Read time: 10 min
Think back to the material you covered in PT school. Let’s go specifically to a class we all loved and thrived in…neuroanatomy. You know, the one with all the colorful tracks and brain regions that sound like Harry Potter characters. Now if you would please pull out a sheet of paper and kindly draw all the tracks of the spinal cord, add in all the neuron synapse locations, and label each region of the brain with the correct spelling. This shouldn’t be an issue because you learned it in school and passed all the exams. Right? Maybe that was too long ago, and I am being unreasonable.
Instead, take the most recent journal article you read and jot down all the specific methods and outcomes in enough detail to replicate it. Well, how about a summary equal to that of an abstract? Hm, well this is depressing? We knew the material for some duration of time did we not? Here’s the kicker. The same phenomenon of poor retention of information applies to a very important group of people…our patients, which is why it’s so important that we as physical therapists strive for learning rather than only performing.
Learning refers to the relatively permanent changes in behavior or knowledge that support long-term retention and transfer. Performance refers to the temporary fluctuations in behavior or knowledge that can be observed and measured during or immediately after the acquisition process. Basically, performance is the ability to ace a test after cramming for 2 days, while learning is the ability to retain the information 3 months later when you need it for treating your patient. With respect to treatment, performance is your patient conducting a deadlift correctly immediately after you tell them to, while learning is the ability to perform the same correct movement two months later when rearranging heavy boxes in their garage. The distinction is vital for both cognitive and motor skill acquisition and retention. It applies to the education you provide patients and the motor patterns you are attempting to help them develop.
Let’s apply a few principles that can be used in the clinic to improve our ability to induce change for both short-term (e.g. outcome measure and pain scores) and long-term (e.g. future participation in community activities and avoidance of medication) outcomes. The first is overlearning. Overlearning is practicing a task despite having already achieved “mastery.” The problem with the perception of mastery is it is only being measured in the immediate term (i.e. performance). How many of you grew up playing an instrument? Can you still “master” the pieces you could play with ease as a child? Probably not. However, if we continued to practice a piece of music which we “mastered” repeatedly, the likelihood we can retain the level of performance over time improves. How many hours did you ride a bike after you learned how, and when was the last time you jumped on one and performed well?
Now let’s shift to cognitive performance and memory. When studying for an exam, we hit a point of perceived saturation where we believe we have mastered the material and can recite all the information at will. How long will this retention last? This is where the principle of overlearning comes into play. Overlearning aids in retention (including more complex verbal materials) and accelerates the rate of relearning (e.g. the amount of time required to learn the material again after some delay).
As demonstrated with riding a bike, overlearning also benefits the learning of motor skills. In fact, learning occurs even after fatigue prevents any further gains in performance during acquisition. This is why it is key to distinguish your patient’s improvement in performance vs. the amount of learning that has occurred. Many of the assessments we perform, no matter how comprehensive they are or how many times they have been validated, still only assess performance.
So how do we best promote learning? Do we keep overlearning until the patient cries uncle? What is the most effective method of overlearning and teaching patients? This brings us to a phenomenon known as the spacing effect. The spacing effect refers to distributed or…well.. ‘spaced’ practice. An abundance of literature over multiple decades has enlightened us that distributed practice is superior to massed practice (many sessions close together) for learning. Now, you may be asking, if this is well known and accepted in the literature, why isn’t this common practice? While we could jump into theory-induced blindness and other biases impairing adoption of evidence, I’m, going to stick with a rather simple reason: spacing impairs performance.
Massing practice promotes rapid performance gains during training as it allows for immediate feedback and frequent repetition of the same task. Distributing practice won’t yield the same level of short-term improvement due to a lower volume of practice, however it does facilitate long-term retention of that skill. In addition to fostering better retention of simple materials, spacing also improves the learning of more complex tasks (e.g. squatting and deadlifting) and higher-level concepts (e.g. pain neuroscience education). For motor and verbal, simple and complex, spacing improves long-term learning and skill retention while massed practice improves short-term performance.
So, the question is, which is more important in your plan of care? It depends. Do you need rapid patient buy in or a quick change in behavior/understanding (e.g. high irritability patients)? Then you may want to start with massed sessions. Do you need to completely unwind a patient’s perception of pain, improve their dietary habits, induce muscle hypertrophy, and develop new motor patterns after a chronic injury? You will likely experience more success with spaced practice. Well how about both? In a perfect world, perhaps.
Unfortunately, there are a couple major barriers for our patients:
1) The ability to tolerate and recover from massed sessions, especially patients with moderate and high irritability and/or patients with poor dietary and sleep habits who are also deconditioned.
2) Cost. Even if you demonstrate your value and a patient seeks the necessary care, they may lack the recourses for a high volume of care. Spacing out the sessions can often lessen the financial burden while getting the best long-term outcome. The key is to ensure the spacing isn’t too large preventing carry-over of information and performance (even with the effects of latent learning). Additionally, compliance with lifestyle changes (especially diet and exercise) become even more if the sessions are spaced.
So, if you are using distributed practice, your patients are adhering to the visits, and showing up for therapy, how do you know if you are successfully facilitating learning? Simple, you test it. While we all dreaded tests growing up, they have been implemented and used for a reason. Yes, testing has its limitations and can be affected by individual variables (e.g. test taking skills, anxiety, mental stamina, etc.), but for the most part, testing allows us to assess what is stored in memory.
A benefit of testing that is frequently overlooked serves as a vehicle that modifies what is stored in memory. Movements that must be learned that are self-produced are typically better learned than those that are externally guided or simply observed. Testing a patient’s memory for verbal information (patient education) or having participants generate the information themselves enhances long-term retention of that material compared to reading or hearing it over and over, even in cases when corrective feedback is not provided.
This does not mean repeating education is useless. It just means that it is an incomplete part of the process. Generating items from semantic memory (successfully retrieved information) is better for learning than simply reading them. There is a caveat. Generated items will always be associated with worse acquisition performance than read items if a test was given immediately after each item.
Similar to unsuccessful retrieval attempts in testing-effect studies, unsuccessful generation attempts prevent exposure to the material that will be tested later. Despite this short-term performance hindrance, generation still enhances long-term learning. Failed retrieval attempts prior to encoding were found to enhance learning. Attempting to predict the to-be-learned response activates the broad semantic network associated with the cue word. The production of errors during acquisition can, under some circumstances, boost long-term retention.
In summation, frequently test your patients’ understanding and ability to perform motor tasks in the clinic and ensure the patient (and yourself) that benefits are obtained despite the lack of improved short-term performance.
Many strategies that we’ve discussed can be implemented to assist with learning: distributed and variable practice, testing (retrieval and generation effects), cueing, and reloading. Additionally, understanding principles such as judgements of learning (prospective and retrospective), stability bias, theory of disuse, and schema theory, can help you when developing a plan of care and choosing interventions.
The key is to be purposeful with your prescription of physical therapy. Soderstrom et al. published a comprehensive review on learning vs. performance and covers these strategies and principles. It discusses how they can often impair one another (e.g. distributed and variable practice worsens immediate performance but improves long term skill development and thus future performance). We encourage you to review the paper and apply these concepts not only to your patient care, but to your own personal and professional development as well.
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