Modifying Motor Learning Tasks Using Verbal Feedback

In my previous article, Making Motor Learning Meaningful, I applied the stages of motor learning to “Helen,” a 70-year-old right-sided stroke survivor.

During her session, I incorporated therapeutic techniques to help Helen paint a small wooden frame and wrap it as a gift for her granddaughter. Although modifications needed to be made, Helen was able to utilize those techniques to complete the activity.

Below, I discuss additional ways for Helen to modify motor learning tasks during her session so she can continue to increase function and participate in meaningful activities in her life.

Constant vs. Variable Practice

• Constant practice–practicing the same task in the same way each time
• Variable practice–practicing variations of the task and is more conducive to transfer of skills to other tasks

Helen engaged in variable practice through these activities:

• She used scissors and then a paper cutting tool to cut the wrapping paper, with each tool requiring a different type of grasp.
• She folded the paper around the box at varying angles, which required different fine motor strategies and hand/wrist positioning.
• I moved the placement of the tools on the table throughout the activity, which required different patterns of scanning, reaching, and trunk movements.

Consider this your invitation to get creative when introducing variation into the activities!

Internal vs. External Focus of Attention

• Internal focus of attention–occurs when the patient relies on attending to how a body part is moving
• External focus of attention–occurs when the patient focuses on the external goal of the movement and is not overly conscious of the movement occurring

I provided Helen with verbal cues for an external focus of attention to facilitate increased automaticity of movement. During reaching tasks, instead of stating “extend your left elbow fully,” I said:

• “Reach to the middle of the table to get the scissors.”
• “Reach to the left to get the tape.”

An external focus of attention is supported by motor learning evidence over an internal focus for increased carryover.¹

Knowledge of Performance vs. Knowledge of Results

• Knowledge of results–verbal feedback about the outcome of a step or activity overall
• Knowledge of performance–verbal feedback about the outcome of a movement that focuses on the quality of the movement

Knowledge of results can be beneficial during early learning as a motivating technique, such as:

• “You cut the paper in a straight line.”
• “You wrapped the box.”

Knowledge of performance can be beneficial at later stages of learning as the patient has a good understanding of the movement required and is seeking to refine or optimize movements. I provided Helen with knowledge of performance feedback during the session, including:

• “You provided just the right amount of pressure to the pen when signing your name.”
• “You folded the paper evenly using both hands before applying the tape.”
• “You used a firm pinch on the ribbon when tying the bow.”

Descriptive vs. Prescriptive Feedback for Knowledge of Performance

When providing feedback for knowledge of performance, you can deliver descriptive or prescriptive feedback.

• Descriptive feedback–“You applied too much pressure to the wrapping paper, causing it to tear.”
• Prescriptive feedback–“Next time you wrap the paper around the box, use less pressure to prevent tearing.”

While it may seem like prescriptive feedback would be better as you are instructing or teaching, both descriptive and prescriptive feedback can prevent the patient from being an active participant in problem solving.²

I suggest asking, “What could you have done differently to prevent the paper from tearing?” This strategy moves the patient from a passive role to an active role, engaging the patient fully in the problem-solving process.

A final word about verbal feedback: Be cognizant of the type and amount of feedback you provide. Too frequent feedback can interrupt the patient’s learning process. If your patient requires more feedback in the initial stages, work toward fading the feedback as skills emerge and are mastered. Also, don’t forget to motivate patients through positive feedback.