E-14 Activity practice
“Practice makes perfect”. This truism applies to everyone, regardless of age, disease, disability or other factors. It is so evident that it is often overlooked in rehabilitation, yet it is perhaps the most effective intervention available. The effect of practice is to increase skill acquisition through learning. Unfortunately, some people feel it is too mundane to refer to learning and say they influence neural plasticity as if it were something different; I will briefly discuss this fallacious distinction in this post. The learning principles apply as much to rehabilitation as to becoming a skilled surgeon, parent, or healthcare professional. Trainees in rehabilitation could read the evidence appertaining to their training. Some rehabilitation professionals are concerned about their patients learning to undertake an activity normally (e.g. the Bobath technique), and I will also discuss that. The primary message is that you should facilitate your patient to practice activities as much as possible and to understand that it is time a person spends practising and not the time in therapy that is the crucial measure.
Table of Contents
The healthcare professional specialised in rehabilitation should be “able to advise the team, patient and others about the benefits of practising activities, the best ways to undertake it, and the reasons for the advice given.” They should also be able to engage the patient in practising by selecting activities the patient values and allowing them to practise as they wish.
Introduction - history
My review of effective rehabilitation interventions found practising at activities to be an intervention seen in many trials that showed benefit from rehabilitation. This was not a surprise because task-related practice has been recognised as effective for 15+ years; this is a significant change from the situation in 1980 when different approaches were expected, for example, Bobath or Proprioceptive Neuromuscular Facilitation were commonly recommended as therapy for people after stroke.
By 2000 the Motor Relearning Programme was being used; it used a task-oriented approach, now also described as task-related practice. The evidence shows it is superior to other therapy approaches, such as Bobath. Practising functional tasks such as walking and using the arm is superior to other techniques.
At the same time, research confirmed how little activity patients undertook in rehabilitation services. Some of this may have been due to a mistaken belief by patients that time in therapy was the critical factor. An interesting qualitative study that was part of a large randomised trial found that people who had additional treatment on a Saturday morning started practising more on Sunday, even though no therapists were present.
This has, in turn, led to altering inpatient rehabilitation environments to encourage more patient activity.
Rehabilitation is learning
A person engaged in rehabilitation will have difficulty in their life that they wish to resolve and attribute to a health issue rather than a social one. Only rarely will someone else perceive the problem and want rehabilitation for the person. This may be due to severe cognitive losses or altered consciousness. I will exclude them from this discussion.
The person will want to achieve some change in the activities they can do, either for their own sake or to achieve a desired social role. Put another way, they wish to adapt to their situation, and rehabilitation can help. Adaptation requires change and learning, whether relearning a previous skill, how to achieve the goal differently, how to use tools to achieve the goal, or even how to manage without achieving the goal.
Learning occurs within the brain, and within the brain, neurones and synapses are involved; all learning is located in the neural tissues and interconnections; all knowledge depends upon neural plasticity. This applies whether the learning occurs as part of an educational programme, starting a new job, using a new piece of equipment, adapting to arthritis in the hands, or adapting to changes after a stroke. There is no unique learning process associated with rehabilitation.
Consequently, we need to understand theories of learning to improve the outcome of rehabilitation.
Activity practice and learning; evidence
There must be thousands of papers on learning theories, and I will only draw your attention to a few.
Martina Maier and colleagues have provided an extensive review of studies of the rehabilitation principles in people with stroke, but, as I have explained, the principles apply generally. The paper gives references for each principle. They identified 15 principles extracted from 17 articles (reviews, perspectives, and debates) published between 2014 and 2019. However, several separate principles are variations on a single principle, and I have reorganised their list.
They are as follows:
- Practise an activity.
Various patterns of undertaking practice are described:
- Massed or repetitive practice. These are episodes where the skill is practised repeatedly with only brief rest periods.
- Spaced practice. The person is asked to practice the skill repeatedly but with planned rest periods interspersed.
- Dose-related practice. Some studies specified the amount of training, such as the time spent or the number of repetitions. Many studies did not identify the dose.
- Task-specific practice. This is simply another variation introduced, describing the course of an activity where the method is not based on ‘normal’ movements.
- Goal-oriented practice. This expands the move from attempting to achieve so-called normal movement patterns to achieve the goal by the best method the patient can use. Identifying and setting goals will also increase the patient’s engagement and motivation, provided they are identified and developed collaboratively with the patient.
- Variable practice. There will inevitably be slight variations in performance each time an activity is undertaken. This category involves planning variations to be included in the procedure.
- Increasing difficulty. This is the last variation on the practice theme, the same as increasing the target goal set.
- Avoiding non-use. The authors refer to this as modulating effector selection, meaning that the person is discouraged from simply avoiding an activity that cannot be carried out. Logically, this is also a form of practising the movement rather than a separate state of learning.
- Sensory stimulation.
- Multisensory stimulation. This has not been evaluated in rehabilitation and is a theory derived from animal experiments; not a helpful principle at present.
- Rhythmic cueing. This refers to auditory stimulation and is most well-known for improving gait in people with Parkinson’s Disease but may help in other conditions such as stroke.
As any trainee will know, this is an essential part of learning. In rehabilitation, it may be:
- Explicit. The patient receives information about how near an action or behaviour is to the goal. This may be verbal or a technical device (e.g. video, accelerometer) and may be direct during the activity or after completion.
- Implicit. The patient receives information during an activity on an aspect of the movement, such as a musical tone showing muscle activation.
- Mental practice.
The authors also highlight that the practice of neurological activity mentally without acting may involve the same processes and is another way of learning. They mention:
- Action observation, where the patient watches the activity being undertaken.
- Motor imagery, where the patient performs the activity in their mind but not in reality. This is a commonly-used technique in everyday life, for example, practising the opening phrases to be used when giving a speech or approaching a patient encounter to provide a difficult message.
- Social interaction.
The authors mention that social interactions are associated with better learning,
A second paper of interest is a review of medical training in motor skills by Gabriele Wulf and colleagues, who identified four influential factors:
- Observational practice. Watching someone perform increases skill, especially if combined with physical training. In rehabilitation, this is a combination of observational mental practice and actual practice.
- The focus of attention. Asking the person to attend to external features of their performance of an activity is better than focusing on the quality and patterns of movement. This can be translated into saying that external feedback is better than internal, implicit feedback.
- Feedback. They stress that feedback improves performance and increases motivation and engagement; in rehabilitation, this translates into feedback on the performance relating it to the goal.
- Self-controlled practice. Practice sessions where the learner controls the details are more effective than sessions where someone else determines what the trainee does. This would translate to encouraging a patient to practice independently without specifying detail on how or what part of an activity.
The document outlining indicative behaviours, knowledge and skills gives some other references to introduce the field.
The overall conclusion is that practice with informative feedback on performance is the best way to improve at an activity affected by an illness, and it should be undertaken in various ways determined by the person and the activity.
This competency is based on one crucial understanding – the patient must practice an activity (including cognitive, communicative, and other non-physical skills) to improve their performance. Understanding the added value of feedback helps; other factors probably have a minor influence on learning. Once the rehabilitation professional has understood and accepted this, the competency depends upon translating the understanding into practical advice to help the patient achieve practice, ensuring an environment where the practice is facilitated and encouraged, and educating the patient and their family so that they understand their role in adapting to the losses. It specifically includes educating the patient and all others that rehabilitation is not a treatment that leads to change; it is an educational process that enables the patient to change.