Motor Learning in Neuro Rehab: The Science of Reteaching the Brain

Neurological rehabilitation is not just about strengthening muscles; it is about reteaching the brain how to control movement. This process is called Motor Learning. Understanding the stages of learning, practice schedules, and feedback types is what separates a technician from a skilled clinician. This guide covers the essential principles you need to optimize neuroplasticity.

1. What is Motor Learning?

Motor learning is defined as a set of processes associated with practice or experience leading to relatively permanent changes in the capability for producing skilled action.

Performance vs. Learning:
Performance is temporary (what they do in the clinic today).
Learning is permanent (what they can still do next week at home).
Warning: Too much feedback improves performance but kills long-term learning!

2. Fitts & Posner's 3 Stages of Learning

Patients progress through three distinct stages. Your role as a therapist changes in each stage.

Stage	Patient's Question	Characteristics	Therapist Role
1. Cognitive	"What do I do?"	High error rate, stiff movement, heavy reliance on vision.	Demonstrate, give clear instructions, provide frequent feedback. Closed environment.
2. Associative	"How do I do it?"	Errors decrease, movement is smoother, reliance shifts to proprioception.	Reduce feedback (fade it), introduce variation, encourage self-correction.
3. Autonomous	"I just do it."	Automatic movement, low error, can dual-task (talk while walking).	Add distractions (dual-tasking), open environment, focus on speed/efficiency.

3. Practice Conditions: The "Dosage"

How you structure the practice session determines retention.

A. Massed vs. Distributed Practice

• Massed Practice: Work time > Rest time (e.g., 20 mins walk, 2 mins rest). Good for high motivation/endurance.
• Distributed Practice: Rest time ≥ Work time (e.g., 5 mins walk, 5 mins rest). Essential for fatigue-prone patients (MS, GBS).

B. Blocked vs. Random Practice (Contextual Interference)

• Blocked Practice (AAA, BBB, CCC): Practicing one task repeatedly (e.g., 10 sit-to-stands).
  Result: Great performance during session, poor retention. Good for Cognitive Stage.
• Random Practice (ACB, BAC, CBA): Mixing tasks in random order (e.g., sit-to-stand, then walk, then reach).
  Result: Poor performance during session, excellent retention. Good for Associative/Autonomous stages.

4. Feedback: The "Instruction"

Feedback drives error correction. It comes in two forms:

• Intrinsic Feedback: Sensory information from the patient's own body (vision, proprioception).
• Extrinsic (Augmented) Feedback: Information from the therapist.

Knowledge of Results (KR) vs. Knowledge of Performance (KP)

Type	Focus	Example
Knowledge of Results (KR)	The Outcome (Success/Fail)	"You walked 10 meters in 15 seconds." or "You missed the cup."
Knowledge of Performance (KP)	The Movement Pattern (Quality)	"Your knee buckled when you stepped." or "Keep your elbow straight."

The Feedback Trap: Giving feedback after every trial makes the patient dependent on you. To promote learning, use:

• Faded Feedback: High initially, then reduce gradually.
• Bandwidth Feedback: Only correct if the error exceeds a certain "safety zone."
• Summary Feedback: Give feedback after a set of 5-10 trials.

5. Revision Notes for Students

Goal: Neuroplasticity & Permanent change.
Stages: Cognitive (Vision dependent) → Associative (Proprioception dependent) → Autonomous (Automatic).
Random Practice: Harder now, better retention later.
Blocked Practice: Easier now, poorer retention later.
Feedback: Less is often more. Don't let the patient rely on your voice. Fade it out.

6. FAQs

Q1. What is Part vs. Whole practice?

Whole Practice: Practicing the entire task (e.g., walking). Best for continuous tasks.
Part Practice: Breaking it down (e.g., just practicing the heel strike). Best for serial tasks with distinct steps (e.g., transfers).

Q2. When should I use blocked practice?

Use blocked practice in the very early Cognitive Stage when the patient is just trying to understand the basic movement map. Switch to random as soon as possible.

Q3. What is "Guidance Hypothesis"?

The theory that 100% feedback acts as a crutch (guidance). It improves immediate performance but degrades learning because the patient stops problem-solving.

7. 10 Practice MCQs

Q1. Which stage of motor learning is characterized by a heavy reliance on vision and a high error rate?

Answer: A) The "What to do" stage requires visual monitoring.

Q2. "You walked 5 meters further than yesterday" is an example of:

Answer: C) KR relates to the outcome of the movement, not the quality.

Q3. Which practice schedule results in poor immediate performance but superior long-term retention?

Answer: B) The Contextual Interference Effect makes the brain work harder, cementing the learning.

Q4. A patient can walk while talking to you about their weekend. Which stage are they in?

Answer: C) The ability to Dual-Task indicates the movement has become automatic.

Q5. Providing feedback only when the patient makes a significant error is called:

Answer: B) Feedback is given only outside a "bandwidth" of correctness.

Q6. Which practice type is best for patients with fatigue (e.g., MS or GBS)?

Answer: B) Rest time ≥ Work time prevents overwork weakness.

Q7. Intrinsic feedback refers to:

Answer: C) Information the patient receives internally.

Q8. "Bend your knee more during the swing phase" is an example of:

Answer: B) Knowledge of Performance relates to the quality/pattern of movement.

Q9. Neuroplasticity relies heavily on which principle?

Answer: C) "Use it and improve it" - the brain rewires based on specific, repeated demands.

Q10. In the Associative Stage, the patient relies mostly on:

Answer: C) They begin to "feel" the movement rather than just watch it.

References

• Shumway-Cook, A., & Woollacott, M. H. (2017). Motor Control: Translating Research into Clinical Practice. Wolters Kluwer.
• Schmidt, R. A., & Lee, T. D. (2011). Motor Control and Learning: A Behavioral Emphasis. Human Kinetics.
• Kleim, J. A., & Jones, T. A. (2008). Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res.