Therapie & Praxis
Motor learning with the THERA-Trainer senso
Discover how the THERA-Trainer senso and the LEARNING WHEEL model support motor learning and fall prevention in rehabilitation. Explore real-life examples, evidence-based principles, and practical insights for everyday transfer. Learn how therapy can feel both effective and engaging.
Miriam Keifert
Product Manager Clinical & Scientific, THERA-Trainer
The principles of motor learning in cognitive-motor training
Re-learning movements or even learning them for the first time in order to be able to lead as self-determined and independent a life as possible is a key element in rehabilitation. Motor learning (ML) is therefore an integral part of modern rehabilitation concepts [1,2,3]. This is because the effectiveness of interventions is determined by the extent to which they incorporate and implement the principles of ML [4]. This article explains the principles of motor learning based on cognitive-motor training using the THERA-Trainer senso. The LEARNING WHEEL is a reference model that can be used to analyse the principles of motor learning in a practical way.
Research on senso has shown that exercise for older people can be viewed as a fun and intrinsically motivating intervention to promote physical and mental activity under dual-task conditions.
The learning wheel
In neurorehabilitation, the focus is on relearning and optimising motor skills. Motor learning plays a central role in relation to the achievement of defined therapy goals. However, motor learning is challenging to implement due to a high level of complexity and lack of an application description. To solve this problem, the LEARNING WHEEL was developed as an evidence-based reference model for motor learning. It allows therapists to use participation-oriented clinical reasoning based on ICF and guidelines in order to develop tailored therapies while taking into account resources, wishes and environmental factors.
At the centre of the LEARNING WHEEL are the motor goals at the activity or participation level (referred to by the German acronym MOZArT) – the nucleus around which everything revolves. The eight most important principles of motor learning (forms of learning, learning phases, transfer, motivation, learning strategies, intensity, feedback and instruction) are arranged equally in the middle circle and do not follow any fixed hierarchy. The outer rings include the methods for implementing these principles, supported by clinical reasoning and targeted information gathering through assessments [5].
In neurorehabilitation, the focus is on relearning and optimising motor skills. Motor learning plays a central role in relation to the achievement of defined therapy goals. However, motor learning is challenging to implement due to a high level of complexity and lack of an application description. To solve this problem, the LEARNING WHEEL was developed as an evidence-based reference model for motor learning. It allows therapists to use participation-oriented clinical reasoning based on ICF and guidelines in order to develop tailored therapies while taking into account resources, wishes and environmental factors.
At the centre of the LEARNING WHEEL are the motor goals at the activity or participation level (referred to by the German acronym MOZArT) – the nucleus around which everything revolves. The eight most important principles of motor learning (forms of learning, learning phases, transfer, motivation, learning strategies, intensity, feedback and instruction) are arranged equally in the middle circle and do not follow any fixed hierarchy. The outer rings include the methods for implementing these principles, supported by clinical reasoning and targeted information gathering through assessments [5].
THERA-Trainer senso
The THERA-Trainer senso is a research-based training device used in neurorehabilitation and training for older people. It is an interactive system that offers a wide range of exercises to improve physical and cognitive skills. The focus is on promoting balance, coordination, responsiveness and cognitive functions [6].
The senso consists of a platform with built-in sensors that detect movement and touch. Users are instructed to perform various tasks via visual and auditory feedback. These tasks may include tapping moving light points, balancing on the platform, or recognising shapes and colours.
The device enables personalised therapy and training since the exercises can be adapted to individual abilities and needs. The senso is often used by therapists in clinical settings, rehabilitation centres or care homes to improve patients’ physical fitness, balance and cognitive functions, and to reduce the risk of falls.
The THERA-Trainer senso is a research-based training device used in neurorehabilitation and training for older people. It is an interactive system that offers a wide range of exercises to improve physical and cognitive skills. The focus is on promoting balance, coordination, responsiveness and cognitive functions [6].
The senso consists of a platform with built-in sensors that detect movement and touch. Users are instructed to perform various tasks via visual and auditory feedback. These tasks may include tapping moving light points, balancing on the platform, or recognising shapes and colours.
The device enables personalised therapy and training since the exercises can be adapted to individual abilities and needs. The senso is often used by therapists in clinical settings, rehabilitation centres or care homes to improve patients’ physical fitness, balance and cognitive functions, and to reduce the risk of falls.
In the case of senso training, the people exercising are not primarily focused on the balance requirements, but on solving tasks in an exergame.
The following case study shows the use of the THERA-Trainer senso in action: Ms. Müller, 72 years old, with existing gait insecurity after a hip fracture and increased fall risk, regularly used the THERA-Trainer senso for cognitive-motor training. The aim was to improve balance, coordination of step movements and responsiveness in everyday situations. Her progress was documented through targeted measurements and training history, while the therapist, Inge, based her approach on the principles of motor learning from the LEARNING WHEEL.
Forms of learning
1. Implicit (unconscious learning): asks what?
What is the task? Unconscious movement control. Requires relatively few cognitive resources;
2. Explicit (conscious learning): asks how?
How should the task be carried out? Conscious movement control. Requires more cognitive resources
1. Implicit (unconscious learning): asks what?
What is the task? Unconscious movement control. Requires relatively few cognitive resources;
2. Explicit (conscious learning): asks how?
How should the task be carried out? Conscious movement control. Requires more cognitive resources
During senso training, Ms Müller was primarily focused on the therapeutic games. In other words, she was focused on fulfilling the tasks shown on the screen (e.g. taking a step forwards at a specific time so that a flying dot lands in the middle of the target). Inge therefore focused on the principle of implicit learning (related to movement performance). She did not want Ms Müller to focus primarily on balance requirements and step movements, but on solving the tasks in the game.
Ms Müller was required to constantly shift attention back and forth between the screen (task in the game) and the balance/step requirements. The requirements are therefore very close to everyday life (this point will be developed further under the transfer of learning principle). Due to the simultaneous recall of the cognitive task (play) and the motor task (movement), Inge was able to evoke dual-task situations typical of everyday life and which caused Ms Müller difficulties, particularly in complex situations, and posed a fall risk.
Ms Müller was required to constantly shift attention back and forth between the screen (task in the game) and the balance/step requirements. The requirements are therefore very close to everyday life (this point will be developed further under the transfer of learning principle). Due to the simultaneous recall of the cognitive task (play) and the motor task (movement), Inge was able to evoke dual-task situations typical of everyday life and which caused Ms Müller difficulties, particularly in complex situations, and posed a fall risk.
he training programme uses an algorithm to automatically adjust the requirement level to the user’s performance level in real time.
Learning phases
1. Cognitive learning phase: understanding the task requires a high level of attention for movement performance;
2. Associative learning phase: less attention for movement performance, partially successful movement, fewer mistakes;
3. Autonomous learning phase: automatism, only minimal attention for movement performance, skilfully performed movement, hardly any mistakes, dual-task capacity during movement performance.
1. Cognitive learning phase: understanding the task requires a high level of attention for movement performance;
2. Associative learning phase: less attention for movement performance, partially successful movement, fewer mistakes;
3. Autonomous learning phase: automatism, only minimal attention for movement performance, skilfully performed movement, hardly any mistakes, dual-task capacity during movement performance.
Ms Müller went through all the learning phases with senso training, because this training was completely new and unfamiliar to her. In the first learning phase, the cognitive demands were particularly high for Ms Müller. At the beginning of the therapy, an additional difficulty was understanding how the exergame (i.e. the task) works and how the floor plate reacts (e.g. how long to apply pressure with the foot on the measuring plate). For Inge, it was important to consider that part of the learning effect in this early learning phase was primarily that of coping with the device and the game. A phenomenon that Inge was already familiar with from the use of other device-based therapies (e.g. robotics) [7].
After some initial difficulties, Ms Müller made good progress. During the second learning phase, Inge was able to observe that she paid less and less attention to going through the movements. She became more confident with her movements and made significantly fewer mistakes in the therapeutic games. This was also evident in the training evaluations.
The improvement in Ms. Müller’s dual-task capacity was an essential characteristic of the third (autonomous) learning phase, which is considered a sign of the automation of a movement. Ms Müller could now concentrate fully on the task on the screen during training. In the autonomous phase, it was primarily speed and precision that determined Ms Müller’s training successes (this point will be discussed in more detail under the intensity learning principle).
After some initial difficulties, Ms Müller made good progress. During the second learning phase, Inge was able to observe that she paid less and less attention to going through the movements. She became more confident with her movements and made significantly fewer mistakes in the therapeutic games. This was also evident in the training evaluations.
The improvement in Ms. Müller’s dual-task capacity was an essential characteristic of the third (autonomous) learning phase, which is considered a sign of the automation of a movement. Ms Müller could now concentrate fully on the task on the screen during training. In the autonomous phase, it was primarily speed and precision that determined Ms Müller’s training successes (this point will be discussed in more detail under the intensity learning principle).
Learning strategies
Trial+Error: Making mistakes and learning from them (consciously and unconsciously), errorless learning, part/whole practice etc., the targeted use of learning strategies promotes ML.
Trial+Error: Making mistakes and learning from them (consciously and unconsciously), errorless learning, part/whole practice etc., the targeted use of learning strategies promotes ML.
As can be seen from the previous descriptions, initial training was largely trial and error learning. Inge initially gave Ms Müller time to try things out so she could understand what senso training required of her. In the process, Ms Müller repeatedly made mistakes, which were important in order to perform the required tasks faster and in a more targeted manner over time.
As training progressed, it became increasingly a question of the timing of targeted movements (e.g. a step at the right time of the game on the front quadrant of the standing space). Movements had to be performed at precisely time X in order to come to a stop exactly on time at target location Y of the floor plate (temporal and spatial components).
In the meantime, Ms. Müller had progressed so far, and her movements were so well practised, that the main focus had shifted to errorless learning. She could solve the movements that were demanded of her, even under additional cognitive strain. She could only improve in the games and in her cognitive-motor skills if she could perform the exercises without errors.
In relation to the therapy goals, Inge sees senso training as fulfilling both the desire to improve safety when walking (part-practice) and anticipatory postural adjustments when standing (whole practice).
As training progressed, it became increasingly a question of the timing of targeted movements (e.g. a step at the right time of the game on the front quadrant of the standing space). Movements had to be performed at precisely time X in order to come to a stop exactly on time at target location Y of the floor plate (temporal and spatial components).
In the meantime, Ms. Müller had progressed so far, and her movements were so well practised, that the main focus had shifted to errorless learning. She could solve the movements that were demanded of her, even under additional cognitive strain. She could only improve in the games and in her cognitive-motor skills if she could perform the exercises without errors.
In relation to the therapy goals, Inge sees senso training as fulfilling both the desire to improve safety when walking (part-practice) and anticipatory postural adjustments when standing (whole practice).
motivation
1. Intrinsic motivation: self-motivated, promoted by autonomy, increased expectations and self-efficacy;
2. Extrinsic motivation: motivated from outside, reward-driven, influenced by the therapeutic relationship and background conditions such as family.
1. Intrinsic motivation: self-motivated, promoted by autonomy, increased expectations and self-efficacy;
2. Extrinsic motivation: motivated from outside, reward-driven, influenced by the therapeutic relationship and background conditions such as family.
In terms of motivation, Inge can see that senso training has a positive influence on Ms Müller’s exercise compliance [8]. Inge knows from professional training on evidence-based practice that the literature indicates that the motivational influence of exergames can wear off over time [9]. To prevent this, Inge regularly compiled new training programmes for Ms Müller from the portfolio of therapeutic games to ensure the necessary variety.
The senso offers a range of attractive game options that can be adapted to individual performance levels, and that can automatically adjust their level of difficulty (this point will be discussed in more detail under the intensity learning principle).
Research on senso has shown that exercise for older people can be viewed as a fun and intrinsically motivating intervention to promote physical and mental activity under dual-task conditions [10]. To be on the safe side, Inge also used an assessment that helped her evaluate the exertion and enjoyment of training with Ms Müller.
Inge regularly discussed how the training tasks relate to the real world with Ms Müller so that she could understand the purpose of the training and how she could repeat similar exercises in everyday life (this point will be discussed in more detail under the transfer of learning principle).
The senso offers a range of attractive game options that can be adapted to individual performance levels, and that can automatically adjust their level of difficulty (this point will be discussed in more detail under the intensity learning principle).
Research on senso has shown that exercise for older people can be viewed as a fun and intrinsically motivating intervention to promote physical and mental activity under dual-task conditions [10]. To be on the safe side, Inge also used an assessment that helped her evaluate the exertion and enjoyment of training with Ms Müller.
Inge regularly discussed how the training tasks relate to the real world with Ms Müller so that she could understand the purpose of the training and how she could repeat similar exercises in everyday life (this point will be discussed in more detail under the transfer of learning principle).
Instruction
1. External focus of attention (EFA): the instruction directs attention to the effect that the movement has on the environment;
2. Internal focus of attention (IFA): the instruction directs attention to one’s own body movements or body feeling.
1. External focus of attention (EFA): the instruction directs attention to the effect that the movement has on the environment;
2. Internal focus of attention (IFA): the instruction directs attention to one’s own body movements or body feeling.
The instructions in senso training primarily have an external focus of attention (EFA). The instructions that the exergames gave Ms. Müller drew her attention to the effect of her movements on how the game unfolded (e.g. taking a step when a ball is in the middle of a target).
Inge wanted Ms Müller’s attention to be focused on the effects of her movements on the environment. Inge therefore followed the constrained action theory, according to which an EFA reduces the need for conscious movement control and thus favours automatic control processes [11].
In addition, Inge gave Ms. Müller an instruction with an internal focus during training. Due to the hip fracture, Ms Müller repeatedly adopted a bent posture during the exercises. This is what Inge wanted to avoid or promote awareness in Ms Müller of her posture. Since body posture cannot be detected by the sensors in the senso, Inge was responsible for this type of instruction.
Inge wanted Ms Müller’s attention to be focused on the effects of her movements on the environment. Inge therefore followed the constrained action theory, according to which an EFA reduces the need for conscious movement control and thus favours automatic control processes [11].
In addition, Inge gave Ms. Müller an instruction with an internal focus during training. Due to the hip fracture, Ms Müller repeatedly adopted a bent posture during the exercises. This is what Inge wanted to avoid or promote awareness in Ms Müller of her posture. Since body posture cannot be detected by the sensors in the senso, Inge was responsible for this type of instruction.
Feedback
1. External feedback: feedback from an external source of information e.g. PT, device, or similar;
2. Self-feedback: Feedback that the person receives or gives to him/herself during a movement. Self-assessment. Feedback is essential for ML. Particularly the ability to provide adequate self-feedback is crucial.
1. External feedback: feedback from an external source of information e.g. PT, device, or similar;
2. Self-feedback: Feedback that the person receives or gives to him/herself during a movement. Self-assessment. Feedback is essential for ML. Particularly the ability to provide adequate self-feedback is crucial.
Ms Müller received feedback from the senso both during and after completing each training sequence. This feedback includes, among other things, the duration of the training sequence, the reaction speed, the accuracy of aim and a game score. Like the instructions, the feedback from the senso has an external focus. It is based on an objective performance assessment of the device.
Self-feedback is not directly requested by the senso. This is where Inge’s therapeutic competence comes into focus. Ms Müller’s subjective assessment was very important to Inge, which is why she had certain aspects of the training session assessed by Ms Müller herself after each unit had been completed. For example, Inge used the BORG scale to subjectively determine the feeling of exertion. This helped her to regulate the load level and training duration.
Self-feedback is not directly requested by the senso. This is where Inge’s therapeutic competence comes into focus. Ms Müller’s subjective assessment was very important to Inge, which is why she had certain aspects of the training session assessed by Ms Müller herself after each unit had been completed. For example, Inge used the BORG scale to subjectively determine the feeling of exertion. This helped her to regulate the load level and training duration.
Intensity
This is the sum of repetition, shaping, training on the challenge point [25]. Intensity is a very relevant aspect for ML. Note: Intensity is more than just the number of repetitions!
This is the sum of repetition, shaping, training on the challenge point [25]. Intensity is a very relevant aspect for ML. Note: Intensity is more than just the number of repetitions!
In the case of senso training, intensity is primarily defined by the difficulty of the task and the duration of the exercise. This then determines the number of movement repetitions. The training programme uses an algorithm to automatically adjust the requirement level in real time to Ms Müller’s performance level [12]. This was a great relief for Inge, as the measurement of reaction times and movements via the senso is extremely precise and scientifically validated.
If Ms Müller was having a good day, she could perform the exergames accurately and quickly. The level of difficulty then increased directly in the training situation. In other words, automatic shaping was carried out, giving Inge the confidence and certainty that Ms Müller was always training at her individual performance limit. So the exercises were neither too easy nor too difficult. Even if Ms Müller was not having good day, the training session did not become a demotivating experience with all the exercises suddenly becoming too difficult for her. Quite the opposite. She entered a kind of “flow state” and was fully immersed in the training, which by this stage had its own dynamism.
Shaping also had a critical advantage for Inge. She was able to use the training evaluations to precisely track how Ms Müller’s performance was progressing. For example, Inge was able to identify that Ms Müller had significant drops in performance during longer training sessions. They therefore reduced the duration of the sessions and then gradually increased them as training continued. At the same time, this finding had an important implication for everyday life. Because here, too, Ms Müller was able to describe to Inge that she would quickly become tired and unsteady during prolonged daily activities. They therefore agreed that Ms Müller would take more frequent breaks, not only during training but also in everyday life, to reduce the risk of falls.
If Ms Müller was having a good day, she could perform the exergames accurately and quickly. The level of difficulty then increased directly in the training situation. In other words, automatic shaping was carried out, giving Inge the confidence and certainty that Ms Müller was always training at her individual performance limit. So the exercises were neither too easy nor too difficult. Even if Ms Müller was not having good day, the training session did not become a demotivating experience with all the exercises suddenly becoming too difficult for her. Quite the opposite. She entered a kind of “flow state” and was fully immersed in the training, which by this stage had its own dynamism.
Shaping also had a critical advantage for Inge. She was able to use the training evaluations to precisely track how Ms Müller’s performance was progressing. For example, Inge was able to identify that Ms Müller had significant drops in performance during longer training sessions. They therefore reduced the duration of the sessions and then gradually increased them as training continued. At the same time, this finding had an important implication for everyday life. Because here, too, Ms Müller was able to describe to Inge that she would quickly become tired and unsteady during prolonged daily activities. They therefore agreed that Ms Müller would take more frequent breaks, not only during training but also in everyday life, to reduce the risk of falls.
Transfer of learning
What is meant here is the transfer of learning to the application situation (everyday life); the more the task and the environment of the therapy situation resemble the application situation, the higher the transfer tendency. Transfer is one of the key themes for successful therapy.
What is meant here is the transfer of learning to the application situation (everyday life); the more the task and the environment of the therapy situation resemble the application situation, the higher the transfer tendency. Transfer is one of the key themes for successful therapy.
Senso training is geared to the demands of daily life. Above all, dual-task situations (combination of a cognitive and a motor performance) can be trained in a “protected” context, a so-called standardised environment, in a safe and controlled manner. However, Inge was aware that capacity improvements as measured by training success in the senso do not necessarily lead to an improvement in performance in Ms Müller’s daily life [13]. Inge therefore included everyday exercises in the therapy plan in addition to senso training in order to ensure transfer of learning into the real world environment.
Outlook
Senso training formed an integral part of standing postural control therapy in the treatment of Ms Müller. Use of the LEARNING WHEEL enabled Inge to conceptualise the principles of motor learning in a meaningful way, and the frame of reference also enabled her to locate the opportunities and limitations of technology. She succeeded in creating an animating therapy environment that continued to motivate Ms Müller to maintain her commitment to and compliance with her training exercises.
The use of targeted training of cognitive-motor dual-task situations enabled Inge to offer Ms Müller some fun ways of training certain aspects of postural control. To ensure that the training tasks connected with the wider environment, Inge additionally considered the issue of transfer and did not rely blindly on spontaneous transfer effects of standing and walking. She also added specific exercise situations in everyday life to the senso training programme.
Senso training formed an integral part of standing postural control therapy in the treatment of Ms Müller. Use of the LEARNING WHEEL enabled Inge to conceptualise the principles of motor learning in a meaningful way, and the frame of reference also enabled her to locate the opportunities and limitations of technology. She succeeded in creating an animating therapy environment that continued to motivate Ms Müller to maintain her commitment to and compliance with her training exercises.
The use of targeted training of cognitive-motor dual-task situations enabled Inge to offer Ms Müller some fun ways of training certain aspects of postural control. To ensure that the training tasks connected with the wider environment, Inge additionally considered the issue of transfer and did not rely blindly on spontaneous transfer effects of standing and walking. She also added specific exercise situations in everyday life to the senso training programme.
senso
Standing & Balancing
Therapy & Practice
THERAPY 2023-III
THERAPY Magazine
Miriam Keifert
Product Manager Clinical & Scientific, THERA-Trainer
Miriam Keifert has a degree in sports science
(M.Sc.) and
works in product management
of THERA-Trainer with the
specialising in "Clinical & Scientific".
Jakob Tiebel
Health Business Consultant
Jakob Tiebel is OT and studied applied psychology with a focus on health economics. He has clinical expertise from his previous therapeutic work in neurorehabilitation. He conducts research and publishes on the theory-practice transfer in neurorehabilitation and is the owner of an agency for digital health marketing.
Martin Huber
Freelancers in outpatient physiotherapy for neurological patients
patients
Martin Huber is a physiotherapist who earned his Master of Science in Neurorehabilitation in 2007. As a therapist, he primarily treats patients with central nervous system disorders. Since 2010, he has been working freelance in outpatient physiotherapy for neurological patients. Several years ago, he published articles in renowned professional journals on postural control and task-oriented therapy, and he has been a speaker at various national physiotherapy congresses.
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- Kleynen M, Beurskens A, Olijve H, et al. Application of motor learning in neurorehabilitation: a framework for health-care professionals. Physiother Theory Pract 2018; 36: 1–20. doi:10.1080/09593985.2018.1483987
- Winstein C, Lewthwaite R, Blanton SR, et al. Infusing Motor Learning Research Into Neurorehabilitation Practice: A Historical Perspective With Case Exemplar From the Accelerated Skill Acquisition Program. Journal of Neurologic Physical Therapy 2014; 38: 190–200. doi:10.1097/NPT.0000000000000046
- Majsak M. Concepts and Principles of Neurological Rehabilitation In Fell D. Lifespan Neurorehabilitation: A Patient-Centered Approach from Examination to Intervention and Outcomes. F.A. Davis; 2018
- Huber M, Janssen C, Erzer Lüscher F, et al. Motorisches Lernen in der Neuroreha. 1. Auflage. Thieme Verlag; 2022
- Dividat Homepage Dividat | Senso: Kognitiv-motorisches Training
- Schweighofer N, Wang C, Mottet D, et al. Dissociating motor learning from recovery in exoskeleton training post-stroke. Journal of NeuroEngineering and Rehabilitation 2018; 15: 89. doi:10.1186/s12984-018-0428-1
- Valenzuela T, Okubo Y, Woodbury A, et al. Adherence to Technology-Based Exercise Programs in Older Adults: A Systematic Review. J Geriatr Phys Ther 2018; 41: 49–61. doi:10.1519/JPT.0000000000000095
- Oesch P, Kool J, Fernandez-Luque L, et al. Exergames versus self-regulated exercises with instruction leaflets to improve adherence during geriatric rehabilitation: a randomized controlled trial. BMC Geriatr 2017; 17: 77. doi:10.1186/s12877-017-0467-7
- Tiebel J. Interaktiv kognitiv-motorisches Training mit dem Dividat Senso - Einfluss des Schwierigkeitsgrades unterschiedlicher Spieleanwendungen auf Motivation, emotionales Spielerlebnis sowie physische und kognitive Beanspruchung. 2020
- Piccoli A, Rossettini G, Cecchetto S, et al. Effect of Attentional Focus Instructions on Motor Learning and Performance of Patients with Central Nervous System and Musculoskeletal Disorders: a Systematic Review. JFMK 2018; 3: 40. doi:10.3390/jfmk3030040
- Jäggi S, Wachter A, Adcock M, et al. Feasibility and effects of cognitive-motor exergames on fall risk factors in typical and atypical Parkinson’s inpatients: a randomized controlled pilot study. Eur J Med Res 2023; 28: 30. doi:10.1186/s40001-022-00963-x
- Lang CE, Holleran CL, Strube MJ, et al. Improvement in the Capacity for Activity Versus Improvement in Performance of Activity in Daily Life During Outpatient Rehabilitation. J Neurol Phys Ther 2023; 47: 16–25. doi:10.1097/NPT.0000000000000413
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