In a previous article, I introduced “Helen,” a 70-year-old right-sided stroke survivor who enjoys making and giving gifts to her loved ones. I discussed the stages of motor learning following a stroke and made sure that Helen was seated comfortably and ready for today’s therapy session.
During a previous session, Helen painted a small wooden frame, which she now intends to give as a gift to her granddaughter. Today’s session will revolve around wrapping this gift—a deeply meaningful activity to Helen.
I’ve planned out this session to ensure that Helen can get the most therapeutic benefit in every step, from how the work environment is set up to the order of individual tasks within the activity.
1. Setting up our environment
To provide a “just right” level of distraction for Helen’s needs and her stage of motor learning (associative), I scheduled our session in the morning in the main therapy gym. If she appeared to be in the cognitive stage of motor learning and less distraction was needed, I could conduct her session in her room. If she appeared to be in the autonomous stage and greater distraction might be therapeutic, I could turn on the radio in the gym or schedule our session during a busier time.
2. Modifying the task
With Helen seated at the table, I place the items needed for our activity to the right, left, and in front of her. This placement elicits visual scanning in the peripersonal space, creates variable reaching distances, and requires trunk movement in the sagittal and transverse planes. I am seated on her left to facilitate attention to this side, helping address her mild left neglect.
What if Helen were further along in her recovery and needed an additional challenge? I could:
- Add additional items beyond those needed for the task in order to target visual scanning, problem solving, and figure-foreground skills
- Offer various-sized boxes to wrap, including some that are oddly shaped, oversized, or very small
- Place more items to the far left to facilitate increased visual scanning, trunk activation, and upper extremity external rotation to the left
And what if Helen were still in the earlier stages of recovery and I needed to decrease the challenge? I could:
- Use pre-cut sheets of wrapping paper appropriate to the box size
- Utilize an ink stamp in the place of a gift tag
- Provide a bright strip of tape on the left side of the table as an anchor for visual scanning to the neglected side
3. Choosing whole vs. part practice
Activities can be practiced in their entirety (whole practice) or broken down into parts (part practice). In the case of part practice, once each part is completed, the patient can move on to the next. When a patient is in the cognitive stage of motor learning, part practice may be more beneficial. Whole practice is usually preferred as the patient progresses.
Because Helen is in the associative stage and gift-wrapping is an activity that is familiar to her, I opt for a whole practice approach.
4. Choosing massed vs. distributed practice
In massed practice, larger amounts of time are spent in practice with shorter breaks in between. In distributed practice, smaller chunks of practice occur and are offset by more frequent breaks. In early learning, massed practice may be more beneficial for improved performance, but for greater retention and long-term carryover, distributed practice is often preferred as movements become more efficient.
During our session, Helen engages in distributed practice, taking breaks after sizing and cutting the wrapping paper as well as after ripping off strips of tape and placing them on the edge of the table for later use.
5. Choosing blocked vs. random practice
During blocked practice, a skill is rehearsed repeatedly. Random practice, as it sounds, involves engaging multiple skills in a random order. While blocked practice can be helpful during early learning, random practice more closely replicates the way in which functional tasks are completed in activities of daily living.
For Helen’s task, I’ve chosen blocked practice for certain steps based on her difficulty with some of the fine motor tasks required. Some of the blocked tasks Helen is practicing include cutting multiple strips and squares of wrapping paper, tying the bow several times, and signing her name a few times.
At the end of the session, Helen proudly admires her wrapped gift, and although it might not be wrapped perfectly, it is perfectly wrapped with love. This simple, inexpensive, yet meaningful activity incorporated the principles of motor learning, addressed a variety of underlying client factors, and progressed the patient toward the goals of increased function and participation in meaningful occupations.