hello welcome to this new webinar titled optimal theory of mortal learning your recipe for motor success I'm your instructor Lily Jimenez and I really hope you enjoy this lecture so what is optimal Theory optimal stands for optimizing performance through intrinsic motivation and attention for learning now let's talk a little bit about motor learning and I've I'm sure you've heard this term before motor learning is the ability for our brains to learn a motor skill or any skill and retain it now in the motor learning um world we hear all these terms like practice conditions augmented feedback model presentations or variable or random practice and all of those things are very very important however sometimes motor learning and the motor learning scientists they don't take into consideration the motivation and the attention and those two things have an important influence on learning as well foreign Dr Wolf and Dr lothwaite propose the optimal theory of motor learning now this Theory it's different to other motor learning theories this one is my favorite because I use it all the time and I see consistent Success Through my practice so more about how this Theory started so motor behavior is something we can observe and as often performed in a social context meaning when we do something with our bodies most likely other people are watching are we doing in front of others when we're walking let's say at the mall other people are around us now sometimes a presence of another person or persons May provide reassurance or a pressure so think about when you're in a practical exam your performance might be make you feel confident or maybe you feel a little bit of pressure similarly cognitions or thoughts can speed up or slow down water learning for example in sports the optimal Theory Builds on the premise that motor learning cannot be understood without considering the motivational meaning social cognitive and effective and attentional influences on Behavior meaning the motivation of a person and where the attention goes will influence their mortar behavior and performance now the motor the optimal theorem motor learning blueprint is this Theory will explain how the strengthening and coupling of goal and actions is important AKA dopamine strengthening intrinsic neuromodulation this means dopamine will strengthen motor memories creating motor learning so learning a new skill with something that drives a dopamine release you get improved motor learning now the three facets or parts are enhanced expectancies external focus of attention and autonomy and we're going to talk about all the three of them let's start with my favorite which is enhanced expectancies well I cannot choose between all three all three are amazing but enhance expectancies is that your patient or even you will expect success after you have been successful or you feel you're going to be successful so think about when you are in a practical exam or being mentored by a mentor if they give you good feedback that will make you feel successful and that will give you confidence for the next time you do it to be successful as well and it creates a feedback loop so now the enhanced expectancies based on the article you can achieve this through many many ways so the first one that I'm going to introduce and for more in a deeper explanation of each of them I suggest reading the article of the optimal theory of motor learning so we're going to start with creating a reward-like state after your patient does well in something you create that reward like state you can give augmented feedback and during that feedback you're going to emphasize the positives kind of ignoring the negative trials even though maybe a negative trial was very very bad you can ignore it but you really really emphasize those positive trials the next one it's positive normative feedback and this one just means telling your patient their score and how they perform compared to other people their age or other people like them the article mentions something really interesting and I had to read it a couple of times to make sure I was reading it correctly so basically in in other words it says that it's okay to tell your patient something that is not true like for example they scored a 20 out of 56 in the birth balance and you know you and I know this is not a good score but telling your patient maybe this is a great score for this first day you actually did better than a lot of people this is a score that not a lot of people are able to reach so even though it's not a true statement um you will create that sense of competence and that sense of empowerment in your patient by letting them know that the score was good even though that's not very very true but your patient doesn't know unless they're a physical therapist but creating that positive normative feedback will promote that sense of uh confidence even though it's a false positive feedback and that based on the article will create more effective performance or grading Improvement than average compared to when you give them a negative feedback such as let's say they scored a 20 out of 56 and if you tell them well you know it was not the score that we wanted but we can improve it that has a negative that is a negative feedback so avoid giving those type of feedback to your patient the next one we're going to talk about is setting the patient for success with positive affect and this one is something that just comes natural to us is saying wow you did amazing you're doing great excellent but remember use this was cut with caution you're patient might hear success but don't forget to let them experience success so always celebrate their successes the next one is vicarious experiences and this is sharing with your patient a story of a patient with a similar diagnosis and how they were successful the next one is conceptions of ability this one explains that some skills are not fixed and and they are amenable to change with practice this means you can explain to your patient that a certain skill is something that they can improve that they're not born with example balance so telling your patient balance is something you can improve you're not born with balance and every time you you don't feel your balance is great there's always a way to improve it so there are other ways to enhance expectancies but this is just an intro for you foreign is autonomy so this one pretty much means giving the patient control so there is a an area in the brain that controls the sense of agency and the sense of agency in the brain pretty much makes you feel you're in control now if you think about it patience after a neurological insult they feel they've lost control control of their arm control of their walking control of their trunk stability control of a lot of things they lost the ability to work they lost the ability to do this or this or this so by giving them autonomy we are indirectly giving them a sense of control and that will tap into the sense of agency in the brain how do we do this this is simple we give them incidental choices that means letting them choose things in the session maybe not everything in the session but maybe some things in the session such as you're gonna you want to use the green band or the Red Band do you want to use the red ball or the blue ball even though these things don't really have to do with the things you're practicing you're giving them some sort of control other ways you can promote autonomy is letting them pick the order of the session today we're going to work on balance strength and range of motion what do you want to start with when you give choices just be careful to not give them many choices because if you tell them what do you want to work on today the patient will probably tell you well I don't know you're the boss so give them some choices but also control the choice the last one that I want to talk about is the autonomy supportive language and this just means to avoid the language that can be controlling such as I want you to do this or do this or please don't do that sometimes saying things like what do you think if we try should we do this or just asking what do you think I like when I'm going to progress an intervention I like to tell my patients do I have your permission to make this a little bit more difficult and even though 100 of The Times They will say yes you're giving them that control the last one is external focus of attention so an internal Focus induces a conscious type of control causing someone to constrain their motor system by interfering in automatic processes which are just not made to focus on our own bodies we don't think about how we walk think about when you injure yourself you start thinking about how you move in so many ways and that can actually disrupt the motor pathways so that's an example of when you can be very internally focused but an external Focus promotes a more automatic mode of control and that promotes automaticity and the Brain really really likes it so some examples for cueing your patients with an external focus is saying things like the markers or the tape versus your feet internal focuses Point your hips forward versus an external Focus point the headlights forward imagine your hips are headlights Point them and you say the direction you want them to point internal Focus will be sit down slowly sometimes patients just okay that is very subjective but an external focus is could be pretend you're like honey pouring into a cup you know it's very very slow all right let's let's pretend you're like honey I've heard other students in the past mention things like pretend there's an egg underneath um or in this in your seat just try not to break that egg and that's a beautiful external Focus an internal Focus for let's say a shoulder flexion isometrics would be on the next one on the right side keep your hands leveled okay my hands but an external Focus will be keep the Thera wand leveled the last one is for gate we love to say heal first when we're promoting heel strike but I like to put a tape a color tape and the patient's heel or heel of the shoe and I tell them let the tape be the first thing that hits the ground so in summary instructions that direct the attention away from one's body parts or self and to the intended movement goal have consistently and this is throughout many many studies these have been found to have an enhancing effect on performance and learning so I call external cues like the magic words and I can tell you it works a hundred percent of the times when I use it and remember that sometimes when an external Focus doesn't work maybe just need to just modify the queuing or just modify the external Focus try something else doesn't mean that your patient cannot do it external Focus will unleash and unlock movement potential so this is a study with golfers um so so this is by anodol and I just wanted to mention it pretty quick so now just to give you a background if you love sports external Focus if you Google it a lot of studies in sports athletes golfers Surfers baseball players external Focus have been used throughout the sports research so this one was with golfers and this is a novice uh well a group of novice golfers they were hitting golf balls under external Focus internal Focus or control conditions the pre-test and retention test so it was after three days included 10 trials whereas the practice blocks that you see in the middle included 25 trials so there was an increasing the angle between shoulder and pelvis during the downswing so if you're not familiar with golf which I have two uh confess that I am not but I had to ask my husband what it what it mean but a downswing just means when the the golf club is going to hit the golf ball so there was like more power during the downswing when using external cues as well as a greater distance traveled by the ball in the external focus group and here you can see it in the top um line graph that's going progressively higher compared to the internal and to the control group so here I'm going to show you some videos where I've used an external focus of attention and I really hope you enjoy these some of them are used with people with a functional neurologic disorder it's a disorder where people um start being very very internally focused and they they somehow their brain um loses that connection to certain body parts and it seems silly but their body forgets how to move properly so this patient came to me with what I would call or describe as a walking down the escalator gate so he would start with um upright and as he walked his knees would progressively be bending more and more so he would not do a heel strike so I wanted to unleash a movement potential so I added some uh Targets on the ground you can see blue tape and I also added a blue tape to his heel so my cue was plea please let the the tapes be the first thing that hits the ground and here in this video you could see that he doesn't have the buckling gate and his gate pretty much looks close to normal and this was pretty much on the second attempt with an external cue after trying million things foreign this next one is an individual with a functional neurologic disorder as well so he um came in with a diagnosis of possible spinal cord injury but the spinal cord was clear everything was clear so therefore it was a functional neurologic Disorder so here in the left video he has trouble unleashing and or unlocking that hip flexion to do a kick on the ball but you can see um a couple moments later the ball comes back with a greater velocity and on the right side he's able to uh really just think about the ball was coming and he hits the ball with the right leg pretty good so you could see how that external Focus after the ball comes back the second time um is unleashing that movement potential because he's focused more on the ball that's coming on the second attempt so watch closely so here he's going to have so much trouble to kick first attempt okay but watch now the ball's coming very very quickly to stop it and to re-kick this second video um we're putting a Thera um a theraband as an external Focus to again promote that um hip flexion and knee extension kicking motion this next video um he had a lot of trouble with ambulation so what we did is we created an external focus by having a male record themselves walking um on the left side of the video um and this is an able-bodied individual recording himself walking at a slow pace just because I wanted to make it realistic for the patient and on the right side I utilize this video to show him as he was walking to deviate his attention from his own self um so I played this video a couple times and did that um concurrently with gate training and then I removed the video and my queue was just focus on the video on your mind um and let's do some neat so I was able to do a couple of trials with an external focus and he demonstrated carryover after removing the external Focus so that is promoting motor learning so this is an idea that you can do with somebody with a functional neurologic disorder yeah so let me show you the first video which I forgot to show you this is the cue that we utilized on an iPad he was watching this the patient on the right was watching this as he was walking to deviate his attention from his own self and focused on the video kind of like a motor imagery action observation kind of thing and it it would help his ambulation the next one is a patient after stroke and she demonstrates right side um hip circumduction and my cue my external Q is walk between the lines to promote that um straight plane movement so you can see um the difference between them so this is without the cue so um and this is with the cube [Music] okay so now that you've seen some videos on how I promote that external Focus here I have other ways that you can pause this video and look at how I've promoted autonomy support enhanced expectancies and external focus of attention when working with someone in a Telehealth environment I did not have the patient in front of me I did not do any Hands-On activity and this was a patient post cerebellar stroke and if we remember cerebellum is a center for Mortar learning and if you have a cerebellar stroke especially if it's a massive stroke like this patient did they have very very slow motor learning so I utilize the optimal Theory as my only my only intervention of course I use PT interventions right but I I base my treatment in the optimal Theory so for example for autonomy I would let her take over some progressions of processions and has expectancies I would tell her positive affect wow that was great what would happen if you've tried this using autonomy supportive language right so for external Focus you can see it on the green so pause this video if you wish to see how did I use the optimal Theory with someone with slowed motor learning in a Telehealth environment foreign lastly I want to talk about other ways that you can utilize the optimal Theory repetition repetition repetition especially I want to emphasize the autonomy because sometimes we forget what would you like to practice again today based on yesterday's session also you can give the patient the autonomy to choose whenever you give the feedback I love when patients are so motivated and they actually take the initiative by seeing what do you think or how did you think I did so you can tell the patient if they're not taking the initiative tell me when you need me to give you some tips and remember the autonomy supportive language versus the controlling language I suggest and versus do this or here's a hint versus you need to do this and in frame has expectancies you can always celebrate that success sometimes even pairing autonomy and enhance expectancies for example we're going to work on single limb stance let's see choose a goal between 10 seconds and 20 seconds how how many seconds you want to try and sometimes you will know that patients progress themselves so let's say in your mind as a therapist you wanted to choose maybe 12 seconds or even 10 seconds but the patient says something like oh um I want to try 15 seconds so they give themselves a progression that maybe you did not think about and now because they chose that they feel like they have to do it now it's like an example of letting a kid choose something from the menu they most likely will eat whatever they choose but if they choose for them probably they're not gonna like it very much so always autonomy and when they they let's say they're able to reach 15 seconds you can enhance that expectation with a positive affect wow that was amazing and that was more than what I thought about do you think we can now aim for 17 seconds celebrate the success so now it's your turn to practice so let's think about it so your 9 A.M patient has left side hemiparesis how can you use an external focus of attention to drive improved way bearing on their affected side let's say that you're working on trunk control and you want them to come to that left side because they're kind of leaning to the right side what do you think what external cues can you give them to make them come to the left side maybe is a reaching maybe is you put your hand next to their left buttock and you can tell something like squeeze my hand or something like that what do you think your client with Parkinson's disease demonstrates bilateral hip weakness what are two ways you can promote autonomy while performing hip strengthening exercises what do you think how can you give them options your client self-identifies as a clumsy person and they're having trouble learning an agility bladder drill how can you use enhanced expectancies here how can you make them feel confident Maybe perform it and then you celebrate it with a positive affect think about how can you enhance their expectations when doing an agility ladder drill and they really feel clumsy so in summary and has expectancies autonomy support and external focus of attention they all will trigger dopamine response and that will benefit Motor Performance and remember internal focus of attention we want to stay out of it even though it's very natural for us pts to use very anatomical terms in our cues but I challenge you to utilize this optimal Theory next time you see a patient and you will see one how much fun or how more fun it is to treat a patient and how it makes therapies more interesting in more patient-centered thank you for your attention I hope you enjoy this webinar