Application of Motor Learning Principles with Stroke Survivors

Application of Motor Learning Principleswith Stroke Survivors

Jodi Schreiber, MS, OTR/LLeslie Sober, MOT, OTR/LLaura Banta, MOT, OTR/L

Lori Glassbrenner, MOT, OTR/LJennifer Haman, MOT, OTR/LNeema Mistry, MOT, OTR/LKeri Olesinski, MOT, OTR/L

ABSTRACT. The purpose of this study was to determine the relation-ship between type of task and type of environment on retention andtransfer of motor skills when applied to stroke survivors, as measuredby time to complete the task and the number of errors. It was expectedthat those performing a purposeful task in a familiar environment(home) would demonstrate greater retention and transfer of the motortask; however, data was inconclusive. [Article copies available for a feefrom The Haworth Document Delivery Service: 1-800-342-9678. E-mailaddress: <[email protected]> Website: <http://www.HaworthPress.com>]

KEYWORDS. Motor learning, stroke, environment

INTRODUCTION

Accounting for at least half of the patients hospitalized with neuro-logical impairments, stroke is the most common disabling neurologi-

Jodi Schreiber is Assistant Professor in the O.T. Program at Chatham College.Leslie Sober, Laura Banta, Lori Glassbrenner, Jennifer Haman, Neema Mistry,

and Keri Olesinski were students in the Occupational Therapy Master’s Program atChatham College (at the time of this study).

Address correspondence to: Jodi Schreiber, Chatham College, Woodland Road,Pittsburgh, PA 15232.

Occupational Therapy in Health Care, Vol. 13(1) 2000� 2000 by The Haworth Press, Inc. All rights reserved. 23

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OCCUPATIONAL THERAPY IN HEALTH CARE24

cal disease of adulthood (Pedretti, 1996). According to Majsak (1996),‘‘Following a stroke, patients often exhibit a very different profile ofmotor control and need to relearn the performance of actions both byusing and modifying old movement strategies and patterns and bydeveloping new ones’’ (p. 27). To facilitate this process, occupationaltherapists often apply motor learning principles. Schmidt (1988) de-fines motor learning as ‘‘a set of cognitive processes associated withpractice, training, or experience that results in relatively permanentchanges in motor behavior’’ (Hanlon, 1996, p. 811). Among the per-manent changes desired are retention and transfer of task. Retentioncan be conceptualized as that which is preserved over time. Beyondretention, transfer of a motor skill, which includes characteristics in-herent of the physical environment and the objects contained within it,enables a person to perform a new task that is similar to the retainedtask (Ferguson & Trombly, 1996).

Among the variables thought to influence motor learning outcomes(i.e., performance upon retention and transfer), type of task and learn-ing environment have been given little emphasis in the research litera-ture. For the purpose of this study, the types of task were categorizedas enabling and purposeful tasks. Pedretti (1996) described enablingactivities as ‘‘non-purposeful’’ because they generally do not have aninherent goal; however, they may be used to practice specific motorpatterns. Contrary to enabling tasks, purposeful tasks are goal-directedbut are not necessarily meaningful to every patient (Chisholm, Dolhi, &Schreiber, 1999). In addition to the type of task being learned, envi-ronmental factors also influence motor learning. Gentile (1972, 1987)has stated that ‘‘different environmental factors elicit different motorreactions’’ (Jarus, 1994, p. 811). For the purpose of this study, thelearning environments were categorized as familiar (i.e., home) andunfamiliar (i.e., simulated clinic environment).

This research study attempted to determine the degree to whichlearning environment and type of task affect the outcomes of motorlearning (i.e., retention and transfer of skill) when applied with strokesurvivors. The principles of motor learning have been used to teachmany individuals important skills to enhance their everyday function-ing. However, healthy adults have been the focus of the majority ofmotor learning research. Although these research studies have beenvery beneficial to the general population, a more narrowed approach

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Schreiber et al. 25

must be considered to address the unique neurological needs of thestroke population. It was the goal of this study to add to the currently available mass ofinformation and to target the differences that exist between strokesurvivors and healthy adults so that clinicians might more effectivelygenerate treatment plans that are sensitive to the needs of this clientpopulation. The authors of this study expected to find that the subjectsperforming the purposeful task in the familiar environment wouldretain and transfer the skills better than subjects in the other threeexperimental groups. The least degree of retention and transfer wasanticipated for the group performing enabling activities in the unfa-miliar environment. It was expected that there would be a positivecorrelation between amount of time the participant took to completethe task and amount of errors made. That is, as motor learning oc-curred and information was retained, all subjects were expected tocomplete the task in less time with decreasing numbers of errorsthroughout the consecutive retention phases.

BACKGROUND

Stages of Recovery

Although the impairments associated with stroke can be life alter-ing, varying degrees of recovery can be expected for stroke survivors.Horgan and Finn (1997) defined motor recovery as the recovery andreturn of movement. A period of spontaneous recovery usually occurswithin the first three months following the attack (Pedretti, 1996)secondary to neuroplasticity, or the brain’s ability to ‘‘rewire’’ its owncircuitry. Pedretti stated that following this period of spontaneousrecovery, ‘‘motor recovery may continue for up to one year and in someinstances even longer.’’ Contrary to spontaneous recovery, Horgan andFinn stated that functional recovery ‘‘refers to the patient’s ability toadapt to the remaining level of disability due to the stroke, and is likelyto be due to the improved use of remaining functions as the patientattempts to maximize independence in everyday activities’’ (p. 64).

Signe Brunnstrom developed one of the most widely accepted theo-ries of motor recovery following stroke during the 1950s. She identi-fied seven sequential stages of recovery during her extensive work

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with stroke patients. According to these stages, the upper and lowerextremities generally progress from flaccidity (stage 1) to normalmotor movements (stage 7) (Sawner & LaVigne, 1992). Furthermore,recovery generally occurs in a proximal to distal pattern. Given thispattern, it is not until stage 6 that all finger prehension types are undercontrol, with individual finger movements present and full range ofvoluntary extension of the digits (Sawner & LaVigne, 1992).

Components of Motor Learning

Practice Schedules

Practice schedules have often been described as random or blocked.Poole (1991) defined random practice as varying the order of taskspracticed over different trials. Blocked practice has been defined as‘‘repetitive practice of one task before the next task is introduced inthe treatment session’’ (Giuffrida, 1998). In numerous studies, the useof random practice has been shown to be more effective than blockedpractice (Battig, 1979; Giuffrida, 1998; Hanlon, 1996; Magill & Hall,1990; Poole, 1991; Schmidt, 1988; Shea & Morgan, 1979). Hanlon(1996) used an experimental retention design to determine the effectsof different motor learning practice schedules on stroke patients’ ratesof acquisition and retention of functional movements using a hemipa-retic upper extremity. The findings of this study suggested that ifretention of a task after termination is the goal, then performance ofupper extremity motor tasks should be varied with other tasks ratherthan performing the task in a continuous and repetitious style.

Types of Feedback

Motor learning literature frequently refers to two types of extrinsicfeedback–knowledge of results (KR) and knowledge of performance(KP) (Poole, 1991). KP is feedback specific to the correctness of themovement pattern and provides the learner with information on howto improve the movement pattern to achieve a desired outcome(Schmidt, 1988). Contrary to KP, KR is a post-response feedback aboutthe movement outcome; that is, it serves to guide error correction,motivate the learner, and reinforce correct performance, ultimatelyleading to ‘‘more efficient error correction and better eventual perfor-mance’’ (Magill, 1989, p. 322). Some motor learning experts have

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Schreiber et al. 27

agreed that too much KR can be detrimental to the individual’s proc-essing of intrinsic information (Giuffrida, 1998; Salmoni, 1984; Shea &Morgan, 1979; Schmidt, 1998; Poole, 1991). According to Poole(1991), ‘‘More feedback is needed in the early stages of learning thanin the later stages. During the later stages, feedback should be moreprecise and should decrease in frequency’’ (p. 536). Therefore, re-duced, or faded, frequency of KR should be given during therapy toretain and learn new skills (Giuffrida; Poole; Salmoni; Schmidt).

Types of Tasks

Different types of tasks are utilized within occupational therapytreatment interventions (Pedretti, 1996). Progressing up the continuumof treatment techniques, these tasks typically include adjunctive, enab-ling or rote, purposeful, and meaningful or occupation-centered activi-ty (Pedretti, 1996). Enabling or rote activities are considered non-pur-poseful because they generally do not have an inherent goal, thoughthey may engage the mental and physical participation of the patient(Pedretti, 1996). More simply put, these are repetitive activities with abeginning but no tangible or meaningful end product. The purposes ofthese activities are to practice specific motor patterns, to train per-ceptual and cognitive skills, and to practice sensorimotor skills neces-sary for function in home and community. Examples of enabling orrote activities include stacking cones and performing dowel rod exer-cises to increase range of motion (Chisholm et al., 1999).

Purposeful activity involves tasks that have an inherent or autono-mous goal, with a beginning and end product, but they are not neces-sarily meaningful to every patient (Chisholm et al., 1999). Some ex-amples of purposeful activities include making doormats and othertypes of art projects in therapy when the client has not had any pre-vious interest or experience with this activity. These activities, thoughnot individualized, can be used to enhance functioning of some perfor-mance components.

Environment

The literature suggests that environmental factors may specificallyinfluence motor learning outcomes (Sabari, 1991; Trombly, 1995).According to Sabari (1991), ‘‘Environmental demands play a criticalrole in the determination of how people organize purposeful move-

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ments’’ (p. 524). Among the theories of motor control, ecologicaltheories emphasize the interaction between the performer and theenvironment and assume that motor behaviors emerge as a result ofregulatory conditions in the environment (Trombly, 1995). The envi-ronment can directly impact movement patterns in order to be success-ful in achieving given goals (Trombly, 1995).

Despite the emphasis on environmental considerations throughoutoccupational therapy literature, limited research is available to supportthe role of the environment in producing positive motor learning out-comes with regard to actual motor skill (Nygard, Bernspang, Fisher, &Winblad, 1994; Park, Fisher, & Velozo, 1994). However, recent find-ings suggest that, where environment does influence motor learning, itis the familiarity of the natural environment that enhances one’s pro-cess skills, enabling a person to compensate for motor and cognitivedeficits (Nygard, Bernspang, Fisher, & Winblad, 1994; Park, Fisher, &Velozo, 1994). Performing in a novel, unfamiliar environment maydemand more ability than a person possesses, resulting in a lowerfunctional level of activities of daily living (ADL) or instrumentalactivities of daily living (IADL) performance. ‘‘If this is the case, thenthe observation of a client’s functional performance in an occupationaltherapy clinic would not be representative of the client’s optimal per-formance’’ (Park et al., 1994, p. 698).

Motor Learning Outcomes

The three main outcomes of motor learning principles are acquisi-tion, retention, and transfer. Acquisition can be described as the abilityto complete a certain task after a period of initial instruction. After thetask is acquired, it may become consolidated and, thus, retained (Maj-sak, 1996). The motor-behavior then becomes part of the learner’smovement strategy and pattern repertoire. Transfer enables a person todraw on past experience to perform a new task and perform it indifferent contexts (Jarus, 1994). These are the optimal goals that occu-pational therapists aim to achieve with their clients.

METHODS

The study followed a design consisting of four single case analyses.The format of the design, which included a two-way factorial compo-

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Schreiber et al. 29

nent, was as follows: A, B1, C1, B2, C2, D. Each letter represented adifferent phase of motor learning during which a typing task wascompleted and time and errors were measured. ‘‘A’’ equals the ac-quisition trial, during which baseline training was given. ‘‘B’’ equalsthe post-random practice measures, and ‘‘C’’ equals the pre-randompractice measures. ‘‘B1’’ equals the first retention trial, and ‘‘B2’’equals the third retention trial. ‘‘C1’’ equals the second retention trial,and ‘‘C2’’ equals the fourth retention trial. ‘‘D’’ refers to the transfertrial.

Subjects were each assigned to one of four treatment conditions.The conditions were determined according to the type of task beingperformed and the environment in which it was learned and weredescribed as follows: enabling/familiar; enabling/unfamiliar; purpose-ful/familiar; purposeful/unfamiliar.

Subjects

Four volunteers, who were recruited from local stroke survivorsupport groups or past rehabilitation programs, constituted the subjectpopulation of this study. Volunteers were excluded if they reportedcurrent participation in occupational therapy. Current participation inoccupational therapy would have interfered with the study results, as itwould not be possible to distinguish if observable gains were made asa result of study intervention or other treatment.

To control for other confounding variables, the following inclusioncriteria were developed:

� Single left unilateral stroke with onset at least six months ago� Cognitively intact, as indicated by a Mini Mental Status Ex-

amination score of 23 or above� Upper extremity muscle tone within functional limits bilaterally,

as indicated by a total Fugl-Meyer score of 30 out of a possible66 points for hemiplegic upper extremity

� Maximum of 2 or less uncrossed lines on the Albert Test� No typing experience

According to Giuffrida (1998), ‘‘the most effective practice condi-tions are those leading to the highest performance on either a novelversion of the task or on the task performed under novel or variableconditions’’ (p. 561). Although the original inclusion criteria called

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for no typing experience, it was not possible, under the given timeconstraints, to recruit subjects who met this criteria. Therefore, thiscriterion was relaxed to include subjects with no typing experiencesince the onset of stroke. For the purpose of this study, the event of astroke constituted ‘‘variable conditions.’’ Therefore, despite any com-puter experience prior to the date of stroke, the experimental taskcould still be considered ‘‘novel,’’ as the brain attack altered the motorperformance components associated with typing on a computer.

Subject 1 was a 60-year-old female and had no typing experienceprior to having the stroke. There were nine months, 29 days betweenthe onset of this subject’s stroke and the day of acquisition. Subject 3was an 82-year-old female who also had no typing experience prior tohaving the stroke. There were three years, eight days between theonset of her stroke and the day of acquisition. Subject 5 was a 77-year-old female with no typing experience prior to having the stroke.There were two years between the onset of her stroke and the day ofacquisition. Subject 6 was a 65-year-old female with some typingexperience prior to having the stroke. There were two years, ninemonths, and 14 days between the onset of her stroke and the day ofacquisition.

Variables and Definitions of Terms

The independent variables of this study were the type of task andtype of environment. There were two levels for each variable. Thetype of task each subject performed was either enabling or purposeful.The enabling task involved typing a non-meaningful, nonsensicalparagraph on a laptop computer. The purposeful task resembled theenabling task but involved typing a paragraph concerning stroke pre-vention. The types of environment that the participants performed thetask in were either the familiar environment (i.e., subject’s permanentresidence) or an unfamiliar, simulated clinic environment.

The dependent variables were retention and transfer of motor learn-ing skills. For example, subjects performed the initial task on a stan-dard laptop keyboard. To assess transfer ability, subjects performedthe same task on a keyboard from a standard personal computer. Bothretention and transfer abilities were measured by time to complete thetask and the number of errors. Time to complete the task was mea-sured by the total number of minutes, beginning at the time of place-ment of hands on the keyboard and ending when subjects made the

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Schreiber et al. 31

final keystroke. Number of errors made by each subject was scored ona hard copy against a master copy of the paragraph. In addition to rawtime and number of errors, the percentage of change in these variableswas calculated as it occurred consecutively from one session to thenext (i.e., the percentage of change from acquisition to the first reten-tion trial, from the first retention trial to the second, etc.).

Procedures

The participants were randomly assigned to one of four groups:purposeful/familiar, purposeful/unfamiliar, enabling/familiar, and en-abling/unfamiliar. Instructions for the experimental task were pro-vided to all subjects at the beginning of each day. The first trial,conducted on Day 1, was considered the acquisition trial. Followingthe acquisition trial, each subject received feedback from the research-er regarding their actual performance (KP) as well as the outcome oftheir performance (KR). Proprioceptive feedback was given to correcttiming and release of fingers from the keyboard. To do this, subjectshad the opportunity to practice holding the keys down with differentdegrees of pressure. Feedback was also given visually by directingsubjects to see their errors on the screen and reviewing the location ofcertain keys (e.g., location of the backspace key). Finally, the research-er used verbal feedback to explain how errors might be correctedduring the trials to follow.

Following the acquisition trial and feedback, each subject practicedsimilar motor tasks, for which their performance was not measured.The order of random practice tasks (i.e., random practice protocol)was varied on each consecutive day but consisted of completing cal-culations on a large calculator and dialing a 7-digit phone number ofchoice to make a phone call before returning to the computer task.Following the random practice tasks, verbal and visual feedback fromthe acquisition trial were reviewed, and the first retention trial wasconducted.

Two days after the acquisition and first retention trials, the secondand third retention trials were conducted according to the randompractice protocol. To fade the feedback, only verbal feedback wasgiven after the second retention trial, and none was reviewed before orafter the third retention trial. On Day 3, one week after the initialacquisition, a fourth retention trial and a transfer trial were conducted

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according to the random practice protocol. No feedback of any kindwas provided on this day.

The measured task required the subjects to type a paragraph exactlyas it appeared on an 8 1/2� � 11� piece of white paper. Paragraphswere pre-formatted so that each was double-spaced, typed in size 14‘‘Times New Roman’’ font. Subject 1 completed the task in a familiarenvironment. Subject 6, completing the task in the simulated clinicenvironment, received a nonsensical ‘‘ABC’’ paragraph representativeof an enabling task. That is, while the nonsensical paragraph consistedof the alphabet typed over repeatedly, it resembled the purposefulparagraph in the number of letters per word, words per line, punctua-tion, and spacing. Subject 3 (familiar) and subject 5 (simulated clinic)received a paragraph more representative of a purposeful task. Thepurposeful paragraph contained information regarding stroke preven-tion, which was expected to be more meaningful to the participants.

The typing task was performed using a laptop computer with astandard laptop keyboard provided by the examiners. The retentiontrials used the same computer and keyboard, as well as the sameparagraph. Transfer trials were performed using the same paragraph,typed on the same laptop computer, but the keyboard was replacedwith one from a standard personal computer. Each time a trial wasconducted, the researcher used a standard stopwatch to record the timein seconds it took to complete the task. This information was thenentered onto a test data sheet and later into a computer for statisticalanalysis.

RESULTS

Demographic information (age, gender, amount of time post-stroke,and hand dominance) was collected and analyzed using descriptivestatistics. Standard deviation (SD) of percent changes in time anderrors made were analyzed in addition to minimum/maximum age,and mean values were analyzed for interval-ratio data.

The raw data was entered into the Statistical Product and ServiceSolutions (SPSS) system. The researchers assigned values for subjectidentification number, the environment in which the test was con-ducted, and the type of task that was completed. Values specific toeach subject were also entered and included the total errors made

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Schreiber et al. 33

during the task and the time it took them to complete the task in theacquisition, retention 1-4, and transfer trials (Tables 1 and 2). Figures 1and 2 are visual representations of the raw data. Data also included thepercent change in time and error for each of the following: acquisitionto retention 1, retention 1 to retention 2, retention 2 to retention 3,retention 3 to retention 4, and retention 4 to transfer. The percentchange values were computed using SPSS for each subject (Tables 3and 4). Figures 3 and 4 are visual representations of the percent changevalues computed.

Overall, for each subject it was anticipated that performance wouldimprove from one motor phase to another, except for the transferphase, in which the task was modified. Improved performance couldbe identified by number of errors and time to complete the task de-creasing over each phase until the transfer phase, during which botherrors and time would be expected to increase. This increase in bothtime and errors during the transfer phase was expected because of theinitial introduction of a new keyboard. However, performance during

TABLE 1. Total Errors in Task Completion for Each Motor Learning Phase

Total # of Errors

Subject Acquisition Retention 1 Retention 2 Retention 3 Retention 4 Transfer1 93 39 23 26 23 243 257 158 135 127 211 465 15 11 0 4 1 46 16 7 4 4 2 12

Note. Subject 1 = familiar, enablingSubject 3 = familiar, purposefulSubject 5 = unfamiliar, purposefulSubject 6 = unfamiliar, enabling

TABLE 2. Time to Complete Task During Each Motor Learning Phase

Total Time

Subject Acquisition Retention 1 Retention 2 Retention 3 Retention 4 Transfer1 16.9 21.5 16.8 15.5 13.7 17.83 13.3 22.2 14.8 14.1 15.0 8.05 15.4 16.2 11.7 21.9 14.0 16.06 39.6 28.5 20.8 18.4 18.2 20.7


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FIGURE 1. Total Errors in Task Completion During Each Motor Learning Phase

300

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100

50

01 2 3 4 5 6

Trials

# of

Err

ors

S1 = F/ES3 = F/PS5 = U/PS6 = U/E

Note. Subject 1 (S1) = familiar (F), enabling (E)Subject 3 (S3) = familiar (F), purposeful (P)Subject 5 (S5) = unfamiliar (U), purposeful (P)Subject 6 (S6) = unfamiliar (U), enabling (E)


FIGURE 2. Time to Complete Task During Each Motor Learning Phase

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1 2 3 4 5 6Trials

Tim

e (in

min

utes

)

S1 = F/ES3 = F/PS5 = U/PS6 = U/E

40

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this phase would still be expected to be better than the initial acquisi-tion performance. For example, subject 6 showed an increase in num-ber of errors from retention 4 (2 errors) to transfer (12 errors). Despitethis increase in number of errors, performance was better than duringthe initial acquisition phase (16 errors). The same pattern occurred for

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Schreiber et al. 35

TABLE 3. Percent Change in Total Errors Between Motor Learning Phases

% Change in Errors

Subject Acq. to Ret 1 Ret 1 to Ret 2 Ret 2 to Ret 3 Ret 3 to Ret 4 Ret 4 to Transfer

1 �58 �41 13 �12 403 �39 �15 �6 66 �785 �27 �100 0 �75 3006 �56 �43 0 �50 500


TABLE 4. Percent Change in Time to Complete Task Between Motor LearningPhases

% Change in Time

Subject Acq. to Ret 1 Ret 1 to Ret 2 Ret 2 to Ret 3 Ret 3 to Ret 4 Ret 4 to Transfer

1 27 �22 �8 �12 303 67 �33 �6 7 �475 5 �28 86 �36 146 �28 �27 �11 �2 14


FIGURE 3. Percent Change in Total Errors Between Motor Learning Phases

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Trials

# of

Err

ors S1 = F/E

S3 = F/PS5 = U/PS6 = U/E


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–200

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FIGURE 4. Percent Change in Time to Complete Task Between Motor LearningPhases

1 2 3 4 5

Trials

Tim

e (in

min

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)

S1 = F/ES3 = F/PS5 = U/PS6 = U/E


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–20

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–60

time, as it increased from retention 4 (18.2 minutes) to transfer (20.7minutes) but was better than performance during acquisition (39.6minutes).

Because raw values were so varied between individuals, it wasnecessary to compare percent changes between motor phases in errorand time to complete the task. With respect to percent change in errorsand time to complete the task between motor phases, improved perfor-mance would be indicated by a negative value. These trends wereanticipated to be greatest for subject 3, who completed the purposefultask in a familiar environment.

Subject 1 (enabling/familiar) demonstrated a decrease in number oferrors between all retention phases except between retention trials 2 (23errors) and 3 (26 errors). As expected, she also showed an increase innumber of errors during the transfer phase. With regard to time, sub-ject 1 completed the task with a decreasing amount of time between allretention phases except from acquisition to retention 1. As expected,the time to complete the task during the transfer phase increased.

Subject 3 (purposeful/familiar), as compared to all other subjects,had the highest number of errors when performing the typing taskduring any of the motor phases (257 errors during the acquisition

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Schreiber et al. 37

phase). However, she, too, demonstrated a decreasing number of er-rors between retention phases except between retention 3 (127 errors)and retention 4 (211 errors). Errors again decreased from retention 4(211 errors) to transfer (46 errors). With respect to time, subject 3demonstrated an increase in the amount of time to complete the taskbetween acquisition (13.3 minutes) and retention 1 (22.2 minutes).Time continued to decrease through retention 3 (14.1 minutes) andthen increased during retention 4 (15 minutes). During the transferphase, subject 3 completed the task in 8 minutes.

Subject 5 (purposeful/unfamiliar) completed the task with a de-creasing number of errors between retention phases except betweenretention 2 (0 errors) and retention 3 (4 errors). Her errors continued todecrease during retention 4 (1 error), and again increased during thetransfer phase (4 errors). Time to complete the task varied for subject 5between all motor learning phases. That is, it increased from acquisi-tion to retention 1, decreased during retention 2, and continued thisalternating pattern through the transfer phase.

Subject 6 (enabling/unfamiliar) demonstrated a decreasing numberof errors between all consecutive motor learning phases until the trans-fer phase, when number of errors increased. Likewise, the time it tooksubject 6 to complete the task decreased between all consecutivephases until the transfer phase, when time increased.

A two-tailed Pearson Correlation (alpha = .05) determined the de-gree of relationship between percent change in errors and percentchange in time occurring between motor learning phases. The follow-ing values were found for each phase change: acquisition to retention1 (r = .27 and p = .73), retention 1 to retention 2 (r = �.29 and p =.71), retention 2 to retention 3 (r = .20 and p = .87), retention 3 toretention 4 (r = .76 and p = .24), and retention 4 to transfer (r = .48 andp = .52). Although none of the above r-values were significant, theywere found to be of positive value, as expected.

When comparing the data collectively, subject 6 (enabling/unfamil-iar) showed the greatest amount of improved performance, followedby subject 1 (enabling/familiar), subject 5 (purposeful/unfamiliar),and subject 3 (purposeful/familiar).

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DISCUSSION

It was expected that subject 3, who performed the purposeful task ina familiar environment, would show the greatest amount of improve-ment in performance from one motor phase to another, as measured bya decrease in the number of errors made when completing the pur-poseful task. This would occur in all motor learning phases except forthe transfer phase, during which the task was modified, when thenumber of errors would increase. Subject 3 did follow a pattern indecreasing the number of errors from acquisition through retention 3.However, when looking at the data for percent change in errors collec-tively, the above mentioned hypothesis was not supported.

Subject 5 (purposeful/unfamiliar) showed the greatest amount ofimproved performance, while subject 3 (purposeful/familiar) showedthe least. Among the confounding factors that may have accounted forthis result, subject 3 was the oldest in age of all four subjects. Otherfactors may have included the time of day the study was completed(i.e., evening), the lack of typing experience pre-stroke, the severity ofstroke, and the motivation to complete the study successfully.

Although errors were expected to decrease through all retentionphases, it was also expected that errors would increase during thetransfer phase due to the modification of the task. However, subject 3demonstrated a 78% decrease in the number of errors. It is speculatedthat the large decrease in her number of errors during this phase wasdue to the larger keys on the standard keyboard.

Subject 3 was also expected to show greater retention and transferof motor learning skills, as evidenced by decreased time to completethe task, except for the transfer phase. This hypothesis was not sup-ported by the data collected. In fact, subject 6 (enabling/unfamiliar)followed the hypothesized pattern most closely and demonstrated thegreatest amount of improvement with respect to time to complete thetask. This was evident by a decrease in the amount of time fromacquisition through retention 4, followed by an increase from retention4 to transfer. This may have been due to the amount of typing experi-ence this subject had prior to onset of stroke.

When comparing the data for all four subjects collectively, withrespect to percent change in time to complete the task, subject 3 did notfollow the anticipated pattern. It is thought that this finding may havebeen the cumulative result of the aforementioned confounding factors.

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Schreiber et al. 39

Although it was anticipated that type of environment and taskwould impact the retention and transfer of motor learning skills withstroke survivors, this study was unable to provide any conclusiveevidence supporting this hypothesis.

The results of this study may have been more sound if the task usedwas one that was more environmentally dependent, that is, if success-ful performance of the task depended on the unique characteristics(e.g., size, location, height, etc.) of an object already in the familiarenvironment. This task, however, involved an unfamiliar object beingimplanted into one’s natural environment, thereby minimizing theeffect of the familiar environment. In addition, the data from this studymay have been more conclusive if the tasks chosen for this study hadbeen more representative of enabling and purposeful tasks. Both theenabling and purposeful tasks designed for this study required use ofthe same fine motor components and varied only with respect tocontent of the paragraph being typed.

Limitations

The primary limitation to this study was the small sample size. Asample size of four, all of whom were women, inhibited the ability toidentify generalizable trends across a population. Another impact ofthe sample size was the inability to control for levels of experience.Although the original inclusion criteria called for subjects with noprevious typing experience, it was not feasible, under the given timeconstraints, to locate volunteers who met this criteria as well as theother inclusion criteria. Therefore, the criteria were modified to in-clude people who had no typing experience since the time of theirstroke.

The impact of this change allowed for a greater number of eligiblesubjects, but it also may have skewed the final results. That is, each ofthe four subjects had different levels of typing experience. Forinstance, subject 3 had no previous typing experience. Therefore, eventhough she practiced under ‘‘ideal’’ conditions (in a familiar environ-ment with a purposeful activity), she may have performed worse as aresult of her inexperience. On the other hand, subject 6 had sometyping experience before the stroke. Despite practicing under the leastideal conditions (in an unfamiliar environment with an enabling activ-ity), her experience may have contributed to the higher degree ofaccuracy of her performance. Thus, a larger sample size may have

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resulted in a greater mix of ability levels within each treatment group,leading to more conclusive results.

The sample size limitation was the cumulative result of other limit-ing factors. For example, two participants (subjects 2 and 4) discontin-ued their participation in the study, leaving only four subjects. Also,the experimental typing task greatly limited the pool of eligible volun-teers. According to the Brunnstrom stages of stroke recovery, wristand finger extension are among the last functional movements toreturn to the stroke survivor (Sawner & LaVigne, 1992). It is unknownhow long this return may take, and many individuals never achievethis advanced stage of recovery (Sawner & LaVigne, 1992). A taskthat incorporated more gross motor function versus controlled finemotor skill would have allowed for a greater number of eligible sub-jects.

While the literature supports the use of faded feedback (Giuffrida,1998; Poole, 1991; Salmoni, 1984; Schmidt, 1998), it was difficult tostandardize a procedure for providing it in a consistent manner. Be-cause each subject made different types of errors, each required differ-ent types of sensory feedback. For example, one subject repeatedlyheld the keys down with too much pressure, producing many strings ofletters throughout the paragraph. Therefore, she required more pro-prioceptive feedback than others who did not make this error. Othersrequired more visual and verbal feedback to make them aware of theirerrors. The variability of types of errors made it difficult to keep thiscondition constant throughout the study and may have confoundedresults.

CONCLUSIONS

Due to the inconsistency in the number of errors made with eachsubject, conclusions could not be drawn with regard to the impact typeof task and type of environment had on retention and transfer of skills.The percent changes in number of errors calculated between motorlearning phases were also inconclusive.

Furthermore, due to the high variability of time and percent changein time shown by all subjects to complete the motor learning task, itwas not possible to draw conclusive statements about retention andtransfer of motor learning skills in relation to type of task and type ofenvironment.

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Schreiber et al. 41

Finally, there was no consistent relationship found between thepercent change in time and errors data. Therefore, trends regarding thesubjects’ typing performance during the motor learning phases couldnot be identified.

Continued research involving the motor recovery of stroke survi-vors will benefit the thousands of people who struggle with the long-term effects of stroke. The task used in this research required move-ments available only to those stroke survivors in the advanced stagesof recovery. Therefore, a less complex task involving gross motormovements of the upper extremity would be more appropriate to drawconclusions about stroke survivors. Finally, more accurate indicatorsof retention and transfer of skill should be identified and implementedinto future research designs, as it is not clear from this study whethertime and number of errors truly reflected the motor learning outcomes.

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Application of Motor Learning Principles with Stroke Survivors