61









17

62

6364






Manual Guidance


65




Go to





66

6768

69


[Nature 1995]





Go to

Go to



References














































































NLM NIH DHHS













4

4



Dominant Theories



6

7




7







10

11

12

13

4

14ndash16





[Phys Ther 1991]




Go to


SKILL ACQUISITION



14ndash16

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18





17







19

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21





22

21

21





23








(3)




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25

17

22


Practice


Amount of Practice



23

2627




[Phys Ther 1999]





28ndash34

35

36ndash39 40

17

See more


[Exp Neurol 1989]










41

23






42ndash45

46







47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

5152

4153ndash55

56








[Neuroreport 1996]





57


[Stroke 1997]


Go to






1723

1723







17

58





1)


2)


3)








4)1759

60

61









17

62

6364






Manual Guidance


65




Go to





66

6768

69


[Nature 1995]





Go to

Go to



References














































































NLM NIH DHHS










Dominant Theories



6

7




7







10

11

12

13

4

14ndash16





[Phys Ther 1991]




Go to


SKILL ACQUISITION



14ndash16

17




18





17







19

20

21





22

21

21





23








(3)




Go to




25

17

22


Practice


Amount of Practice



23

2627




[Phys Ther 1999]





28ndash34

35

36ndash39 40

17

See more


[Exp Neurol 1989]










41

23






42ndash45

46







47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

5152

4153ndash55

56








[Neuroreport 1996]





57


[Stroke 1997]


Go to






1723

1723







17

58





1)


2)


3)








4)1759

60

61









17

62

6364






Manual Guidance


65




Go to





66

6768

69


[Nature 1995]





Go to

Go to



References














































































NLM NIH DHHS











7







10

11

12

13

4

14ndash16





[Phys Ther 1991]




Go to


SKILL ACQUISITION



14ndash16

17




18





17







19

20

21





22

21

21





23








(3)




Go to




25

17

22


Practice


Amount of Practice



23

2627




[Phys Ther 1999]





28ndash34

35

36ndash39 40

17

See more


[Exp Neurol 1989]










41

23






42ndash45

46







47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

5152

4153ndash55

56








[Neuroreport 1996]





57


[Stroke 1997]


Go to






1723

1723







17

58





1)


2)


3)








4)1759

60

61









17

62

6364






Manual Guidance


65




Go to





66

6768

69


[Nature 1995]





Go to

Go to



References














































































NLM NIH DHHS












10

11

12

13

4

14ndash16





[Phys Ther 1991]




Go to


SKILL ACQUISITION



14ndash16

17




18





17







19

20

21





22

21

21





23








(3)




Go to




25

17

22


Practice


Amount of Practice



23

2627




[Phys Ther 1999]





28ndash34

35

36ndash39 40

17

See more


[Exp Neurol 1989]










41

23






42ndash45

46







47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

5152

4153ndash55

56








[Neuroreport 1996]





57


[Stroke 1997]


Go to






1723

1723







17

58





1)


2)


3)








4)1759

60

61









17

62

6364






Manual Guidance


65




Go to





66

6768

69


[Nature 1995]





Go to

Go to



References














































































NLM NIH DHHS









Go to


SKILL ACQUISITION



14ndash16

17




18





17







19

20

21





22

21

21





23








(3)




Go to




25

17

22


Practice


Amount of Practice



23

2627




[Phys Ther 1999]





28ndash34

35

36ndash39 40

17

See more


[Exp Neurol 1989]










41

23






42ndash45

46







47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

5152

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56








[Neuroreport 1996]





57


[Stroke 1997]


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1723

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58





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60

61









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62

6364






Manual Guidance


65




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66

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References














































































NLM NIH DHHS











18





17







19

20

21





22

21

21





23








(3)




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25

17

22


Practice


Amount of Practice



23

2627




[Phys Ther 1999]





28ndash34

35

36ndash39 40

17

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[Exp Neurol 1989]










41

23






42ndash45

46







47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







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56








[Neuroreport 1996]





57


[Stroke 1997]


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1723

1723







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58





1)


2)


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4)1759

60

61









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62

6364






Manual Guidance


65




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66

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[Nature 1995]





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References














































































NLM NIH DHHS












17







19

20

21





22

21

21





23








(3)




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25

17

22


Practice


Amount of Practice



23

2627




[Phys Ther 1999]





28ndash34

35

36ndash39 40

17

See more


[Exp Neurol 1989]










41

23






42ndash45

46







47

48

49


[Hum Mov Sci 2011]


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5152

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56








[Neuroreport 1996]





57


[Stroke 1997]


Go to






1723

1723







17

58





1)


2)


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60

61









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62

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66

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[Nature 1995]





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References














































































NLM NIH DHHS














19

20

21





22

21

21





23








(3)




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25

17

22


Practice


Amount of Practice



23

2627




[Phys Ther 1999]





28ndash34

35

36ndash39 40

17

See more


[Exp Neurol 1989]










41

23






42ndash45

46







47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

5152

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56








[Neuroreport 1996]





57


[Stroke 1997]


Go to






1723

1723







17

58





1)


2)


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4)1759

60

61









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62

6364






Manual Guidance


65




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66

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69


[Nature 1995]





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References














































































NLM NIH DHHS











22

21

21





23








(3)




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25

17

22


Practice


Amount of Practice



23

2627




[Phys Ther 1999]





28ndash34

35

36ndash39 40

17

See more


[Exp Neurol 1989]










41

23






42ndash45

46







47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

5152

4153ndash55

56








[Neuroreport 1996]





57


[Stroke 1997]


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1723

1723







17

58





1)


2)


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60

61









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62

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66

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69


[Nature 1995]





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References














































































NLM NIH DHHS












23








(3)




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25

17

22


Practice


Amount of Practice



23

2627




[Phys Ther 1999]





28ndash34

35

36ndash39 40

17

See more


[Exp Neurol 1989]










41

23






42ndash45

46







47

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49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

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56








[Neuroreport 1996]





57


[Stroke 1997]


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1723

1723







17

58





1)


2)


3)








4)1759

60

61









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62

6364






Manual Guidance


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66

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[Nature 1995]





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References














































































NLM NIH DHHS















(3)




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25

17

22


Practice


Amount of Practice



23

2627




[Phys Ther 1999]





28ndash34

35

36ndash39 40

17

See more


[Exp Neurol 1989]










41

23






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47

48

49


[Hum Mov Sci 2011]


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[Neuroreport 1996]





57


[Stroke 1997]


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1723

1723







17

58





1)


2)


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60

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62

6364






Manual Guidance


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66

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[Nature 1995]





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References














































































NLM NIH DHHS









Go to




25

17

22


Practice


Amount of Practice



23

2627




[Phys Ther 1999]





28ndash34

35

36ndash39 40

17

See more


[Exp Neurol 1989]










41

23






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46







47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

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56








[Neuroreport 1996]





57


[Stroke 1997]


Go to






1723

1723







17

58





1)


2)


3)








4)1759

60

61









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62

6364






Manual Guidance


65




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66

6768

69


[Nature 1995]





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References














































































NLM NIH DHHS









Practice


Amount of Practice



23

2627




[Phys Ther 1999]





28ndash34

35

36ndash39 40

17

See more


[Exp Neurol 1989]










41

23






42ndash45

46







47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

5152

4153ndash55

56








[Neuroreport 1996]





57


[Stroke 1997]


Go to






1723

1723







17

58





1)


2)


3)








4)1759

60

61









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62

6364






Manual Guidance


65




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66

6768

69


[Nature 1995]





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References














































































NLM NIH DHHS












28ndash34

35

36ndash39 40

17

See more


[Exp Neurol 1989]










41

23






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46







47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

5152

4153ndash55

56








[Neuroreport 1996]





57


[Stroke 1997]


Go to






1723

1723







17

58





1)


2)


3)








4)1759

60

61









17

62

6364






Manual Guidance


65




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66

6768

69


[Nature 1995]





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References














































































NLM NIH DHHS












41

23






42ndash45

46







47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

5152

4153ndash55

56








[Neuroreport 1996]





57


[Stroke 1997]


Go to






1723

1723







17

58





1)


2)


3)








4)1759

60

61









17

62

6364






Manual Guidance


65




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66

6768

69


[Nature 1995]





Go to

Go to



References














































































NLM NIH DHHS













42ndash45

46







47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

5152

4153ndash55

56








[Neuroreport 1996]





57


[Stroke 1997]


Go to






1723

1723







17

58





1)


2)


3)








4)1759

60

61









17

62

6364






Manual Guidance


65




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66

6768

69


[Nature 1995]





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References














































































NLM NIH DHHS











47

48

49


[Hum Mov Sci 2011]


[J Mot Behav 2008]







2350ndash52

5152

4153ndash55

56








[Neuroreport 1996]





57


[Stroke 1997]


Go to






1723

1723







17

58





1)


2)


3)








4)1759

60

61









17

62

6364






Manual Guidance


65




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66

6768

69


[Nature 1995]





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References














































































NLM NIH DHHS














2350ndash52

5152

4153ndash55

56








[Neuroreport 1996]





57


[Stroke 1997]


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1723

1723







17

58





1)


2)


3)








4)1759

60

61









17

62

6364






Manual Guidance


65




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66

6768

69


[Nature 1995]





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References














































































NLM NIH DHHS











57


[Stroke 1997]


Go to






1723

1723







17

58





1)


2)


3)








4)1759

60

61









17

62

6364






Manual Guidance


65




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66

6768

69


[Nature 1995]





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References














































































NLM NIH DHHS









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1723

1723







17

58





1)


2)


3)








4)1759

60

61









17

62

6364






Manual Guidance


65




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66

6768

69


[Nature 1995]





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References














































































NLM NIH DHHS














17

58





1)


2)


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4)1759

60

61









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62

6364






Manual Guidance


65




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66

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[Nature 1995]





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References














































































NLM NIH DHHS












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2)


3)








4)1759

60

61









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62

6364






Manual Guidance


65




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[Nature 1995]





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References














































































NLM NIH DHHS














4)1759

60

61









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62

6364






Manual Guidance


65




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[Nature 1995]





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References














































































NLM NIH DHHS













17

62

6364






Manual Guidance


65




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66

6768

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[Nature 1995]





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References














































































NLM NIH DHHS










Manual Guidance


65




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66

6768

69


[Nature 1995]





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References














































































NLM NIH DHHS









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66

6768

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[Nature 1995]





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References














































































NLM NIH DHHS









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References














































































NLM NIH DHHS
















































































NLM NIH DHHS








applying principles of motor learning

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principles ofmotor control

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published article

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