Research in Developmental Disabilities 35 (2014) 2766–2772
Contents lists available at ScienceDirect
Research in Developmental Disabilities
Effects of self-control and instructor-control feedback on
motor learning in individuals with cerebral palsyRasool Hemayattalab a,b,*a University of Tehran, Faculty of Physical Education and Sport Sciences, Tehran, Iranb Research Scholar, Columbia University, New York, U.S.A
A R T I C L E I N F O
Article history:
Received 12 April 2014
Received in revised form 24 June 2014
Accepted 2 July 2014
Available online
Keywords:
Self-control feedback
Instructor-control feedback
Motor learning
Cerebral palsy
Dart throwing
A B S T R A C T
In this study we investigated the effects of ‘‘self-control and instructor-control feedback’’
on motor learning in individuals with cerebral palsy (CP). For this reason 22 boy students
with CP type I (12.26� 3.11 years of age) were chosen. They were put into self-control
feedback, instructor-control feedback and control groups. All participants practiced dart
throwing skill for 5 sessions (4 blocks of 5 trails each session). The self-control group received
knowledge of results (KR) feedback for half of their trials whenever they wanted. The
instructor-control group received KR feedback after half of both their good and bad trails. The
control group received no feedback for any trails. The acquisition test was run immediately at
the end of each practice session (the last block) and the retention and transfer tests were run
24 h following the acquisition phase. Analyses of variance with repeated measures and Post
hoc tests were used to analyze the data. According to the results of this study, individuals with
CP have the ability of acquiring and retaining a new motor skill. Also, it was found that self-
control feedback is effective than instructor-control feedback on learning of a motor task in
individuals with CP as in the average population. These findings show that rules regarding
feedback also apply to people afflicted with CP.
� 2014 Elsevier Ltd. All rights reserved.
1. Introduction
Cerebral palsy (CP) is one of the most common causes of physical disability in children (Krageloh-Mann & Cans, 2009). It isgenerally agreed that children with CP constitute the largest clinical group seen in pediatric occupational therapy (Novak,Cusick, & Lannin, 2009). Most notable are motor deficits that interfere with functional tasks and mobility, although variouscognitive and sensory deficits are frequently associated (Batshaw, Pellegrino, & Roizen, 2007). The impairments, activitylimitations, and accompanying disturbances may be directly related or secondary to functional changes over time(Rosenbaum et al., 2007). Extreme limitations are also seen in motor tasks such as putting on clothes, eating, and moving.These limitations exist in communal tasks like playing with other children and, therefore, have significant effects onchildren’s social role-taking (Peacock, 2000). This disability, postpones development and acquisition of skills (Rosenbaumet al., 2007).
Researchers are trying to determine how the brain responds to damage and how practice affects these responses inindividuals with this disorder (e.g., Hemayattalab & Movahedi, 2010). As CP is considered a condition primarily impactingmotor control and movement, motor learning is an important focus of research. Motor learning research studies the
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E-mail addresses: [email protected], [email protected]
http://dx.doi.org/10.1016/j.ridd.2014.07.006
0891-4222/� 2014 Elsevier Ltd. All rights reserved.
R. Hemayattalab / Research in Developmental Disabilities 35 (2014) 2766–2772 2767
acquisition or modification of movement with the goal of developing skilled movements or actions (Shumway-Cook &Woollacott, 2012). These children are able to improve motor function with practice (Hemayattalab & Rashidi Rostami, 2010).Functional and task oriented treatment approaches have the potential for improving motor function when implementedwith adequate intensity (Gordon & Magill, 2012).
Effective motor learning is thought to primarily depend upon the practice parameters such as feedback conditions inplace during the learning (Schmidt & Lee, 2014). The term feedback was originally characterized as sensory information thatindicates something about the actual state of a person’s movement. Intrinsic feedback is sensory information that arises asnatural consequences of producing a movement (Schmidt & Wrisberg, 2008). In this kind of feedback, knowledge of results(KR) seems to be essential for learning and performance (Young & Schmidt, 1992). KR has a reinforcing and guidance effect onthe person and informs him about the corrections he should make in his next performance. However, this kind of feedbackcan also be related to association (Flinn & Radomski, 2002; Salmoni, Schmidt, & Walter, 1984).
In order to help patients learn a skill, therapists initially provide feedback regarding performance but ultimately theprimary goal is to assist in the development of intrinsic feedback. It has been well established that this kind of feedback playsan important role in acquiring a motor skill (Shea & Wulf, 2005). However, KR not only has no effects on learning but mightalso affect it negatively, such as when a coach or therapist provides immediate feedback during every trial or right after it(Winstein & Schmidt, 1990). These results show that feedback may be provided so excessively that individuals becomedependent on it in a way that they do not perform well without it (Schmidt, 1991).
Recently, researchers have focused their efforts on understanding the role of learner autonomy in motor skill acquisition(Sanli, Patterson, Bray, & Lee, 2013). Often termed ‘‘self-control’’ in the motor domain, the idea of allowing learners controlover some aspect of their learning environment (e.g., feedback administration) is rooted in self-regulation research in socialcognitive psychology. Studies have indicated that giving learners control over some aspect of an instructional protocolfacilitates motor learning when compared to protocols that are completely prescribed by the researcher or instructor(Chiviacowsky, Wulf, de Medeiros, Kaefer, & Tani, 2008; Wu & Magill, 2011; Wulf, 2007).
Although there are many studies regarding self-control feedback and its impacts on learning, the focus of these studieshas mainly been on typically developing populations (Aiken, Fairbrother, & Post, 2012; Chiviacowsky & Wulf, 2002;Chiviacowsky, Wulf, de Medeiros, Kaefer, & Wally, 2008; Chiviacowsky, Wulf, Lewthwaite, & Campos, 2012; Fairbrother,Laughlin, & Nguyen, 2012; Hansen, Pfeiffer, & Patterson, 2011; Sanli et al., 2013). There are no studies that examined effectsof self-control feedback on motor learning in CPs.
There are some reasons to expect that individuals who engage in relatively low levels of physical activity (e.g., CPs) mightbehave differently compared to more active peers in a self-controlled feedback protocol (Fairbrother et al., 2012).Researchers have showed that connecting sensory consequences with the outcome of a movement is an important aspect ofmotor learning and prominent explanations for self-control feedback benefits have emphasized the role of such self-evaluation of performance (Chiviacowsky, Wulf, de Medeiros, Kaefer, & Tani, 2008). It may be that physically inactiveindividuals will have difficulty interpreting sensory consequences when learning certain types of skills given their relativeinexperience engaging in fundamental motor skills. Mutsaarts, Steenbergen, and Bekkering (2006) investigated anticipatoryplanning deficits and task context effects in hemiparetic CP. The results suggested an anticipatory planning deficit inhemiparetic CP participants that may be caused by impairment at the motor imagery level. Consequently, as an alternativestrategy, performance in hemiparetic CP participants was predominantly based on information directly available in the taskcontext. According to this study learning a new motor skill may be challenging for children with CP because new argumentsare proposed that CP is not only about muscular disability but also planning the activity in the central nervous system(Mutsaarts et al., 2006).
If these results are true for CPs in general, we might expect diminished effectiveness of self-controlled feedback comparedto normal counterparts. Presumably, it is likely that normal and active individuals by virtue of more experience withmovement skills will outperform their less active counterparts. It is possible that such a difference in performance mightprompt different patterns of feedback requests. For example, relatively poor performance might lead less active individualsto seek corrective feedback (after bad trials) more often than active individuals (Fairbrother et al., 2012). Whether or notdivergent patterns of feedback requests would influence the effectiveness of self-control feedback is unknown, butidentifying such behavior would be helpful to inform the expectations of physical therapists and practitioners implementingself-control feedback protocols and to further current thought on how feedback is used in motor learning (Chiviacowsky &Wulf, 2007). Of course, it is also possible that self-control feedback will prompt similar behavior from both normal and CPs,and will also facilitate motor learning for both groups. Such a demonstration would be important in establishing theseprotocols as potentially effective interventions in helping CPs who struggle with skill barriers to physical activityparticipation.
2. Methods
2.1. Participants
22 boy students diagnosed with CP type I (12.26� 3.11 years of age) participated in this study. Participants were selectedfrom a group of individuals who all were right-handed (left-side hemipilegia). According participants’ clinical documents, theyhad no visible disabilities in performing hand and also had no gross visual and mental deficits. They were all novices in the dart
R. Hemayattalab / Research in Developmental Disabilities 35 (2014) 2766–27722768
throwing skill. All participants and their parents gave informed consent. The research design was approved by an academic ethicscommittee.
2.2. Apparatus and task
The participants were asked to practice and learn dart throwing skill. This task was similar to the one used byHemayattalab and Rashidi Rostami (2010). In this study we used two apparatus. The first one was a two-sided standarddart with which I used the center-peripheral method for gaining a high score. In this method if participants threw thedart closer to the center of the dart board they would score higher. If the dart was in the center of the target, point 10;outside of the target, point 0; and other areas of the target, point 9, 8, 7, 6, 5, 4, 3, 2, and 1 were given, respectively(Fig. 1). If it landed on the line, the higher score was recorded. The second apparatus was an electrical sensor that couldturn off the dart screen so participants could just see the result of their action, according to the examiner’s plan (givingfeedback according to the research design for each group).
2.3. Procedure
After participants were selected, one session was devoted to teaching and practicing the technique of dart throwingwith their dominant (less-affected) hand. In this session, participants learned how to perform the task. After thedemonstration and modeling of the skill, participants started practicing. A dart-specialized trainer corrected andenhanced their performances during practice by providing knowledge of performance feedback. At the end of thisprimary practice session, participants were randomly assigned to self-control feedback (n = 8), instructor-controlfeedback (n = 7), and control (n = 7) groups. The self-control feedback group was told that they would be allowed toaccess feedback (knowledge of results) of their throwing score after 50% of trails during acquisition. The instructor-control feedback group received knowledge of results after 50% of both good and bad trails. The control group receivedno feedback and never saw where the darts landed. During the acquisition phase, participants completed 100 trails in 5days (4 blocks of 5 trials each session). The last block (5-trial) in each practice session was assigned as an acquisitiontest. Approximately 24 h following acquisition, participants returned to the facility to complete a 5-trial retention testfollowed by a 5-trial transfer test. During acquisition and retention, participants completed the task from the standardline (205 cm). During transfer, the task was completed from the 300 cm line.
2.4. Data analysis
For the acquisition phase, average scores were analyzed using 3 (group)� 5 (day) analyses of variance (ANOVA)with repeated measures on the last factor. For retention and transfer, scores were analyzed using one way ANOVAand Tukey Post hoc tests. [(Fig._1)TD$FIG]
Fig. 1. The center-peripheral side of dart board and scoring.
[(Fig._2)TD$FIG]
Fig. 2. Mean scores for self-control, instructor-control, and control groups during acquisition phase and retention and transfer tests.
R. Hemayattalab / Research in Developmental Disabilities 35 (2014) 2766–2772 2769
3. Results
Fig. 2 and Table 1 show mean scores for the self-control feedback, instructor-control feedback, and control groupsthroughout the acquisition, retention, and transfer phases. Regardless of the type of feedback, all groups showed significantprogress in the acquisition and retention phases (Table 2). Although the experimental groups produced slightly higherscores than the control group throughout the acquisition phase, the differences only reach significance during lastpractice day (fifth day). This observation for the acquisition phase was supported by a significant group� day interactionwith F (8, 76) = 2.272, p = 0.031, h = 0.193, and main effect of day with F (4, 76) = 42.837, p = 0.001, h = 0.693, but the maineffect of group F (2, 19) = 3.192, p = 0.067, was not significant. Multiple comparison Post hoc testing showed that theself-control feedback group scored significantly higher than instructor-control feedback (p = 0.043) and control (p = 0.001)groups in the last session.
In the retention test, the self-control group performed better than the instructor-control and control groups. Thisobservation was supported by a significant main effect for the group with F (2, 19) = 5.321, p = 0.015. Post hoc testingindicated that there was only a significant difference between the self-control and control groups (p = 0.014). There wereno significant differences between other groups in the retention test (p> 0.05).
Table 1
Mean scores for self-control, instructor-control, and control groups during acquisition phase, retention and transfer.
Self-control feedback group Instructor-control feedback
group
Control group
Mean SD Mean SD Mean SD
First day 2.375 0.744 2.429 0.534 2.286 0.488
Second day 3.125 0.641 3.286 0.488 2.714 0.488
Third day 3.500 0.535 3.571 0.535 3.286 0.488
Fourth day 4.000 0.756 3.714 0.488 3.429 0.534
Fifth day 4.500 0.534 3.857 0.378 3.429 0.787
Retention test 4.250 0.707 3.571 0.534 3.286 0.756
Transfer test 3.875 0.641 3.143 0.378 2.857 0.690
Table 2
Paired sample t-test results for self-control, instructor-control, and control groups in acquisition, retention and transfer tests.
Self-control feedback group Instructor-control feedback group Control group
Paired differences Significant Paired differences Significant Paired differences Significant
Mean SD Mean SD Mean SD
First day-last day �2.125 0.991 0.001* �1.429 0.534 0.000* �1.143 0.378 0.000*
First day-retention �1.875 0.835 0.000* �1.429 0.378 0.000* �1.000 0.577 0.004*
First day-transfer �1.500 0.926 0.003* �0.714 0.488 0.008* �0.571 0.786 0.103
* Significant differences (p< 0.05).
R. Hemayattalab / Research in Developmental Disabilities 35 (2014) 2766–27722770
There was a significant difference between groups in the transfer test, F (2, 19) = 6.031, p = 0.009. The self-control groupdemonstrated higher performance than other groups. Post hoc testing showed that there was a significant differencebetween the self-control and control groups (p = 0.009). However, there were no significant differences between othergroups in this phase (p> 0.05).
4. Discussion
Recent research has indicated that giving learners control over some aspect of a practice protocol facilitates performanceand motor learning when compared to protocols that are completely prescribed by the instructor (Andrieux, Danna, & Thon,2012; Brydges, Carnahan, Rose, & Dubrowski, 2010, Brydges, Carnahan, Safir, & Dubrowski, 2009; Bund & Wiemeyer, 2004;Patterson & Carter, 2010; Wulf, 2007). It has been shown that the provision of self-control feedback during practice enhancesmotor learning and performance (Chiviacowsky & Wulf, 2005; Chiviacowsky, Wulf, de Medeiros, Kaefer, & Tani, 2008;Janelle, Barba, Frehlich, Tennant, & Cauraugh, 1997; Janelle, Kim, & Singer, 1995). However, the majority of research has beenrelated to typically developing individuals. Thus, it is important to establish an understanding of whether a population withCP responds in a similar way. Based on current self-control research, it was expected that the self-control feedback groupwould outperform the other groups in acquisition, retention, and transfer tests. The self-control feedback group scoredhigher than the other two groups in the last sessions of the acquisition phase and retention and transfer tests. These resultsare consistent with the findings of Aiken et al. (2012), Chiviacowsky, Wulf, de Medeiros, Kaefer, and Tani (2008),Chiviacowsky and Wulf (2002), Fairbrother et al. (2012) in typically developing people and Hemayattalab, Arabameri,Pourazar, Dehestani-Ardakani, and Kashefi (2013) in CPs.
According to Chiviacowsky, Wulf, de Medeiros, Kaefer, and Tani (2008), the self-control phenomenon could beexplained from both cognitive and motivational perspectives. In fact, there was an inverse relationship betweencognitive and motivational processes. From a motivational perspective, factors such as goal setting, requesting feedbackwhen wanted, and having more independence led to higher levels of intrinsic motivation and more effort in the learningprocess in the self-control condition. From a cognitive perspective, however, the self-control condition was followed bymore pressure on learners because the learning process should be decided based on the learner’s own knowledge of thetask, how often and how they request feedback, how many times they need to choose feedback, and eventually, whenand to what extent they should change task difficulties. It seems that in this study, the motivational processes led tobetter motor learning and performance in the self-control feedback group.
Also, the present findings were in agreement with the prediction of a challenge point framework (Guadagnoli & Lee,2004; Pollock, Boyd, Hunt, & Garland, 2014) suggesting that an interaction between task outcomes, characteristics oflearners, and exercise conditions would change the level of individuals’ involvement during exercise. Maximum benefitof exercise for learning would occur in an optimized challenge point. If challenges were more than the optimized point,the result would be an increase in cognitive effort more than the information processing capability and, consequently, adecrease in learning benefits.
According to the challenge point framework results, if the task used in this study leads to a higher challenge, theparticipants in the self-control feedback condition organize their training requirements to reach an optimized challengepoint. Based on this finding, self-controlled feedback is considered as a suitable approach to examine the predictions ofthe challenge point framework because children in this group could match their needs with exercise requirements(Chiviacowsky & Wulf, 2002; Janelle et al., 1997). Several factors seem to be involved in effectiveness of the self-controlconditions compared to the other conditions in retention and transfer tests. It is suggested that giving the opportunityof control over practice protocol leads to a deeper information processing (Chen, Hendrick, & Lidor, 2002), a higher levelof motivation (Bandura, 2001), greater use of self-control strategies (Kirschenbaum, 1984), and eventually moreresponsibility for the learning process (Ferrari, 1996) in participants. According to the studies which showed thatpeople affected by central nervous system disorders would respond to feedback in the same way as normal people(Hemayattalab et al., 2013; Hemayattalab & Rashidi Rostami, 2010), these methods could be used with CPs.
One of the interesting findings of this study was the progress of the control group with no feedback. As seen in figureand Table 2, this group made progress without any extrinsic or intrinsic feedback; this is consistent with Magill’s view.According to Magill (2011), sometimes the existence of extrinsic feedback is not essential to learning skills. But, thisseems logical only when intrinsic feedback is present (Magill, 2011; Schmidt & Lee, 2014). Considering that in this studyvisual intrinsic feedback was also blocked in the control group by a sensor (they did not see the dart board and theirperformance results), thus, the existing contradiction can be assigned to deliberate practice than to the effect offeedback. Deliberate practice has an important place in learning-related studies (Coughlan, Williams, McRobert, & Ford,2014; Hyllegard & Yamamoto, 2007; Liou, Chang, Tsai, & Cheng, 2013; Movahedi, Sheikh, Bagherzadeh, Hemayattalab, &Ashayeri, 2007; Pachman, Sweller, & Kalyuga, 2013). According to studies (Bastos, Tani, de Araujo, Walter, &Freudenheim, 2010; Schmidt & Lee, 2014), the most important factor in learning is the amount of practice and othereffective factors which are considered practice factors.
Today, there are various methods which are used to help motor learning in CP or other disabilities in the central nervoussystem. Different experimental methods are used to rehabilitate these people (Garvey, Giannetti, Alter, & Lum, 2007).However, the results of this study can help instructors and physiotherapists to provide better services in the planning ofpractice for CPs in motor learning and performance.
R. Hemayattalab / Research in Developmental Disabilities 35 (2014) 2766–2772 2771
Acknowledgments
The author thanks the students with cerebral palsy who participated in this study and Professor Andrew M. Gordon fortechnical assistance and comments on manuscript.
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