Errorless learning is superior to trial and error when learning a practical skill in rehabilitation: a randomized controlled trial

Construct validity, responsiveness, and interpretability of the Utrecht Scale for Evaluation of Rehabilitation (USER) in patients admitted to inpatient geriatric rehabilitation

OBJECTIVE

The Utrecht Scale for Evaluation of Rehabilitation is a multi-domain measurement with good content validity, structural validity and reliability for measuring physical functioning (mobility, selfcare) and cognitive functioning in geriatric rehabilitation. We aimed to determine the construct validity of both Utrecht Scale for Evaluation of Rehabilitation scales and the responsiveness and interpretability of the scale for physical functioning in geriatric rehabilitation.

DESIGN

Prospective follow-up study embedded in routine care.

SETTING

Four care organisations in The Netherlands.

SUBJECTS

Patients admitted for inpatient geriatric rehabilitation (2021-2022).

MAIN MEASURES

Data collection included the Utrecht Scale for Evaluation of Rehabilitation, Mini-Mental State Examination, Barthel index, and a global rating scale anchor on recovery. Hypothesis testing was used to determine construct validity and responsiveness. For interpretability, minimal important change and floor and ceiling effects were determined.

RESULTS

The mean age of participants (n = 211) was 77 (SD 10.4). Their mean length of stay was 38.6 days (SD 26.3), and 81% returned home. The Utrecht Scale for Evaluation of Rehabilitation showed adequate construct validity, as all three hypotheses were confirmed for both scales. The Utrecht Scale for Evaluation of Rehabilitation-physical function scale showed adequate responsiveness, with all five hypotheses confirmed. The mean change for physical function (scale range 0-70) was 15.5 points (SD 17.1). The minimal important change for Utrecht Scale for Evaluation of Rehabilitation-physical function was 14.5 points difference for improvement. This scale showed no floor (2%) and ceiling effects (14%) at admission and discharge.

CONCLUSIONS

The Utrecht Scale for Evaluation of Rehabilitation showed to be effective for evaluating physical functioning during geriatric rehabilitation as well as screening cognitive functioning. In total, 14.5 points difference has been established as a minimal important change for physical functioning.

A comparison of stimulus fading and stimulus shaping on perceptual category learning

Errorless learning strategies such as stimulus fading and stimulus shaping are commonly used to teach complex skills like categorisation and concept formation. Despite widespread use, very few studies have explored the comparative effectiveness of these procedures in well-controlled analyses. The vast majority of existing studies have been undertaken with clinical populations and have involved small numbers of participants (e.g., Single-case designs). The present study sought to compare stimulus fading, stimulus shaping, and trial-and-error learning in a perceptual categorisation task. In Experiment 1, we found robust benefits of stimulus shaping when compared to stimulus fading or trial-and-error learning on measures of initial acquisition of discrimination and one measure of stimulus generalisation. These findings were replicated in a second experiment in which the dimension of fading/shaping was changed from a modification of the comparison stimuli (S-) to a modification of the target stimulus (S +). We discuss the implications of our findings for the selection of errorless learning strategies in clinical settings.

A scoping review of the application of motor learning principles to optimize myoelectric prosthetic hand control

Although prosthetic hand rejection rates remain high, evidence suggests that effective training plays a major role in device acceptance. Receiving training early in the rehabilitation process also enhances functional prosthetic use, decreases the likelihood of developing an overreliance on the intact limb, and reduces amputation-related pain. Despite these obvious benefits, there is a current lack of evidence regarding the most effective training techniques to facilitate myoelectric prosthetic hand control, and it remains unknown whether training is effective in facilitating the acquisition and transfer of prosthetic skill. In this scoping review, we introduced and summarized key motor learning principles related to attentional focus, implicit motor learning, training eye-hand coordination, practice variability, motor imagery, and action observation, and virtual training and biofeedback. We then reviewed the existing literature that has applied these principles for training prosthetic hand control before outlining future avenues for further research. The importance of optimizing early and appropriate training cannot be overlooked. While the intuition and experience of clinicians holds enormous value, evidence-based guidelines based on well-established motor learning principles will also be crucial for training effective prosthetic hand control. While it is clear that more research is needed to form the basis of such guidelines, it is hoped that this review highlights the potential avenues for this work.

Gameful Learning for a More Sustainable World

Municipal waste sorting is an important but neglected topic within sustainability-oriented Information Systems research. Most waste management systems depend on the quality of their citizens pre-sorting but lack teaching resources. Thus, it is important to raise awareness and knowledge on correct waste sorting to strengthen current efforts. Having shown promising results in raising learning outcomes and motivation in domains like health and economics, gamification is an auspicious approach to address this problem. The paper explores the effectiveness of gameful design on learning outcomes of waste sorting knowledge with a mobile game app that implements two different learning strategies: repetition and elaboration. In a laboratory experiment, the overall learning outcome of participants who trained with the game was compared to that of participants who trained with standard analogue non-game materials. Furthermore, the effects of two additional, learning-enhancing design elements – repetition and look-up – were analyzed. Learning outcome in terms of long-term retention and knowledge transfer were evaluated through three different testing measures two weeks after the training: in-game, through a multiple-choice test and real-life sorting. The results show that the game significantly enhanced the learning outcome of waste sorting knowledge for all measures, which is particularly remarkable for the real-life measure, as similar studies were not successful with regard to knowledge transfer to real life. Furthermore, look-up is found to be a promising game design element that is not yet established in IS literature and therefore should be considered more thoroughly in future research and practical implementations alike.

Evaluation of the feasibility of an error-minimized approach to powered wheelchair skills training using shared control

BACKGROUND

Powered wheelchairs promote participation for people with mobility limitations. For older adults with cognitive impairment, existing training methods may not address learning needs, leading to difficulty with powered wheelchair skills. Error-minimized training, facilitated by shared control technology, may provide learning opportunities more suited to this population.

OBJECTIVE

The objective of this study was to evaluate the feasibility of an error-minimized approach to powered wheelchair skills training using shared control in residential care. Feasibility indicators were hypothesized a priori to be feasible for use in a definitive RCT.

METHODS

A 2 × 2 factorial RCT compared an error-minimized powered wheelchair skills training program (Co-pilot) to a control intervention at two doses (6 sessions vs. 12 sessions). Data were collected on the feasibility of study processes (e.g., recruitment), resources (e.g., participant time), management (e.g., technology reliability), and training outcomes (e.g., adverse events, clinical outcomes).

RESULTS

Twenty-five older adults with cognitive impairment participated in the study. Technical issues were encountered in 14.5% of training sessions. Participants receiving 6 sessions of training adhered better to the treatment than those receiving 12 sessions. All participants learned the skills required for PWC use with minor errors, regardless of the training method or dose. Co-pilot participants and trainers reported feelings of safety and training benefits with the use of shared control technology.

CONCLUSIONS

Individuals with mild to moderate cognitive impairment are able to learn the skills required to drive a powered wheelchair in as few as six training sessions. Further evaluation of the Co-pilot training program is required.IMPLICATIONS FOR REHABILITATIONShared control teleoperation technology may be used to augment learning in older adults with cognitive impairments.Evaluation of the feasibility of use of novel rehabilitation technologies is critical prior to engaging in large-scale clinical research.Individuals with cognitive impairment are able to learn the required skills for operation of a powered wheelchair.

Feasibility RCT protocol evaluating a powered-wheelchair training program for older adults

Background.

Powered-wheelchair use improves participation for people with mobility limitations; however, many individuals do not receive powered-wheelchair skills training that meets their learning needs.

Purpose.

The aim of this work is to evaluate the feasibility of a powered-wheelchair training program for older adults with cognitive impairment, using errorless learning strategies facilitated by shared control technology.

Method.

A feasibility 2 × 2 factorial randomized controlled trial will recruit 32 older adults in residential care with mild to moderate cognitive impairment who are new powered-wheelchair use. The intervention consists of six or 12 training sessions, facilitated by shared control technology, using errorless learning techniques. Control participants will receive six or 12 training sessions using trial-and-error methods. Feasibility and clinical outcomes data (primary outcome: powered-wheelchair skills) will be collected.

Implications.

Errorless learning facilitated by shared control technology may be an alternative to meet the powered-wheelchair learning needs of older adults with cognitive impairments.

OPTIMAL practice conditions enhance the benefits of gradually increasing error opportunities on retention of a stepping sequence task

INTRODUCTION

Physical therapists should implement practice conditions that promote motor skill learning after neurological injury. Errorful and errorless practice conditions are effective for different populations and tasks. Errorful learning provides opportunities for learners to make task-relevant choices. Enhancing learner autonomy through choice opportunities is a key component of the Optimizing Performance through Intrinsic Motivation and Attention for Learning (OPTIMAL) theory of motor learning. The objective of this study was to evaluate the interaction between error opportunity frequency and OPTIMAL (autonomy-supportive) practice conditions during stepping sequence acquisition in a virtual environment.

METHODS

Forty healthy young adults were randomized to autonomy-supportive or autonomy-controlling practice conditions, which differed in instructional language, focus of attention (external vs internal) and positive versus negative nature of verbal and visual feedback. All participants practiced 40 trials of 4, six-step stepping sequences in a random order. Each of the 4 sequences offered different amounts of choice opportunities about the next step via visual cue presentation (4 choices; 1 choice; gradually increasing [1-2-3-4] choices, and gradually decreasing [4-3-2-1] choices). Motivation and engagement were measured by the Intrinsic Motivation Inventory (IMI) and the User Engagement Scale (UES). Participants returned 1-3 days later for retention tests, where learning was measured by time to complete each sequence. No choice cues were offered on retention.

RESULTS

Participants in the autonomy-supportive group outperformed the autonomy-controlling group at retention on all sequences (mean difference 2.88s, p < .005, t[6835] = 3.42). Participants in both groups had the most difficulty acquiring the decreasing choice (4-3-2-1) sequence (p < .001, t[6835] = -4.26) and performed most poorly on the errorful (4 choice) sequence (p < .034, t[6835] = 2.65) at retention. Participants in the autonomy-supportive group performed best at retention on the increasing choice (1-2-3-4) sequence (p < .033, t[6835] = -2.7). Participants in both groups who reported greater attention to the task on the UES Average Focused Attention subscale during acquisition had poorer retention performance, particularly for the decreasing choice (4-3-2-1) sequence (p < .005, t(6835) = 3.39). Participants in the autonomy-supportive group reported significantly higher overall motivation (p = .007, t(38) = 0.728, d = 0.248) on the IMI as compared to the autonomy-controlling group.

CONCLUSION

Individual benefits of errorless learning and autonomy-supportive practice conditions, with an interaction effect for practice that begins errorless but adds increasing error opportunities over time, suggest that participants relied on implicit learning strategies for this full body task and that feedback about successes minimized errors and reduced their potential information-processing benefits. Subsequent work will continue to examine how assigning a positive versus a negative quality to error provision influences the benefits of errorful learning in a variety of tasks.

A Meta-Analysis Suggests Different Neural Correlates for Implicit and Explicit Learning

A meta-analysis of non-human primates performing three different tasks (Object-Match, Category-Match, and Category-Saccade associations) revealed signatures of explicit and implicit learning. Performance improved equally following correct and error trials in the Match (explicit) tasks, but it improved more after correct trials in the Saccade (implicit) task, a signature of explicit versus implicit learning. Likewise, error-related negativity, a marker for error processing, was greater in the Match (explicit) tasks. All tasks showed an increase in alpha/beta (10-30 Hz) synchrony after correct choices. However, only the implicit task showed an increase in theta (3-7 Hz) synchrony after correct choices that decreased with learning. In contrast, in the explicit tasks, alpha/beta synchrony increased with learning and decreased thereafter. Our results suggest that explicit versus implicit learning engages different neural mechanisms that rely on different patterns of oscillatory synchrony.

Efficient Vocational Skills Training for People with Cognitive Disabilities: An Exploratory Study Comparing Computer-Assisted Instruction to One-on-One Tutoring

BACKGROUND

This study compared the effectiveness of computer-assisted instruction to that of one-on-one tutoring for teaching people with mild and moderate cognitive disabilities when both training methods are designed to take account of the specific mental deficits most commonly found in cognitive disability populations.

METHOD

Fifteen participants (age 22-71) received either computer-assisted instruction or one-on-one tutoring in three content domains that were of functional and daily relevance to them: behavioural limits, rights and responsibilities (two modules) and alphabetical sorting. Learning was assessed by means of a series of pretests and four learning cycle post-tests. Both instructional conditions maintained time-on-task and teaching material equivalence, and both incorporated a set of best-practices and empirically supported teaching techniques designed to address attentional deficits, stimulus processing inefficiencies and cognitive load limitations.

RESULTS

Strong evidence of learning was found in both instructional method conditions. Moreover, in all content domains the two methods yielded approximately equivalent rates of learning and learning attainment.

CONCLUSIONS

These findings offer tentative evidence that a repetitive, computer-assisted training program can produce learning outcomes in people with mild and moderate cognitive disabilities that are comparable to those achieved by high-quality one-on-one tutoring.

Facilitating the use of implicit memory and learning in the physical therapy management of individuals with Alzheimer disease: a case series

BACKGROUND AND PURPOSE

Physical rehabilitation of individuals with Alzheimer disease (AD) is often complicated by impairments in explicit memory and learning. Rehabilitation strategies that facilitate the use of the preserved implicit memory system may be effective in treating patients with AD. The purpose of this case series is to describe the application of these strategies, including high-repetition practice, errorless learning (EL), and spaced retrieval, to the physical therapy management of individuals with moderate AD.

CASE DESCRIPTION

Three women aged 89 to 95 years with moderate AD who resided in an assisted living facility participated in physical therapy to address their mobility limitations.

INTERVENTION

Twelve physical therapy sessions were scheduled over a period of 4 weeks. Interventions were individually designed to address the mobility needs of each patient, and rehabilitation strategies based on implicit learning principles were integrated into the interventions.

OUTCOMES

All patients participated in at least 10 of the 12 physical therapy sessions. Improvements in performance of objective measures of balance were observed in all patients, although only 1 patient's balance score exceeded the minimal detectable change. No significant clinical change was observed in any patients on the Timed Up and Go Test or self-selected gait speed.

DISCUSSION

Principles of implicit learning were integrated into the interventions for these patients with moderate AD. However, the feasibility of applying the EL paradigm was limited. Further research on the effectiveness of EL, spaced retrieval, and other rehabilitation strategies that facilitate implicit learning of mobility skills in patients with AD is needed to promote optimal physical therapy outcomes in this patient population.

Effects of error experience when learning to simulate hypernasality

PURPOSE

The purpose of this study was to evaluate the effects of error experience on the acquisition of hypernasal speech.

METHOD

Twenty-eight healthy participants were asked to simulate hypernasality in either an errorless learning condition (in which the possibility for errors was limited) or an errorful learning condition (in which the possibility for errors was not limited). The nasality level of the participants' speech was measured with a nasometer and reflected by nasalance scores (in percentages). Errorless learners practiced producing hypernasal speech with a threshold nasalance score of 10% at the beginning, gradually increasing to a threshold of 50% at the end. The same set of threshold targets were presented to errorful learners but in a reversed order. Errors were defined by the proportion of speech with a nasalance score below the threshold. A retention test and a transfer test were administered.

RESULTS

Relative to errorful learners, errorless learners displayed fewer errors and a higher mean nasalance score during acquisition. Furthermore, errorless learners outperformed errorful learners in both retention and transfer tests.

CONCLUSION

The results suggest that errorless learning is more effective than errorful learning in acquiring a novel speech motor task that involves manipulation of the nasality level of speech.

Evaluation of a computer-assisted errorless learning-based memory training program for patients with early Alzheimer's disease in Hong Kong: a pilot study

BACKGROUND

Improving the situation in older adults with cognitive decline and evidence of cognitive rehabilitation is considered crucial in long-term care of the elderly. The objective of this study was to implement a computerized errorless learning-based memory training program (CELP) for persons with early Alzheimer's disease, and to compare the training outcomes of a CELP group with those of a therapist-led errorless learning program (TELP) group and a waiting-list control group.

METHODS

A randomized controlled trial with a single-blind research design was used in the study. Chinese patients with early Alzheimer's disease screened by the Clinical Dementia Rating (score of 1) were recruited. The subjects were randomly assigned to CELP (n = 6), TELP (n = 6), and waiting-list control (n = 7) groups. Evaluation of subjects before and after testing, and at three-month follow-up was achieved using primary outcomes on the Chinese Mini-Mental State Examination, Chinese Dementia Rating Scale, Hong Kong List Learning Test, and the Brief Assessment of Prospective Memory-Short Form. Secondary outcomes were the Modified Barthel Index, Hong Kong Lawton Instrumental Activities of Daily Living Scale, and Geriatric Depression Scale-Short Form. The data were analyzed using Friedman's test for time effect and the Kruskal-Wallis test for treatment effect.

RESULTS

Positive treatment effects on cognition were found in two errorless learning-based memory groups (ie, computer-assisted and therapist-led). Remarkable changes were shown in cognitive function for subjects receiving CELP and emotional/daily functions in those receiving TELP.

CONCLUSION

Positive changes in the cognitive function of Chinese patients with early Alzheimer's disease were initially found after errorless training through CELP. Further enhancement of the training program is recommended.

The DRESS trial: a feasibility randomized controlled trial of a neuropsychological approach to dressing therapy for stroke inpatients

OBJECTIVE

To investigate two approaches to treating patients with persistent dressing problems and cognitive difficulties following stroke.

DESIGN

Pilot randomized controlled trial.

SETTING

Inpatient stroke rehabilitation service.

SUBJECTS

Seventy consecutive stroke patients with persistent dressing problems and accompanying cognitive difficulties at two weeks after their stroke.

INTERVENTIONS

Patients were randomly allocated to six weeks of either a systematic neuropsychological approach, based on analysis of dressing problems and further cognitive testing, or to the control group who received conventional (functional) dressing practice. Both groups received treatment three times a week in accordance with two separately prepared manuals.

MAIN MEASURES

Nottingham Stroke Dressing Assessment (NSDA), Line Cancellation, 10-hole peg transfer test, Object Decision, Gesture Imitation. Patients were assessed at six weeks after randomization by an independent assessor masked to group allocation.

RESULTS

Both neuropsychological and functional groups improved performance on the NSDA over the treatment period (31% and 22%, respectively) but there was no significant difference between groups at six weeks. However, the neuropsychological group showed a significantly greater improvement on a line cancellation test of visual neglect (t(62) = 2.1, P < 0.05) and a planned subanalysis for those with right hemisphere damage showed a trend towards better dressing outcome (P = 0.07, one-tailed).

CONCLUSIONS

Results demonstrate the potential benefits of a systematic neuropsychological approach to dressing therapy, particularly for patients with right hemisphere damage. This study suggests the need for a phase III study evaluating the efficacy of a systematic neuropsychological approach in treating dressing difficulties, targeting patients with right hemisphere stroke and visuospatial impairments.