Choose your words wisely: Optimizing impacts on standardized performance testing

A clinical examination of OPTIMAL theory application in people with multiple sclerosis: a proof-of-concept study and implications for rehabilitation practice

We investigated the potential to improve motor learning and performance in people with multiple sclerosis (PwMS) with OPTIMAL theory conditions. OPTIMAL theory predicts that three main factors [i.e. autonomy support (AS), enhanced expectancies (EE), and external focus (EF)] facilitate performance and learning. We examined whether the implementation of all three combined in a consecutive manner during practice would be beneficial for the motor learning and performance in a clinical population facing physical, cognitive, and emotional challenges. Thirty PwMS with mild-to-moderate disability (Expanded Disability Status Scale = 2.0-5.0) were randomly assigned to one of two groups (optimized and control) and practiced a novel motor-cognitive task involving rapid square-stepping to memorized patterns. Following a pretest (no group difference), optimized group participants practiced under each of three factors across practice phase (EE: feedback after good trials; AS: choice of mat color; and EF: external focus to the mat). Control group participants practiced under neutral conditions. The optimized group had significantly shorter movement times than the control group in the practice phase [174.7 (27.4) s vs. 236.8 (35.8) s, P  < 0.0001], on the 24-h retention test [69.3 (9.3) s vs. 159.7 (15.5) s, P  < 0.0001], and the 24-h transfer test [146.1 (14.9) s vs. 223.1 (38.9) s, P  < 0.0001]. Thus, optimized practice combining AS, EF, and EE enhanced motor skill learning. Key factors in the OPTIMAL theory can be used to improve patients' motor learning. Further studies are warranted to extend these proof-of-concept observations for potential clinical applications.

Optimising children's movement assessment batteries through application of motivational and attentional manipulations

An external focus of attention, enhanced expectancies, and autonomy support (i.e., OPTIMAL factors) are key factors to optimise motor performance and uncover latent movement capabilities. However, research on the combination of OPTIMAL factors, particularly in children's dynamic movement settings is limited. Therefore, this study examined the combined effects of OPTIMAL factors on children's performance on a dynamic movement assessment battery, hypothesising higher performance scores in the optimised version of the assessment battery versus standardised version of the assessment. Forty-nine children (15 boys, 34 girls; mean age 10.61 ± 1.38 years) completed the Dragon Challenge (DC) dynamic movement assessment battery. Performance was measured via a summation of movement process (technique), outcome, and time-to-completion scores (max score N = 54) with higher scores representing better performance. Participants completed a standardised and an optimised version of the DC in a counterbalanced fashion. For the latter, DC protocols were optimised via the provision of choice (autonomy support); external focus instructions augmented by simple knowledge statement, positive feedback and promotion of a growth mindset (Enhanced expectancies). Results indicate that motor performance (DC score) was better in the optimised (M = 31.08 ± 6.66) vs. standardised (M = 29.04 ± 5.88). The findings indicate that the combination of OPTIMAL factors can improve children's motor performance in dynamic movement settings and that standardised motor assessment may not reveal children's true movement capabilities.

Either Autonomy Support or Enhanced Expectancies Delivered Via Virtual-Reality Benefits Frontal-Plane Single-Leg Squatting Kinematics

Our purpose in this study was to determine the effects of a virtual reality intervention delivering specific motivational motor learning manipulations of either autonomy support (AS) or enhanced expectancies (EE) on frontal plane single-leg squatting kinematics. We allocated 45 participants (21 male, 24 female) demonstrating knee, hip, and trunk frontal plane mechanics associated with elevated anterior cruciate ligament injury risk to one of three groups (control, AS, or EE). Participants mimicked an avatar performing five sets of eight repetitions of exemplary single-leg squats. AS participants were given the added option of choosing the color of their avatar. EE participants received real-time biofeedback in the form of green highlights on the avatar that remained on as long as the participant maintained pre-determined 'safe' frontal plane mechanics. We measured peak frontal plane knee, hip, and trunk angles before (baseline) and immediately following (post) the intervention. The control group demonstrated greater increases in knee abduction angle (Δ = +2.3°) than did the AS (Δ = +0.1°) and EE groups (Δ = -0.4°) (p = .003; η2p = .28). All groups demonstrated increased peak hip adduction (p = .01, ηp2 = .18) (control Δ = +1.5°; AS Δ = +3.2°; EE Δ = +0.7°). Hip adduction worsened in all groups. AS and EE motivation strategies appeared to mitigate maladaptive frontal plane knee mechanics.

Similarities between explaining dizziness and explaining pain? Exploring common patient experiences, theoretical models, treatment approaches and potential therapeutic narratives for persistent dizziness or pain

Pain and dizziness are common experiences throughout the lifespan. However, nearly a quarter of those with acute pain or dizziness experience persistence, which is associated with disability, social isolation, psychological distress, decreased independence, and poorer quality of life. Thus, persistent pain or dizziness impacts peoples' lives in similarly negative ways. Conceptual models of pain and dizziness also have many similarities. Many of these models are more expansive than explaining mere symptoms; rather they describe pain or dizziness as holistic experiences that are influenced by biopsychosocial and contextual factors. These experiences also appear to be associated with multi-modal bodily responses related to evaluation of safety, threat detection and anticipation, as influenced by expectations, and predictions anticipation, not simply a reflection of tissue injury or pathology. Conceptual models also characterize the body as adaptable and therefore capable of recovery. These concepts may provide useful therapeutic narratives to facilitate understanding, dethreaten the experience, and provide hope for patients. In addition, therapeutic alliance, promoting an active movement-based approach, building self-efficacy, and condition-specific approaches can help optimize outcomes. In conclusion, there are significant overlaps in the patient experience, theoretical models and potential therapeutic narratives that guide care for people suffering with persistent pain or dizziness.

Steady, Aim, Fire! Optimized Instructions Enhance Performance and Reduce Intra-Trial Variability in a Shooting Task

The present study examined the influence of the individual and sequential combination of the key components of OPTIMAL (Optimizing Performance Through Intrinsic Motivation and Attention for Learning) theory (i.e., enhanced expectancies, autonomy support, and external focus), on the performance of a laser-pistol shooting task. In addition to shooting accuracy, intra-trial variability in the sway of forearm/pistol motion prior to movement execution (pulling the trigger) was the primary variable of interest. In a between-within-subject design, thirty-six participants (Mage = 21.27 ± 1.75 years) were randomized into either a control or an optimized group. Enhanced expectancies, autonomy support, and an external focus were implemented via sequential blocks of trials for participants in the optimized group. Participants in the control group performed all trials under “neutral” conditions. Our results showed that motor performance was enhanced for participants in the optimized group compared to those in the control group. Moreover, greater reductions in forearm sway leading up to the trigger pull were observed for the optimized group compared to the control group. These findings suggest higher movement effectiveness and efficiency, potentially through better attunement to task and environmental constraints, when implementing optimized instructions in a self-initiated fine motor task.

Immersive Real-Time Biofeedback Optimized With Enhanced Expectancies Improves Motor Learning: A Feasibility Study

CONTEXT

An Optimizing Performance through Intrinsic Motivation and Attention for Learning theory-based motor learning intervention delivering autonomy support and enhanced expectancies (EE) shows promise for reducing cognitive-motor dual-task costs, or the relative difference in primary task performance when completed with and without a secondary cognitive task, that facilitate adaptive injury-resistant movement response. The current pilot study sought to determine the effectiveness of an autonomy support versus an EE-enhanced virtual reality motor learning intervention to reduce dual-task costs during single-leg balance.

DESIGN

Within-subjects 3 × 3 trial.

METHODS

Twenty-one male and 24 female participants, between the ages of 18 and 30 years, with no history of concussion, vertigo, lower-extremity surgery, or lower-extremity injuries the previous 6 months, were recruited for training sessions on consecutive days. Training consisted of 5 × 8 single-leg squats on each leg, during which all participants mimicked an avatar through virtual reality goggles. The autonomy support group chose an avatar color, and the EE group received positive kinematic biofeedback. Baseline, immediate, and delayed retention testing consisted of single-leg balancing under single- and dual-task conditions. Mixed-model analysis of variances compared dual-task costs for center of pressure velocity and SD between groups on each limb.

RESULTS

On the right side, dual-task costs for anterior-posterior center of pressure mean and SD were reduced in the EE group (mean Δ = -51.40, Cohen d = 0.80 and SD Δ = -66.00%, Cohen d = 0.88) compared with the control group (mean Δ = -22.09, Cohen d = 0.33 and SD Δ = -36.10%, Cohen d = 0.68) from baseline to immediate retention.

CONCLUSIONS

These findings indicate that EE strategies that can be easily implemented in a clinic or sport setting may be superior to task-irrelevant AS approaches for influencing injury-resistant movement adaptations.

A comparison of placebo and nocebo effects on objective and subjective postural stability: a double-edged sword?

Background: Positive expectations (i.e., placebo effect) can improve postural control during quiet standing. This raises an important question: if postural control is susceptible to positive expectations, is it possible to elicit the opposite, a decline in postural stability, simply by suggesting a performance impairment (i.e., nocebo) will take place? Yet no studies have examined the nocebo effect on balance performance. To better understand both phenomena, comparative studies, which include both placebo and nocebo conditions, are needed.

Method: Forty-two healthy adults were initially assessed for objective (center of pressure movement) and subjective (perceived) postural stability and performance expectations. Participants were then randomly assigned in equal numbers to a placebo (positive expectation), nocebo (negative expectation) or control (no suggestion) group. Participants in the placebo/nocebo groups were deceptively administered an inert capsule described as a potent supplement which would either positively or negatively influence their balance performance. Objective and subjective postural stability, and performance expectations were reassessed 20 min later.

Results: The nocebo procedure evoked an increase in COP sway movements and reduced perceived stability compared to a control group. The placebo group presented with reductions COP sway movements and increased perceived stability following expectation manipulation. Compared to the control group, the placebo group showed a significantly higher performance expectation whilst the nocebo group showed a significantly lower performance expectation. Regression analyses also revealed that performance expectations following the placebo/nocebo procedure significantly predicted perceptions of postural instability (i.e., perceived performance), accounting for around 50% of the variance. These results remained even when controlling for actual performance (i.e., objective postural stability).

Conclusion: Our findings indicate that positive and negative performance expectations evoked by instructional manipulation can profoundly influence both objective and subjective postural stability. Postural control—and perceptions regarding such—are clearly susceptible to expectation manipulation, which could have important practical implications and repercussions on testing, training interventions and rehabilitation programs. Positive and negative expectancies are a double-edged sword for postural control.

Direction of attentional focus in prosthetic training: Current practice and potential for improving motor learning in individuals with lower limb loss

OBJECTIVE

Adopting an external focus of attention has been shown to benefit motor performance and learning. However, the potential of optimizing attentional focus for improving prosthetic motor skills in lower limb prosthesis (LLP) users has not been examined. In this study, we investigated the frequency and direction of attentional focus embedded in the verbal instructions in a clinical prosthetic training setting.

METHODS

Twenty-one adult LLP users (8 female, 13 male; 85% at K3 level; mean age = 50.5) were recruited from prosthetic clinics in the Southern Nevada region. Verbal interactions between LLP users and their prosthetists (mean experience = 10 years, range = 4-21 years) during prosthetic training were recorded. Recordings were analyzed to categorize the direction of attentional focus embedded in the instructional and feedback statements as internal, external, mixed, or unfocused. We also explored whether LLP users' age, time since amputation, and perceived mobility were associated with the proportion of attentional focus statements they received.

RESULTS

We recorded a total of 20 training sessions, yielding 904 statements of instruction from 338 minutes of training. Overall, one verbal interaction occurred every 22.1 seconds. Among the statements, 64% were internal, 9% external, 3% mixed, and 25% unfocused. Regression analysis revealed that female, older, and higher functioning LLP users were significantly more likely to receive internally-focused instructions (p = 0.006, 0.035, and 0.024, respectively).

CONCLUSIONS

Our results demonstrated that verbal instructions and feedback are frequently provided to LLP users during prosthetic training. Most verbal interactions are focused internally on the LLP users' body movements and not externally on the movement effects.

IMPACT STATEMENT

While more research is needed to explore how motor learning principles may be applied to improve LLP user outcomes, clinicians should consider adopting the best available scientific evidence during treatment. Overreliance on internally-focused instructions as observed in the current study may hinder prosthetic skill learning.

Neural correlates of within-session practice effects in mild motor impairment after stroke: a preliminary investigation

While the structural integrity of the corticospinal tract (CST) has been shown to support motor performance after stroke, the neural correlates of within-session practice effects are not known. The purpose of this preliminary investigation was to examine the structural brain correlates of within-session practice effects on a functional motor task completed with the more impaired arm after stroke. Eleven individuals with mild motor impairment (mean age 57.0 ± 9.4 years, mean months post-stroke 37.0 ± 66.1, able to move ≥ 26 blocks on the Box and Blocks Test) due to left hemisphere stroke completed structural MRI and practiced a functional motor task that involved spooning beans from a start cup to three distal targets. Performance on the motor task improved with practice (p = 0.004), although response was variable. Baseline motor performance (Block 1) correlated with integrity of the CST (r = - 0.696) while within-session practice effects (change from Block 1 to Block 3) did not. Instead, practice effects correlated with degree of lesion to the superior longitudinal fasciculus (r = 0.606), a pathway that connects frontal and parietal brain regions previously shown to support motor learning. This difference between white matter tracts associated with baseline motor performance and within-session practice effects may have implications for understanding response to motor practice and the application of brain-focused intervention approaches aimed at improving hand function after stroke.

Maximal force production requires OPTIMAL conditions

The OPTIMAL theory of motor learning identifies several motivational and attentional factors that draw out latent motor performance capabilities. One implication of the OPTIMAL theory of motor learning (Wulf & Lewthwaite, 2016) is that standardized motor performance assessments likely do not reflect maximal capabilities unless they are "optimized" with appropriate testing conditions. The present study examined the effects of three key motivational (enhanced expectancies, EE, and autonomy support, AS) and attentional (external focus, EF) variables in the OPTIMAL theory on maximum force production. In Experiment 1, a handgrip strength task was used. EE, AS, and EF were implemented, in a counterbalanced order, on consecutive trial blocks in an optimized group. A control group performed all blocks under neutral conditions. While there were no group differences on Block 1 (baseline), the optimized group outperformed the control group on all other blocks. In Experiment 2, participants performed two one-repetition maximum (1-RM) squat lift tests, separated by one week. Two groups, an optimized group and control group, had similar 1-RM values on the first test performed under neutral conditions. However, on the second test, a group performing under optimized conditions (EE, AS, EF) showed an increase in 1-RM, while there was no change from the first to the second test for a control group. We argue that standard test conditions may not produce true maximal performance. The findings corroborate the importance of key factors in the OPTIMAL theory and should be applied to ensure accurate strength performance assessment.