Learning is a complex process! Although is still not fully understood, there are some factors that we know of, that can influence learning especially after a stroke.

To learn and relearn

The concept of neurorehabilitation implies that our brain is able to learn or relearn after a stroke. We assume that motor learning leads to motor recovery after injury. (1)

The goal of motor learning is to automate and optimize motor skills. In general, it can be said that motor learning involves different neural areas depending on the type of the task and stage of learning. Motor learning includes many attributes such as external or internal drive, cues, context, phase of learning and so on. (2)

Learning does not only happen in therapy or with cognitive strategies but also without our explicit awareness for example within activities of daily life. However motor learning of a new sequence or strategy might not take place without conscious realization. (2,3)

Error-based learning and errorless learning
Motor learning also depends on the type of measures used.
Two known contrasting types of learning are error-based learning and errorless learning.

Both, error-based and errorless learning show effectiveness in rehabilitation after neurological injury. That is to say, it strongly depends on the “What, Where, and When”.
While errorless learning shows results in preventing patients from making errors during source learning, error-based learning offers opportunities to make task-relevant choices and enhancing autonomy. (4,5)

Improving self-awareness and enhancing autonomy could be a therapy goal reachable through error-based learning. (6)

5 Keys to efficient learning

  1. Feedback and Reward
    Its always nice to have someone cheer for you. Studies show that it’s actually helpful to have extrinsic feedback for motor learning after stroke. The effect of reward and punishment on learning is a known fact. While punishment only leads to motor performance improvement, reward also lead to an increase in learning. Extrinsic feedback can be used for implicit motor learning after stroke. (7,8)
  2. Repetition
    Practice makes perfect also applies to stroke survivors.
    Repetition of a motor sequence is essential for motor learning and most therapy methods for the upper and lower limbs are put into practice by repetition. Studies show that stroke survivors actually need even more repetitions of a sequence in order to re-learn movements. (9,10)
  3. Motivation
    Motivation has been shown to be one of the key values for learning and is associated with improved well-being. Being in a motivational climate during rehabilitation can, in time, effect the intrinsic motivation. This demonstrates the importance of extrinsic and intrinsic motivation already at the beginning of the rehabilitation process. (11,12)
  4. Goals
    Setting therapy goals is a therapists daily job. Using therapy goals, especially for stroke patients, to measure their sometimes small steps of recovery is common practice. Finding personally relevant goals and linking them to meaningful actions can result in greater satisfaction and improvement during rehabilitation. (13,14)
  5. Train and Rest – Sleep as a key factor
    It‘s known that sleep is deeply involved in processes of memory formation and also enabling the gain of new memories. Sleep disturbance after stroke was found as a negative factor for learning. But getting sufficient sleep and established times of rest can be critical for the recovery of motor functions. (15, 16, 17)

What is Learned Non-Use

Learned non-use, is a phenomenon describing the loss of functional use, of a limb after a neurological injury. This so called non-use is persistent even after regaining motor innervation, which leaves the limb immobilized. (18)

Studies present evidence that hours of constraining a body part can alter our coordination and movement. Also the sensorimotor representation can be affected after an eight hour period when immobilising one arm. (19,20)

An effective intervention for upper limb recovery after stroke is the Modified Constraint-Induced Movement Therapy (CIMT). (21)

How I use this information in therapy
Every time I do researched learning, I notice how little I knew. Even experts are still unsure about a lot, regrarding this subject.
Still my take away after this research session is, that I can influence the learning path of my patients by sticking to key factors like feedback, repetition, motivation, setting goals and enabling rest.

What are your key factors? How do you enable learning after stroke?

Bibliography

    1. Kitago, T., & Krakauer, J. W. (2013). Motor learning principles for neurorehabilitation. Handbook of Clinical Neurology, 110, 93–103. https://doi.org/10.1016/B978-0-444-52901-5.00008-3
    2. Marinelli, L., Quartarone, A., Hallett, M., Frazzitta, G., & Ghilardi, M. F. (2017). The many facets of motor learning and their relevance for Parkinson’s disease. Clinical Neurophysiology, 128(7), 1127–1141. https://doi.org/10.1016/j.clinph.2017.03.042
    3. Moisello, C., Crupi, D., Tunik, E., Quartarone, A., Bove, M., Tononi, G., & Ghilardi, M. F. (2009). The serial reaction time task revisited: a study on motor sequence learning with an arm-reaching task. Experimental Brain Research, 194(1), 143–155. https://doi.org/10.1007/s00221-008-1681-5
    4. Levac, D., Driscoll, K., Galvez, J., Mercado, K., & O’Neil, L. (2017). OPTIMAL practice conditions enhance the benefits of gradually increasing error opportunities on retention of a stepping sequence task. Human Movement Science, 56, 129–138. https://doi.org/10.1016/j.humov.2017.10.017
    5. El Haj, M., Kessels, R. P. C., & Allain, P. (2016). Source Memory Rehabilitation: A Review Toward Recommendations for Setting Up a Strategy Training Aimed at the “What, Where, and When” of Episodic Retrieval. Applied Neuropsychology: Adult, 23(1), 53–60. https://doi.org/10.1080/23279095.2014.992071
    6. Ownsworth, T., Fleming, J., Tate, R., Beadle, E., Griffin, J., Kendall, M., … Shum, D. H. K. (2017). Do People With Severe Traumatic Brain Injury Benefit From Making Errors? A Randomized Controlled Trial of Error-Based and Errorless Learning. Neurorehabilitation and Neural Repair, 31(12), 1072–1082. https://doi.org/10.1177/1545968317740635
    7. Subramanian, S. K., Massie, C. L., Malcolm, M. P., & Levin, M. F. (2010). Does provision of extrinsic feedback result in improved motor learning in the upper limb poststroke? a systematic review of the evidence. Neurorehabilitation and Neural Repair, 24(2), 113–124. https://doi.org/10.1177/1545968309349941
    8. Dayan, E., & Cohen, L. G. (2011). Neuroplasticity subserving motor skill learning. Neuron, 72(3), 443–454. https://doi.org/10.1016/j.neuron.2011.10.008
    9. Fleming, M. K., Newham, D. J., & Rothwell, J. C. (2018). Explicit motor sequence learning with the paretic arm after stroke. Disability and Rehabilitation, 40(3), 323–328. https://doi.org/10.1080/09638288.2016.1258091
    10. Kwakkel, G., Veerbeek, J. M., van Wegen, E. E. H., & Wolf, S. L. (2015). Constraint-induced movement therapy after stroke. The Lancet Neurology, 14(2), 224–234. https://doi.org/10.1016/S1474-4422(14)70160-7
    11. Whitfield-Gabrieli, S., Gabrieli, J. D. E., Knutson, B., Thangavel, A., & Adcock, R. A. (2006). Reward-Motivated Learning: Mesolimbic Activation Precedes Memory Formation. Neuron, 50(3), 507–517. https://doi.org/10.1016/j.neuron.2006.03.036
    12. Brinkman-Majewski, R. E., & Weiss, W. M. (2018). The Motivational Climate and Intrinsic Motivation in the Rehabilitation Setting. Journal of Sport Rehabilitation, 27(5), 460–468. https://doi.org/10.1123/jsr.2016-0228
    13. Lewthwaite, R., & Wulf, G. (2017). Optimizing motivation and attention for motor performance and learning. Current Opinion in Psychology, 16, 38–42. https://doi.org/10.1016/j.copsyc.2017.04.005
    14. Rice, D. B., McIntyre, A., Mirkowski, M., Janzen, S., Viana, R., Britt, E., & Teasell, R. (2017). Patient-Centered Goal Setting in a Hospital-Based Outpatient Stroke Rehabilitation Center. PM&R, 9(9), 856–865. https://doi.org/10.1016/j.pmrj.2016.12.004
    15. Peigneux, P., Laureys, S., Delbeuck, X., & Maquet, P. (2001). Sleeping brain, learning brain. The role of sleep for memory systems. Neuroreport, 12(18), A111-24. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11742260
    16. Joa, K.-L., Kim, W.-H., Choi, H.-Y., Park, C.-H., Kim, E.-S., Lee, S.-J., … Jung, H.-Y. (2017). The Effect of Sleep Disturbances on the Functional Recovery of Rehabilitation Inpatients Following Mild and Moderate Stroke. American Journal of Physical Medicine & Rehabilitation, 96(10), 734–740. https://doi.org/10.1097/PHM.0000000000000744
    17. Gudberg, C., & Johansen-Berg, H. (2015). Sleep and motor learning: Implications for physical rehabilitation after stroke. Frontiers in Neurology, 6(NOV), 1–10. https://doi.org/10.3389/fneur.2015.00241
    18. Taub, E., Uswatte, G., Mark, V. W., & Morris, D. M. M. (2006). The learned nonuse phenomenon: implications for rehabilitation. Europa Medicophysica, 42(3), 241–56. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17039223
    19. Moisello, C., Crupi, D., Tunik, E., Quartarone, A., Bove, M., Tononi, G., & Ghilardi, M. F. (2009). The serial reaction time task revisited: a study on motor sequence learning with an arm-reaching task. Experimental Brain Research, 194(1), 143–155. https://doi.org/10.1007/s00221-008-1681-5
    20. Debarnot, U., Huber, C., Guillot, A., & Schwartz, S. (2018). Sensorimotor representation and functional motor changes following short-term arm immobilization. Behavioral Neuroscience, 132(6), 595–603. https://doi.org/10.1037/bne0000274
    21. Fleet, A., Page, S. J., MacKay-Lyons, M., & Boe, S. G. (2014). Modified Constraint-Induced Movement Therapy for Upper Extremity Recovery Post Stroke: What Is the Evidence? Topics in Stroke Rehabilitation, 21(4), 319–331. https://doi.org/10.1310/tsr2104-319