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Perspectives on theory and application of implicit and explicit motor learning in neurological rehabilitation

Movement is an essential part of our lives. Throughout our lifetime, we acquire many different motor skills that are necessary to take care of ourselves (e.g., eating, dressing), to work (e.g., typing, using tools, care for others) and to pursue our hobbies (e.g., running, dancing, painting). However, as a consequence of aging, trauma or chronic disease, motor skills may deteriorate or become “lost”. Learning, relearning, and improving motor skills may then be essential to maintain or regain independence. There are many different ways in which the process of learning a motor skill can be shaped in practice. The conceptual basis for this thesis was the broad distinction between implicit and explicit forms of motor learning. Physiotherapists and occupational therapists are specialized to provide therapy that is tailored to facilitate the process of motor learning of patients with a wide range of pathologies. In addition to motor impairments, patients suffering from neurological disorders often also experience problems with cognition and communication. These problems may hinder the process of learning at a didactic level, and make motor learning especially challenging for those with neurological disorders. This thesis focused on the theory and application of motor learning during rehabilitation of patients with neurological disorders. The overall aim of this thesis was to provide therapists in neurological rehabilitation with knowledge and tools to support the justified and tailored use of motor learning in daily clinical practice. The thesis is divided into two parts. The aim of the first part (Chapters 2‐5) was to develop a theoretical basis to apply motor learning in clinical practice, using the implicit‐explicit distinction as a conceptual basis. Results of this first part were used to develop a framework for the application of motor learning within neurological rehabilitation (Chapter 6). Afterwards, in the second part, strategies identified in first part were tested for feasibility and potential effects in people with stroke (Chapters 7 and 8). Chapters 5-8 are non-final versions of an article published in final form in: Chapter 5: Kleynen M, Moser A, Haarsma FA, Beurskens AJ, Braun SM. Physiotherapists use a great variety of motor learning options in neurological rehabilitation, from which they choose through an iterative process: a retrospective think-aloud study. Disabil Rehabil. 2017 Aug;39(17):1729-1737. doi: 10.1080/09638288.2016.1207111. Chapter 6: Kleynen M, Beurskens A, Olijve H, Kamphuis J, Braun S. Application of motor learning in neurorehabilitation: a framework for health-care professionals. Physiother Theory Pract. 2018 Jun 19:1-20. doi: 10.1080/09593985.2018.1483987 Chapter 7: Kleynen M, Wilson MR, Jie LJ, te Lintel Hekkert F, Goodwin VA, Braun SM. Exploring the utility of analogies in motor learning after stroke: a feasibility study. Int J Rehabil Res. 2014 Sep;37(3):277-80. doi: 10.1097/MRR.0000000000000058. Chapter 8: Kleynen M, Jie LJ, Theunissen K, Rasquin SM, Masters RS, Meijer K, Beurskens AJ, Braun SM. The immediate influence of implicit motor learning strategies on spatiotemporal gait parameters in stroke patients: a randomized within-subjects design. Clin Rehabil. 2019 Apr;33(4):619-630. doi: 10.1177/0269215518816359.

Multidisciplinary Views on Applying Explicit and Implicit Motor Learning in Practice

Background A variety of options and techniques for causing implicit and explicit motor learning have been described in the literature. The aim of the current paper was to provide clearer guidance for practitioners on how to apply motor learning in practice by exploring experts’ opinions and experiences, using the distinction between implicit and explicit motor learning as a conceptual departure point. Methods A survey was designed to collect and aggregate informed opinions and experiences from 40 international respondents who had demonstrable expertise related to motor learning in practice and/or research. The survey was administered through an online survey tool and addressed potential options and learning strategies for applying implicit and explicit motor learning. Responses were analysed in terms of consensus (
70%) and trends (
50%). A summary figure was developed to illustrate a taxonomy of the different learning strategies and options indicated by the experts in the survey.

Explicit teaching and scaffolding to enhance concept learning by design challenges

This paper presents a mixed methods study in which 21 first-year student teachers took part that investigated learning outcomes of a modified learning by design task. The study is part of a series of studies that aims to improve student learning, teaching skills and teacher training. Design-based science challenges are reasonably successful project-based approaches for breaking down the boundaries between traditional school subjects. Previous learning outcomes of the extensively studied Learning by Design (LBD) approach demonstrated a strong positive effect on students’ skills. However, compared to traditional classroom settings, LBD provided little or no profit on (scientific) concept learning. For this, according to two preliminary studies, a lack of explicit teaching and scaffolding strategies, both strongly teacher-dependent, bears a share of responsibility. The results of this third study indicate that more emphasis on these strategies indeed strengthens concept learning without reducing positive effects on skill performance.

Promoting explicit instruction of strategies for self-regulated learning

The effects of implicit and explicit motor learning in gait rehabilitation of people after stroke

Background: A significant part of neurological rehabilitation focuses on facilitating the learning of motor skills. Training can adopt either (more) explicit or (more) implicit forms of motor learning. Gait is one of the most practiced motor skills within rehabilitation in people after stroke because it is an important criterion for discharge and requirement for functioning at home. Objective: The aim of this study was to describe the design of a randomized controlled study assessing the effects of implicit motor learning compared with the explicit motor learning in gait rehabilitation of people suffering from stroke. Methods: The study adopts a randomized, controlled, single-blinded study design. People after stroke will be eligible for participation when they are in the chronic stage of recovery (>6 months after stroke), would like to improve walking performance, have a slow walking speed (<1 m/s), can communicate in Dutch, and complete a 3-stage command. People will be excluded if they cannot walk a minimum of 10 m or have other additional impairments that (severely) influence gait. Participants will receive 9 gait-training sessions over a 3-week period and will be randomly allocated to an implicit or explicit group. Therapists are aware of the intervention they provide, and the assessors are blind to the intervention participants receive. Outcome will be assessed at baseline (T0), directly after the intervention (T1), and after 1 month (T2). The primary outcome parameter is walking velocity. Walking performance will be assessed with the 10-meter walking test, Dynamic Gait Index, and while performing a secondary task (dual task). Self-reported measures are the Movement Specific Reinvestment Scale, verbal protocol, Stroke and Aphasia Quality of Life Scale, and the Global Perceived Effect scale. A process evaluation will take place to identify how the therapy was perceived and identify factors that may have influenced the effectiveness of the intervention. Repeated measures analyses will be conducted to determine significant and clinical relevant differences between groups and over time. Results: Data collection is currently ongoing and results are expected in 2019. Conclusions: The relevance of the study as well as the advantages and disadvantages of several aspects of the chosen design are discussed, for example, the personalized approach and choice of measurements.

Implicit and explicit motor learning interventions have similar effects on walking speed in people after stroke

Objective. Clinicians may use implicit or explicit motor learning approaches to facilitatemotor learning of patients with stroke. Implicit motor learning approaches have shown promising results in healthy populations. The purpose of this study was to assess whether an implicit motor learning walking intervention is more effective compared with an explicit motor learning walking intervention delivered at home regarding walking speed in people after stroke in the chronic phase of recovery. Methods. This randomized, controlled, single-blind trial was conducted in the home environment. The 79 participants, who were in the chronic phase after stroke (age = 66.4 [SD = 11.0] years; time poststroke = 70.1 [SD = 64.3] months; walking speed = 0.7 [SD = 0.3] m/s; Berg Balance Scale score = 44.5 [SD = 9.5]), were randomly assigned to an implicit (n = 38) or explicit (n = 41) group. Analogy learning was used as the implicit motor learning walking intervention, whereas the explicit motor learning walking intervention consisted of detailed verbal instructions. Both groups received 9 training sessions (30 minutes each), for a period of 3 weeks, targeted at improving quality of walking. The primary outcome was walking speed measured by the 10-MeterWalk Test at a comfortable walking pace. Outcomes were assessed at baseline, immediately after intervention, and 1 month postintervention. Results. No statistically or clinically relevant differences between groups were obtained postintervention (between-group difference was estimated at 0.02 m/s [95% CI = −0.04 to 0.08] and at follow-up (between-group difference estimated at −0.02 m/s [95% CI = −0.09 to 0.05]). Conclusion. Implicit motor learning was not superior to explicit motor learning to improve walking speed in people after stroke in the chronic phase of recovery. Impact. To our knowledge, this is the first study to examine the effects of implicit compared with explicit motor learning on a functional task in people after stroke. Results indicate that physical therapists can use (tailored) implicit and explicit motor learning strategies to improve walking speed in people after stroke who are in the chronic phase of recovery.