Monday, March 25, 2019

Coaching and Life Lessons from Amelie

A little thing happened since we last chatted…

Just when we were starting to think that Amelie was going to scoot across the stage to receive her high school diploma, Amelie proved yet again, that she marches to the beat of her own drummer not ours. In doing so, she taught me a valuable lesson about motor learning that greatly impacts how I engage in this process in the clinic.

**Special thanks to Joe Hannigan (Skyline's student-extraordinaire) who helped lay the foundation for this blog post with his incredible motor learning in-service!

10,000 Foot View:

What is motor learning? Motor learning is a relatively permanent change in the ability to execute a motor skill as a result of practice or experience1. In our Amelie case study, the motor skill of interest is walking.

Amelie (and Joe) helped me realize that there are 3 crucial tenets of motor learning that must be addressed in order to achieve a successful outcome: salience, specificity, and intensity2.

1. Salience – importance to the person. Amelie was not going to engage in the process of learning to walk unless she found it important to her. Judging by the look on her face while scooting, she was in no rush to give this form of locomotion up.

Salience is crucial. If the learner does not connect with the perceived importance of the task, then they will not be willing to put in the work (and it is a lot of work) to master the skill.

2. Specificity – the proverbial steps on the journey to walking must be specific to the end goal – walking – not scooting, not crawling, not climbing. No matter how beneficial these tactics might be in the development of strength, mobility, and endurance (more on these to come), task specificity is walking.

3. Intensity – motor learning requires the learner to push themselves out of their comfort zone, over and over again.

Precursor to motor learning:
Capacity (mobility, strength, endurance) is a precursor to motor learning – establish capacity first3. Or, in the words of our fearless leader, Richard Jackson: Stretch -> Strengthen -> Functionally Retrain.

Even if Amelie decides that it is important to learn to walk, she must possess the requisite capacity to engage in the learning process.

I have spent a lot of time reflecting on capacity as a foundation for learning. What are the metrics that I can use to track mobility, strength, and endurance? Do these metrics directly relate back to the end goal of the motor skill? Remember, two of the keys to motor learning are salience (importance to the person) and specificity. If you are building a foundation of mobility, strength and endurance that is specific to the movement of concern and is important to the patient, you are on your way!

Low Hanging Fruit:

We can challenge intensity through4:

1. Feedback - How does Amelie know if she is improving her walking? The ideal feedback is dichotomous – easy to determine pass vs fail. In Amelie’s case, fail equals falling. Everything else is a pass. This feedback is immediate and specific to the task.

I am constantly working to improve the feedback I give my patients. Is my feedback something tangible for the patient (don’t fall) or is it some nebulous cue to engage some deep muscle that they cannot identify or pronounce, let alone engage? As the learner improves, you can alter the feedback to enhance learning. This can come in the form of reducing the frequency of the feedback, changing the input of feedback (visual cue vs auditory cue), or providing summative feedback rather than feedback in the moment - just to name a few. The iterations of feedback are endless, but I try to make sure the feedback is dichotomous and salient to the learner.

2. Weight – Amelie worked to modify weight by first walking with a rolling walker. 

As she becomes a more proficient walker, Amelie will begin walking while wearing a weight vest. What are we without progress :) ?

3. Environment – Early in the learning process, Amelie practiced walking in a controlled environment, where we could limit distractions and obstacles to her performance (our house). From here, she progressed to environments that were less controlled and had more potential distractions (daycare). Eventually, she progressed to chasing every dog in Shirlington Village, screaming “bow wow wow” and giggling with glee.

Remember – just because your patient performs a skill in the clinic, does not ensure the same success in the outside world. Practice in the environment in which they will have to perform.

4. Dual task – Involves divided attention in the performance of the skill. In Amelie’s case, this most frequently involves singing Baby Shark while pushing her walker.

5. Speed/accuracy – This was best tested through chasing our cats around the house. Can Amelie catch the cats? To do so, she needs speed. Can she successfully grab their tails? To do so, she needs accuracy. These are parameters of intensity that Rebecca does not support nearly as enthusiastically as I do. 

*Disclaimer – no cats were harmed in the making of this blog post.

6. Practice – Our method of exploration. Practice the task. Learn the limits of your capabilities and improve them. In the book Peak: Secrets from the New Science of Expertise, Anders Ericsson describes deliberate practice as the gold standard to building new skills and abilities.

What is deliberate practice? Practice that is purposeful and systematic. Deliberate practice demands near-maximal effort, which is generally not enjoyable. This goes back to the idea that you need the requisite foundational skills (mobility, strength, endurance) to even allow yourself to engage in deliberate practice. Additionally, deliberate practice depends on effective mental representations of the task - make it possible to monitor how one is doing. This is critical! What does successful performance look like? The answer should be clear and concrete.

7. Error – We learn through trial and error. Amelie did not read any books on the mechanics of walking (despite my encouragement to do so) or listen to my futile attempts to lecture her on the importance of walking. She learned to walk through trial and error (once she decided it was important for her to learn to walk). This also ties back to the point about feedback - The error with Amelie’s walking is a fall. Anything else is a success. This is a clear method for assessment, did I fall? Yes = fail. No = pass. Amelie does not need me to tell her if she passed or not. Your goal with any motor learning task is to set up a clear dichotomy of consequences – pass/fail.

What Did I Learn?

I cannot force motor learning. It is something that I can only nurture when Amelie is ready and when it is important to her. Thank you Amelie, for yet another incredible life lesson.

1. Haibach-Beach P, Reid G, Collier D. Motor Learning and Development – 2nd Edition.
2. Motor Learning – An Application in the Orthopedic Setting. In-Service – Joe Hannigan, SPT – 3/19
3. Understanding Human Movement as a Dynamical System – Erik Meira (2018) – as part of the course: Complex Understandings for Simple Solutions
4. Mowder-Tinney and Streeter 2018: Translating Motor Learning into Practice: What is M.I.A. from your patient care?
5. Ericcson KA, Pool R. Peak: Secrets from the New Science of Expertise (2016)

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