In today’s healthcare system, we are experiencing a push for shorter lengths of stay along with increased efficiency and productivity standards. Additionally, our patients have a strong desire to age in place as independently as possible. This makes it crucial for occupational therapists to utilize our patients’ therapy time wisely with evidence-based practice.
I advocate for the use of “occupation as means” for skilled intervention, incorporating the most current principles of motor learning. This research-supported approach facilitates neuroplasticity and normalized movement patterns and remediates underlying factors such as strength, balance, range of motion, cognition, visual perception, coordination, and endurance.1 The end goal of these interventions is the generalization of performance to other environments and transference of acquired motor skills to other areas of occupation.
“Helen” is a married 70-year-old woman who lives with her spouse in a ranch home. One of their daughters lives nearby, as well as three small grandchildren. As a hobby, Helen enjoys painting china, wooden frames, and decorative signs. She reports that her roles of mother and grandmother are meaningful to her and that giving her family handmade gifts for birthdays and holidays brings her joy and purpose.
Recently, Helen experienced a right-sided stroke, leaving her with residual left-sided weakness, reduced fine motor coordination, mild peripersonal left neglect, mild cognitive impairment, and reduced balance and endurance. She also has increased tone in the left scapula and internal rotators, reducing her left shoulder AROM during flexion, abduction, and external rotation. Her sensation and proprioception remain intact.
Stages of Learning
When planning therapeutic activities, consider Helen’s stage of motor learning. Understanding these stages is critical to ensure the appropriate level of challenge, the type of practice, and the amount and type of feedback.
There are three stages of motor learning:
- Cognitive—In this stage, patients are figuring out what to do. They rely heavily on external feedback and require a low-distraction environment. There is high attentional demand for movement, and large areas of the brain are activated. Through repetition, intensity, trial and error, and engagement in specific and salient activities, movement patterns are refined.
- Associative—In this stage, patients are figuring out how to complete tasks and rely on internal feedback, or how the movement feels, as movements are further optimized. The environment can contain some distractors since less attention is required, and smaller areas of the brain are activated as learning is consolidated.
- Autonomous—This stage is the ultimate goal. Patients can now complete movements fluidly with little to no attention needed in an environment of high distractors. Even smaller areas of the brain are activated as motor plans are further consolidated. The patient no longer relies on feedback, but feedforward. Movements are now predictive and made in anticipation of the demand. The cerebellum ensures smooth and accurate actions, appropriate for the context. Patients also now achieve dual tasking and are able to walk while talking to a spouse, dress while watching the news, or drive while enjoying a favorite song.
Helen is in the associative stage. She tolerates moderate environmental distractors and focuses on how to execute more effective movements during functional tasks. Before beginning our session, I explain how the activity we’ve chosen will move her closer to achieving her therapy goals. Deeper understanding of the rationale will promote greater investment in the process as well as increase self-efficacy and motivation.
Preparing for Success
While it can be tempting to jump right into the activity, proper preparation supports success. During an assessment of Helen’s sitting posture, I note posterior pelvic tilt pulling her trunk into flexion, her scapulae into abduction, and her shoulders into further internal rotation. While this posture is common in elderly patients, it disrupts the kinematic chain and is a major barrier to effective upper extremity movement. To relieve her posture challenge, I position Helen on a supportive chair with manual assist to achieve anterior pelvic tilt with lumbar, thoracic, and cervical extension.
Now that Helen is seated comfortably and prepared for this activity, we can begin choosing how best to adapt the activity itself to Helen’s needs, which we will address in part two of this series.
- Muratori, L. M., Lamberg, E. M., Quinn, L., & Duff, S. V. (2013). Applying principles of motor learning and control to upper extremity rehabilitation. Journal of Hand Therapy, 26(2), 94-102.