1. The document discusses concepts related to therapeutic exercise instruction including clinical decision making, evidence-based practice, motor learning, types of motor tasks, stages of motor learning, types of practice, and feedback.
2. Key requirements for clinical decision making include knowledge, skills, experience, critical thinking abilities, and understanding patient values.
3. Evidence-based practice involves identifying a patient problem, searching literature, critically analyzing evidence, integrating evidence with expertise and patient factors, and assessing outcomes.
2. Patient Management and
Clinical Decision-Making:
An Interactive Relationship
Clinical Decision-Making:
Clinical decision-making refers
to a dynamic, complex process of
reasoning and analytical
(critical) thinking that involves
making judgments and
determinations in the context of
patient care.
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3. Requirements for Skilled Clinical
Decision-Making During Patient
Management
◍ Knowledge of pertinent information about the problem(s) based on the
ability to collect relevant data by means of effective examination strategies.
◍ Cognitive and psychomotor skills to obtain necessary knowledge of an
unfamiliar problem.
◍ Use of an efficient information-gathering and information processing style.
◍ Prior clinical experience with the same or similar problems.
◍ Ability to recall relevant information.
◍ Ability to integrate new and prior knowledge.
◍ Ability to obtain, analyze, and apply high-quality evidence from the
literature.
◍ Ability to critically organize, categorize, prioritize, and synthesize
information.
◍ Ability to recognize clinical patterns
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4. 4
• Ability to form working hypotheses about
presenting problems and how they might be solved.
• Understanding of the patient’s values and goals.
• Ability to determine options and make strategic
plans.
• Application of reflective thinking and self-
monitoring strategies to make necessary
adjustments.
6. The process of evidence-based practice involves the
following steps:
1. Identify a patient problem and convert it into a specific question.
2. Search the literature and collect clinically relevant, scientific studies that
contain evidence related to the question.
3. Critically analyze the pertinent evidence found during the literature
search and make reflective judgments about the quality of the research
and the applicability of the information to the identified patient problem.
4. Integrate the appraisal of the evidence with clinical expertise and
experience and the patient’s unique circumstances and values to make
decisions.
5. Incorporate the findings and decisions into patient management.
6. Assess the outcomes of interventions and ask another
question if necessary.
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8. 1. Select a non distracting
environment for exercise
instruction.
2. Initially teach exercises that
replicate movement patterns of
simple functional tasks.
3. Demonstrate proper performance of
an exercise (safe vs. unsafe
movements; correct vs. incorrect
movements). Then have the patient
model your movements.
4. If appropriate or feasible, initially
guide the patient through the
desired movement.
Strategies for effective exercise and task
specific instruction
5.Use clear and concise verbal and written
directions.
6. Complement written instructions for a
home exercise program with illustrations
(sketches) of the exercise.
7.Have the patient demonstrate an exercise to
you as you supervise and provide feedback.
8.Provide specific, action-related feedback
rather than general, non descriptive feedback.
For example, explain why the exercise was
performed correctly or incorrectly.
9.Teach an entire exercise program in small
increments to allow time for a patient to
practice and learn components of the program
over several visits
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9. Concepts of Motor Learning:
A Foundation for Exercise
and Task-Specific Instruction
Motor learning is a
complex set of internal
processes that involves
the acquisition and
relatively permanent
retention of a skilled
movement or task
through practice.
In the motor-learning
literature a distinction is
made between motor
performance and motor
learning
Performance involves
acquisition of the ability to
carry out a skill, whereas
learning involves both
acquisition and retention.
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10. Types of Motor Tasks
There are three basic types of motor tasks: discrete, serial, and
continuous.
◍ Discrete task. A discrete task involves an action or
movement with a recognizable beginning and end. Isolating
and contracting a specific muscle group (as in a quadriceps
setting exercise), grasping an object, doing a push-up,
locking a wheelchair, and kicking a ball are examples of
discrete motor tasks. Almost all exercises, such as lifting and
lowering a weight or performing a self-stretching maneuver,
can be categorized as discrete motor tasks.
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11. Types of Motor Tasks
◍ Serial task. A serial task is composed
of a series of discrete movements that
are combined in a particular sequence.
For example, to eat with a fork, a
person must be able to grasp the fork,
hold it in the correct position, pierce
or scoop up the food, and lift the fork
to the mouth.
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12. Types of Motor Tasks
◍ Continuous task. A continuous task
involves repetitive, uninterrupted
movements that have no distinct
beginning and ending. Examples include
walking, ascending and descending
stairs, and cycling.
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14. Conditions and Progression of Motor
Tasks
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There are four main task dimensions
addressed in the taxonomy:
(1) the environment in which the task is
performed;
(2) the inter-trial variability of the
environment that is imposed on a task.
(3) the need for a person’s body to remain
stationary or to move during the task.
(4) the presence or absence of
manipulation of objects during the task.
15. Closed or open environment
A closed environment is one in
which objects around the patient and
the surface on which the task is
performed do not move. Examples of
tasks performed in a closed
environment are drinking or eating
while sitting in a chair and maintaining
an erect trunk, standing at a sink and
washing your hands or combing your
hair, walking in an empty hallway or in
a room where furniture placement is
consistent.
Open environment: It is one in
which objects or other people are
in motion or the support surface is
unstable during the task. The
movement that occurs in the
environment is not under the
control of the patient. Tasks that
occur in open environments
include maintaining sitting or
standing balance on a movable
surface (a balance board or
BOSU®), standing on a moving
train or bus
16. Inter-trial variability in the environment:
absent or
present.
Lifting and carrying objects of different sizes and weight, climbing stairs of different
heights, or walking over varying terrain are tasks with inter-trial variability.
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17. Stages of Motor Learning
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◍ Cognitive Stage: When learning a skilled movement, a patient first must figure
out what to do—that is, the patient must learn the goal or purpose and the
requirements of the exercise or functional task. Then the patient must learn how
to do the motor task safely and correctly.
◍ Associative Stage: The patient makes infrequent errors and concentrates on
fine tuning the motor task during the associative stage of learning. Learning
focuses on producing the most consistent and efficient movements. The timing of
the movements and the distances moved also may be refined. The patient
explores slight variations and modifications of movement strategies while doing
the task under different environmental conditions (inter-trial variability). At this
stage, the patient requires infrequent feedback from the therapist and, instead,
begins to anticipate necessary adjustments and make corrections even before
errors occur.
18. Stages of Motor Learning
◍ Autonomous Stage: Movements are automatic in this final stage of
learning. The patient does not have to pay attention to the movements in
the task, thus making it possible to do other tasks simultaneously. Also,
the patient easily adapts to variations in task demands and environmental
conditions.
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21. Types of Practice for Motor Learning
◍ Part versus Whole
Practice
◍ Part practice. A task is
broken down into separate
dimensions. Individual and
usually the more difficult
components of the task are
practiced. After mastery of
the individual segments,
they are combined in
sequence so the whole task
can be practiced.
◍ Whole practice. The entire
task is performed from
beginning to end and is not
practiced in separate
segments.
◍ Blocked-order practice.
The same task or series of
exercises or tasks is
performed repeatedly under
the same conditions and in
a predictable order.
◍ Random-order practice.
Slight variations of the same
task are carried out in an
unpredictable order.
◍ Random/blocked-order
practice. Variations of the
same task are performed in
random order, but each
variation of the task is
performed more than once.
◍ Physical Versus Mental
Practice
◍ Physical practice. The
movements of an
exercise or functional task
are actually performed.
◍ Mental practice. A
cognitive rehearsal of how
a motor task is to be
performed occurs prior to
actually executing the
task; the terms
visualization and motor
imagery practice are used
synonymously with
mental practice.
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22. Feedback
◍ Feedback is sensory
information that is
received and
processed by the
learner during or after
performing or
attempting to perform
a motor skill.
◍ Intrinsic Feedback
■Sensory cues that are
inherent in the execution of a
motor task.
■ Arises directly from
performing or attempting to
perform the task.
■ May immediately follow
completion of a task or may
occur even before a task has
been completed.
■ Most often involves
proprioceptive, kinesthetic,
tactile, visual, or auditory cues.
◍ Augmented
(Extrinsic) Feedback
■ Sensory cues from an
external source that are
supplemental to intrinsic
feedback and that are not
inherent in the execution
of the task.
■ May arise from a
mechanical source or from
another person.
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23. Feedback schedules
◍ The feedback schedules could be concurrent or post
response, Immediate, Delayed, and Summary post
response Feedback, variable or constant.
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25. ◍ COGNITIVE
STAGE:
Characteristics of the
Learner:
Must attend only to the
task at hand; must think
about each step or
component; easily
distractible; begins to
understand the demands
of the motor task; starts
to get a “feel” for the
exercise; makes errors
and alters performance;
begins to differentiate
correct versus incorrect
and safe versus unsafe
performance.
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Instructional Strategies:
Closed environment.
Purpose of exercise.
Modeling or demonstration.
Break complex movements into parts when
appropriate.
How far or fast to move.
Feedback
Self correction.
Initially, use blocked-order practice;
gradually introduce random-order practice.
Allow trial and error to occur within safe
limits.
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ASSOCIATIVE STAGE:
Characteristics of the Learner:
Performs movements more
consistently with fewer errors,
executes movements in a well-
organized manner; refines the
movements in the exercise or
functional task; detects and self-
corrects movement errors when
they occur; is less dependent on
augmented/extrinsic feedback from
the therapist; uses prospective
cues and anticipates errors before
they occur.
Instructional Strategies:
More practice and variety of tasks.
More complexity and vary the sequence
of exercise.
Allow the patient to practice
independently.
Feedback.
Increase the level of distraction in the
exercise environment.
Prepare the patient to carry out the
exercise program in the home or
community setting.
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AUTONOMOUS STAGE:
Characteristics of the Learner:
Performs the exercise program
or functional tasks consistently
and automatically and while
doing other tasks; applies the
learned movement strategies to
increasingly more difficult tasks
or new environmental situations;
if appropriate, performs the task
more quickly or for an extended
period of time at a lower energy
cost.
Instructional Strategies:
Set up a series of progressively more
difficult activities the learner can do
independently.
Suggest ways the learner can vary the
original exercise or task.
Provide assistance, as needed, to
integrate the learned motor skills into
fitness or sports activities.
