How do we improve outcomes for individuals with neurological deficits or balance difficulties when our treatment time is shorter and shorter? As an NDT trained therapist, I have always had a passion for facilitating my patients’ movement. I can make my patients look great while walking just by using my hands. Although I didn’t always see them improve quickly, I always saw them improve.
Helping Patients Learn Motor Movements with Error
Research has found the nervous system constantly uses trial and error information to improve motor movement via motor adaptation.1 The evidence has shown us that the question isn’t if we should allow our patients to learn by trial and error,1-2 but rather when and how much error to use.3 Now we need to ask ourselves when to focus on facilitating movement during a treatment session and when to progress to facilitating error.
There are many times when I work with people who just don’t yet have the strength to move or the sensory input or cerebellum function to detect an error.4 Commonly, this is early in rehabilitation when the only way to get them moving is by facilitating their movement. Without our hands-on skills, they would not be able to begin functional tasks. We know early progressive mobility should be a goal in acute care,5 and we will use whatever we need to be successful, from our hands to equipment like unweighted harness systems. However, there is a time when we must take our hands off our patients. This may be sooner than we think.
5 Steps to Add Trial-Error Learning
Where do you start? How do you design the session? What does a trial-error based intervention even look like? Here are five things to consider.
1. Confirm your patient’s ability to detect discrepancy
You need to know if the patient has the ability to detect a discrepancy between the goal and the actual movement.2 Don’t allow cognitive deficits to prevent you from trying something more challenging, even if the patients don’t seem like they can identify errors – but make sure you are aware of their potential limitations. Also, remember if they have cerebellum damage, this type of strategy will be limited since the cerebellum is where the discrepancy is identified and addressed.4
2. Confirm your patient’s ability to perform active movement
The patient doesn’t need to be strong but they need to be able to actively move through at least partial range of motion. I have been guilty of underestimating my patient’s potential and used my hands too much and too often. When you first try a challenging activity, don’t be afraid when they look worse before they look better.
3. Identify a safe environment
Do you need to use a harness? Have a chair backed against the wall? Use a corner with walls for support? Or add an extra pair of hands? We need to have our hands off the patient so they can explore their movement, while always maintaining a safe environment. However, that is easier said than done. We inherently guard our patients. But when preventing them from falling, we commonly prevent them from experiencing any type of error. Now – don’t get me wrong. I did NOT say to let your patient fall unless they are in some type of protective harness system, but we need to allow them to lose their balance or struggle with the activity to the point of error. This week in clinic, try and be more aware of how quickly you come to your patients rescue and assess if adjustments can be made.
4. Add error
We now need to add error, or design the intervention, to allow the patient to practice variability when learning a new task.6 How do we do that? There are many options for you to explore. To get started, always think about how you could use Theraband. Try resisting the patient when they are walking7 or when performing sit to stand. The first few times you may need to assist them through the movement so they can get the feel but then try different options. Consider a weighted vest or performing activities with eyes closed.
5. Use an acceptable amount of error
If you add a challenge to an activity and your patient is successful over half the time and isn’t getting frustrated, then continue with the challenge. As a guideline, use the 60-80% range that we commonly use to guide us when designing strengthening and aerobic conditioning programs. If your patient is moving close to perfect, then the activity is too easy. In addition, it has been noted that the error needs to appear relevant to the brain and provide a realistic limitation.1 In essence, the error needs to feel natural. If it is too large, then not only can the person become frustrated with the inability to perform the movement, but the brain recognizes that the movement is likely to be unsuccessful. 3
Overall, make sure to hold back with not only your physical support but also your verbal support. Instead of immediately telling them how to make it better – ask them to tell you how they could improve the movement. Greater learning occurs if the patient is put in charge of determining how they performed.8 Maintaining some aspect of motivational engagement in the activity will support a positive change,9 so include them in the problem solving process of how to make the activity harder or improve their performance.
Most of all, have fun trying new ways to challenge your patient. Reflect on what you tried, the result, and then make appropriate adjustments. There are many answers to still be found, but enjoy the process as you work through them.
- Wei K and Lording K.. Relevance of Error: What drives motor adaptation? J Neurophysiol. 2009;101:655-664.
- Hinder MR etal. Real-time error detection but not error correction drives automatic visuomotor adaptation. Exp Brain Res. 2010;201:191-207.
- Torres-Oviedo G. Bastian AJ. Natural error patterns enable transfer of motor learning to novel contexts. J Neurophysiol. 2012;107:346-356.
- Morton SM, Bastian AJ. Cerebellar contributions to locomotor adaptations during splitbelt treadmill walking. J Neurosci. 2006;26(36):9107-16.
- Cameron S. etal. Early mobilization in the critical care unit: A review of adult and pediatric literature. J Crit Care. 2015:30(4):664-672.
- Lewek MD, Cruz TH, Moore JL, et al. Allowing intralimb kinematic variability during locomotor training poststroke improves kinematic consistency: a subgroup analysis from a randomized clinical trial. Phys Ther. 2009;89:829–839
- Reisman DS, McLean H, Bastian AJ. Split-belt treadmill training poststroke: a case study. J Neurol Phys Ther. 2010;34(4):202-207.
- Liu J, Wrisberg CA. The Effect of Knowledge of Results Delay and the Subjective Estimation of Movement Form on the Acquisition and Retention. Research Quarterly for Exercise and Sport. 1997;68(2): 145-151.
- Shirzad N, Van der Loos HF. Error amplification to promote motor learning and motivation in therapy robotics. Conf Proc IEEE Eng Med Biol Soc. 2012;2012:3907-10.