Athletic Training and Sports Health Care

Pearls of Practice 

The Power of Language: Using the OPTIMAL Theory to Coach Your Patients to Recovery

David A. Sherman, DPT, ATC; Sarah G. Sherman, DPT, ATC, SCS; Grant E. Norte, PhD, ATC, CSCS

Abstract

A joint injury constitutes a change in tissue integrity, sensorimotor integration, and neuromuscular control, each of which alters motor performance. Following injury, patients are charged with relearning motor skills during a period of gross motor impairment and disability through the guidance of rehabilitation professionals. It is our contention that rehabilitation, which necessitates predominantly preplanned isolated motor skills in a predictable, controlled environment, may not optimize motor relearning. Although largely applied to healthy performance paradigms, advances in the field of motor learning may offer simple solutions (eg, changes in clinician language and cueing1,2) to the complex challenges faced in rehabilitation. The Optimizing Performance Through Intrinsic Motivation and Attention for Learning (OPTIMAL) theory offers a straightforward and tested framework.1 The purpose of this column is to summarize the OPTIMAL theory of motor learning, discuss implications for neuromuscular recovery during early rehabilitative care, and provide clinical examples of application in the archi-type of the early postoperative phase of rehabilitation.

We encourage the reader to consider a subacute patient case or the following case example throughout. An 18-year-old male volleyball player had left anterior cruciate ligament reconstruction with patellar tendon autograft 2 weeks previously. He had no prior injury history. Postoperative quadriceps atrophy and apprehension to muscle contraction were noted on examination. Short-term goals include recovery of full passive knee flexion range of motion and improvement of active terminal knee extension with quadriceps activation. Long-term goals include return to campus ambulation and school and team activities without limitation (Division I volleyball).

The majority of studies in the field of motor learning demonstrate the importance of an individual learner's mindset, motivation, self-efficacy, and attention in motor performance (eg, reaction time, movement efficiency, target accuracy, and muscular power) and learning (eg, new motor pattern development).1,3 Through their work investigating the OPTIMAL theory of motor learning, Wulf and Lewthwaite1 proposed that three major elements (enhanced expectancies, patient autonomy, and external focus of attention) can be manipulated by clinicians to enrich motor performance and learning. As injured athletes, our patients may benefit from adaptation of these findings while relearning motor skills in rehabilitation.2 The abundance and promise of the existing evidence suggest that early adoption of these principles into clinical practice is warranted. The proposed changes can be achieved through small adjustments in the way practitioners provide feedback to their patients regardless of practice setting or specific exercise goal.

Similar to healthy individuals, our patients prefer to hear positive information about themselves and their progress. Enhanced expectancies can be adopted by clinicians through positive framing of feedback and beliefs about recovery and performance. Positive feedback plays an important role in all learning processes because the belief that one is doing well instills confidence in being able to perform well in the future.1,3 In brief, this comes by way of verbal feedback and encouragement, patient perception of ability, and progressive success during task practice. Table 1 presents applied examples. These examples of enhanced expectancies and the principle of autonomy are considered critical components to motivation in motor learning.…

A joint injury constitutes a change in tissue integrity, sensorimotor integration, and neuromuscular control, each of which alters motor performance. Following injury, patients are charged with relearning motor skills during a period of gross motor impairment and disability through the guidance of rehabilitation professionals. It is our contention that rehabilitation, which necessitates predominantly preplanned isolated motor skills in a predictable, controlled environment, may not optimize motor relearning. Although largely applied to healthy performance paradigms, advances in the field of motor learning may offer simple solutions (eg, changes in clinician language and cueing1,2) to the complex challenges faced in rehabilitation. The Optimizing Performance Through Intrinsic Motivation and Attention for Learning (OPTIMAL) theory offers a straightforward and tested framework.1 The purpose of this column is to summarize the OPTIMAL theory of motor learning, discuss implications for neuromuscular recovery during early rehabilitative care, and provide clinical examples of application in the archi-type of the early postoperative phase of rehabilitation.

We encourage the reader to consider a subacute patient case or the following case example throughout. An 18-year-old male volleyball player had left anterior cruciate ligament reconstruction with patellar tendon autograft 2 weeks previously. He had no prior injury history. Postoperative quadriceps atrophy and apprehension to muscle contraction were noted on examination. Short-term goals include recovery of full passive knee flexion range of motion and improvement of active terminal knee extension with quadriceps activation. Long-term goals include return to campus ambulation and school and team activities without limitation (Division I volleyball).

The majority of studies in the field of motor learning demonstrate the importance of an individual learner's mindset, motivation, self-efficacy, and attention in motor performance (eg, reaction time, movement efficiency, target accuracy, and muscular power) and learning (eg, new motor pattern development).1,3 Through their work investigating the OPTIMAL theory of motor learning, Wulf and Lewthwaite1 proposed that three major elements (enhanced expectancies, patient autonomy, and external focus of attention) can be manipulated by clinicians to enrich motor performance and learning. As injured athletes, our patients may benefit from adaptation of these findings while relearning motor skills in rehabilitation.2 The abundance and promise of the existing evidence suggest that early adoption of these principles into clinical practice is warranted. The proposed changes can be achieved through small adjustments in the way practitioners provide feedback to their patients regardless of practice setting or specific exercise goal.

Similar to healthy individuals, our patients prefer to hear positive information about themselves and their progress. Enhanced expectancies can be adopted by clinicians through positive framing of feedback and beliefs about recovery and performance. Positive feedback plays an important role in all learning processes because the belief that one is doing well instills confidence in being able to perform well in the future.1,3 In brief, this comes by way of verbal feedback and encouragement, patient perception of ability, and progressive success during task practice. Table 1 presents applied examples. These examples of enhanced expectancies and the principle of autonomy are considered critical components to motivation in motor learning.

Examples of Clinical Guidance to Promote Enhanced Expectancies

Table 1:

Examples of Clinical Guidance to Promote Enhanced Expectancies

The constructs of autonomy and self-efficacy are known to improve movement efficiency and motor performance.1,3 Despite this, in most rehabilitation settings, clinicians determine the plan of care and the details of each rehabilitation session (especially in the early postoperative period) without input from the patient. Use of controlling language instruction and negative verbal feedback can further limit learning and increase patient frustration and dependence. Simply, “self-controlled learning” and using language that empowers the patient, such as emphasizing overall progress rather than the status of individuals' goals, can be used to encourage autonomy. Table 2 presents applied examples. Allowing patients to make choices that are appropriate to the plan of care yet incidental to the goal of the exercise, such as choice of physio ball color or resistance type (eg, elastic band vs free weight), and providing positive feedback on better-than-average repetitions may improve motor relearning similarly to healthy individuals.1–3

Examples of Clinical Guidance to Promote Learner Autonomy

Table 2:

Examples of Clinical Guidance to Promote Learner Autonomy

External focus of attention has recently been applied in several studies in motor performance,1 injury prevention, and rehabilitation.2 External focus of attention, which is focused on the result of movement as opposed to the movement itself, is repeatedly credited with improved movement efficiency, mechanics, and performance.1,4 According to the constrained action hypothesis,3,4 internal focus of attention disrupts automatic control of movement by causing individuals to constrain movement by locking degrees of freedom, whereas external focus of attention promotes automaticity of movement through unconscious and reflective control process. In other words, from a neurophysiologic perspective, external focus of attention requires fewer attentional resources (better neural efficiency) and leads to more synchronous movement and implicit motor re-learning. Table 3 presents applied examples.

Examples of Verbal Cueing to Promote External Focus of Attention

Table 3:

Examples of Verbal Cueing to Promote External Focus of Attention

Patients are challenged with motor relearning during a time of sensorimotor impairments that disrupt function and motor learning. Chronic sensorimotor system impairments after joint injury5 demonstrate that the current state of rehabilitation fails to address underlying neural impairments. Despite literature gaps within the early postoperative population, the concepts of the OPTIMAL theory appear to provide support for early postoperative rehabilitation by improving motor relearning and performance. Simple manipulation of the patient's attention, autonomy, and expectations will allow intuitive interaction with the task (exercise) and environment, which may facilitate implicit motor learning. Clinicians should adopt these principles early in accordance with patient needs and goals. These small adjustments in language and exercise set-up can safely be applied at all stages of rehabilitation. Together, optimization of enhanced expectancies, patient autonomy, and external focus of attention within the early phases of rehabilitation may enrich the motor relearning experience of patients.

References

  1. Wulf G, Lewthwaite R. Optimizing performance through intrinsic motivation and attention for learning: the OPTIMAL theory of motor learning. Psychon Bull Rev. 2016;23(5):1382–1414. doi:10.3758/s13423-015-0999-9 [CrossRef]
  2. Gokeler A, Neuhaus D, Benjaminse A, Grooms DR, Baumeister J. Principles of motor learning to support neuroplasticity after ACL injury: implications for optimizing performance and reducing risk of second ACL injury. Sports Med. 2019;49(6):853–865. doi:10.1007/s40279-019-01058-0 [CrossRef]
  3. Lewthwaite R, Wulf G. Optimizing motivation and attention for motor performance and learning. Curr Opin Psychol. 2017;16:38–42. doi:10.1016/j.copsyc.2017.04.005 [CrossRef]
  4. Neumann DL. A systematic review of attentional focus strategies in weightlifting. Frontiers in Sports and Active Living. August9, 2019. doi:10.3389/fspor.2019.00007 [CrossRef]
  5. Needle AR, Lepley AS, Grooms DR. Central nervous system adaptation after ligamentous injury: a summary of theories, evidence, and clinical interpretation. Sports Med. 2017;47(7):1271–1288. doi:10.1007/s40279-016-0666-y [CrossRef]

Examples of Clinical Guidance to Promote Enhanced Expectancies

CategoryTraditional (Negative)OPTIMAL (Positive)
Performance feedbackDelivering feedback on every trial, good or bad.Delivering positive feedback on better-than-average trials.
Exercise descriptionsDescriptions of task difficulty, “This is a new exercise for you today and it is going to be challenging.”Descriptions of relative task ease, “Patients that have great _____ (like you), typically do very well on this exercise.”
Incremental challengesQuad set where success is defined as full terminal knee extension.Quad set where success is defined as progressive improvements in heel height.
Perception of ability“Those exercises were done very well.”“You are a great patient. Your recovery is going very well.”

Examples of Clinical Guidance to Promote Learner Autonomy

CategoryTraditional (Control Language) InstructionsOPTIMAL (Autonomy-Supportive) Instructions
Involvement in plan of care“This is the plan for today.”“Here are a few options. What would you like to work on today?”
Self-controlled paceClinician determined exercises, exercise order, rest periods, etc.Patient is given options of exercises, and allowed to select order, rest period, etc.
Incremental successes“This looks too easy. It's time to make this exercise harder.”“You've mastered this exercise. You can handle this progression.”

Examples of Verbal Cueing to Promote External Focus of Attention

ExerciseTraditional (Internal Focus) InstructionsOPTIMAL (External Focus) Instructions
Quad sets“Squeeze your quad as hard as you can.”“Try to ‘pop’ your heel up off the table.”
Heel slides“Slide your heel to your hip.”“Slide your sock up the table.”
Mini squat“Slowly bend your knees to lower your body, keep your feet flat and your knees behind your toes.”“Pretend that you are going to sit on a chair while holding a heavy box.”
Authors

From the Athletic Training Program, School of Exercise and Rehabilitation Sciences, University of Toledo, Toledo, Ohio.

The author has no financial or proprietary interest in the materials presented herein.

Correspondence: David A. Sherman, DPT, ATC, Athletic Training Program, School of Exercise and Rehabilitation Sciences, University of Toledo, 2801 W. Bancroft St., HH 2505H, Mail Stop 119, Toledo, OH 43606. Email: david.sherman2@rockets.utoledo.edu

10.3928/19425864-20200205-02

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