There are three distinct phases of motor learning, each with its own unique characteristics and requirements. Therefore, we will need distinct exercise strategies, appropriate to each phase, for learning to optimally transfer from exercise to ADL.
In this months’ blog and next, follow brief descriptions of the phases motor learning—applicable whether learning a new skill or re-learning an old/established skill in a more optimum way. The three phases are cognitive, associative and autonomous. The cognitive phase is featured this month.
This is where we start—with exploratory movement, using trial and error. We have determined a ‘provisional target’ that we think would benefit our person—now we want to train our person to recognize, execute, reproduce and utilize our suggested ‘corrective pattern’.
We know that normal, everyday movement is not primarily willful, or cognitive. We don’t think about everything we do, movement-wise. From sitting posture and gait patterns to knee alignment and spinal stabilization, most movement is habitualized and relegated to auto-pilot.
But our proposed solutions, our new and improved movement patterns, cannot be habitualized and filed immediately into the sub-conscious. They need intermediary steps, and the cognitive phase is the first one. When doing movement training, or exercise for motor control purposes, we start by exploring options, training attentional focus and encouraging patient self-evaluation. In essence:
- What are my options—what are the key differences between them—what is my preferred choice?
Exploration of Options
When I go to the optometrist, we work cooperatively. He has gadgets that approximate lens correction, but he doesn’t stop there—he doesn’t assume that his choice is my choice, but provides me with options.
Together, we go through a process by which I can see differences in quality between varying strength or shaped lenses. He suggests based on clinical judgement. I evaluate based on internal sensory criteria. I decide which ‘correction’ I like best.
Training complex and integrated movement or postural patterns is very similar. We suggest movement-based solutions to movement-based problems and provide our didactic reasoning. We then proprioceptively ‘show’ our patients contrastsbetween their sub-optimal and possibly tissue damaging behaviors and our more elegant and comfy propositions. Examples might include:
- Patellar pain descending stairs, where we see the affected knee go into valgus and shear too far forward.
- Low back pain when bending, where we see lumbar flexion hypermobility and a lack of hip flexion mobility.
- Cervical pain when looking up, where we see no thoracic contributions and obvious localized movement stresses at C4-5.
In all these scenarios:
- We bring our patients attention to their ‘pattern at fault’.
- We propose a solution and demonstrate a ‘corrective pattern’ or a ‘provisional target’.
- We have our patient feel the difference between the two experientially.
- We ask our patient to determine a preference.
But how do we get from exploration of options to determination of preference?
Training Attentional Focus
Inherent in any exploration of options is recognition of differences. My optometrist doesn’t provide me options that are identical; he wants me to recognize the qualitative difference between choice A and choice B. Lucky for him, vision is pretty easily accessible for most everybody. Unlucky for us, it is not visual differences we want our patients to focus on, but proprioceptive differences.
Sadly, many people wander around in a proprioceptive haze. They don’t know where to ‘look’ to distinguish the difference between knee alignment and non-alignment, or between lumbar hypermobility and stability. Often, we need to teach them where, or how to, focus their attention.
Depending on your clinical target, you might ask your patient to notice:
- Bony relationships or patterns—is there a shape to be recognized?
- Muscular effort—is there someplace unfamiliar that needs to step up, or is there someplace else that is working unnecessarily?
- Distribution of movement—is there someplace that’s moving a lot and another place that’s not moving at all?
- Differences left to right—are my imbalances linked to my discomfort?
Setting up optimal conditions for learning is helpful:
- Minimizing unnecessary noise (voices, TV, music) and closing the eyes to highlight proprioceptive information—the Weber-Fechner Law (another time).
- Minimizing effort to make muscle engagement more obvious/accessible.
- Going slowly to give ample time to recognize what’s going on.
Using specific language to provide a guided tour of the movement and how they are doing it.
- Inquisitive Language. Asking questions to direct their inquiry to specific key themes.
- What is the shape of your back when you bend?
- Is your weight more toward the big toe side or the little toe side of your foot?
- Does your shoulder blade move up or down when you reach your arm forward?
- Descriptive Language. Describe to your patient in proprioceptive terms both what to do and what to pay attention to.
- Feel your low back flatten to the ground when you roll your pelvis upward.
- Notice the difference in where your effort is when ‘anchoring your arm’ to your neck vs to your back.
- Notice differences in hamstring length between your two sides while rotating your pelvis in plantar grade.
So we have displayed our wares and have trained our patient in recognizing proprioceptive contrasts. They can now execute our ‘provisional target’ and can perceive differences between it and their habitual whatever. Now we move to close the deal.
Encouraging Patient Self-Evaluation
The last step in the cognitive phase, and before moving on the associative phase, is establishment of preference—or encouraging patient self-evaluation. In neuro rehab, this is called autonomy—meaning people learn better when they have some say over what they are doing. Give them a choice and let them decide.
- What do you want the shape of your back to be?
- How would you rather anchor your arm?
- Does it feel best to have your foot rolled inward, outward or in the middle?
- Does your low back feel better coming up from bending with back extension or with hip extension?
This preference can’t be imposed, though it can be anticipated and even encouraged. But ultimately, it is the person you are working with who needs to do the work—to get some skin in the game:
- To pop open the hood and try out the movements.
- To ‘listen’ to their body and to proprioceptively recognize differences in contrasting options.
- To make the decisions and to benefit from the consequences.
In a Nutshell
So these are the characteristics of the cognitive phase:
- Slow and small and eyes closed helps to minimize distracting sensory chatter.
- Directing your patients inquiry into unfamiliar patterns by using inquisitive and descriptive language.
- Providing options (including clarifying their habitual and sub-optimal choice), contrasting options and ranking options on a subjective scale of good/better/best.
In the next phase, we stress different exercise strategies—more advanced and appropriate for the associative phase of motor learning. To be addressed next month.