Applying explicit and implicit learning models during early gait rehabilitation post stroke: a feasibility trial

This may take forever to infiltrate stroke rehab. I can't ever see our therapists getting away from telling us exactly what to do.
http://www.physiotherapyuk.org.uk/presentation/applying-explicit-and-implicit-learning-models-during-early-gait-rehabilitation-post

Presenter(s): 

Dr Louise Johnson

Abstract: 

Relevance: Motor learning can be either explicit or implicit. Explicit learning is conscious and cognitive, occurring with task specific knowledge. Implicit learning is sub-conscious and unintentional, occurring in the absence of consciously accessible knowledge. Sports science and psychology research shows the benefits of an implicit approach, particularly for retention of motor skills1. Research comparing explicit and implicit learning within stroke rehabilitation is limited. Stroke rehabilitation therapists tend to use an explicit approach; giving frequent, internally-focussed instructions and feedback during motor task practice2. Current practice is therefore at odds with evidence from healthy populations. It is not known whether a more implicit approach to learning would be favourable for the retention of motor skills in people with stroke.
Purpose: Following definition of implicit and explicit learning, guidelines were developed for clinical application. The purpose of this study was to test the ability of physiotherapists to apply the guidelines within an acute stroke setting.
Methods: Double blind feasibility trial using a randomised matched pairs design. Patients were matched for age, baseline function (Berg Balance Score) and presence or absence of an attentional deficit. They received three days of early gait training using either an explicit or implicit approach. The explicit approach used frequent instructions/feedback and an internal focus of attention; the implicit approach reduced the quantity of instructions/feedback, and promoted an external focus of attention. Treatment sessions were digitally recorded, and later analysed using a validated matrix4. Patients and therapists were interviewed post-intervention to gain insight into their perceptions of the two approaches.
Analysis: Analysis identified episodes of instruction and feedback, and categorised them according to their focus of attention. Compliance with the intervention guidelines was achieved if patients in the implicit group received fewer statements of instruction/feedback and a higher proportion of internally focussed statements, when compared to those in the explicit learning group. Comparison was made between groups using a liner regression model. Interviews were transcribed verbatim and thematically analysed.
Results: 21 patients and 3 therapists took part. There were significant differences between groups in terms of the quantity of statements (p< 0.01); and their focus of attention (p< 0.01). Those in the implicit group also had significantly more periods of silence, allowing practice without concurrent verbal input. Interview data found both approaches to be acceptable to patients and therapists, however therapists reported particular challenges with creating an external focus of attention.
Conclusions: It is feasible for therapists to adopt a more implicit approach. Despite this, therapists found the promotion of an external focus of attention (implicit group) challenging. It is recommended that a treatment manual is developed before commencing a Phase II trial.
Impact and Implications: The findings from this phase will be used to design a clinically grounded Phase II Pilot study, which will compare implicit and explicit learning paradigms post stroke. Given the strength of evidence in healthy populations to support the use of implicit strategies for learning motor skills, the findings could have important implications for the delivery of rehabilitation interventions for people with stroke.