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Learning a Partial-Weight-Bearing Skill: Effectiveness of Two Forms of

Feedback

Article  in  Physical Therapy · October 1996

DOI: 10.1093/ptj/76.9.985 · Source: PubMed

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Carolee Winstein Patricia S Pohl

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 Learning a Partial-Weight-Bearing
Skill: Effectiveness of Two Forms of
Feedback
Background and Purpose. Partial weight bearing (PWB) is a skill
commonly taught by physical therapists. This study compared the
effects of practice with either augmented feedback provided during
the task (concurrent feedback) o r augmented feedback provided after
the task (postresponse feedback) for the learning of PWB with
crutches. Subjects. Sixty young adults without known impairment of
the neuromusculoskeletal system volunteered for the study. Methods.
Subjects practiced supporting 30% of body weight while stepping onto
a floor scale. Augmented feedback was provided during each trial for
the concurrent feedback group and either following each trial o r after
every five trials for the postresponse feedback groups. Subjects
returned 2 days later for a no-feedback retention test. Results. During
practice, the concurrent feedback group was more accurate and
consistent than either of the postresponse feedback groups. During
retention, however, the postresponse feedback groups were the most
accurate; all groups were equally consistent during retention. Conclu-
sion and Discussion. These results suggest that practice with concur-
rent feedback is beneficial for the immediate performance but not for
the learning of this sensorimotor skill. [Winstein CJ, Pohl PS, Cardinale
C, et al. Learning a partial-weight-bearing skill: effectiveness of two
forms of feedback. Phys Ther. 1996;76:985-993.1

Key Words: Feedback; Learning Posture, tests and measurements; Psychomotor performance;
Sensorimotor.

CaroleeJ Winstein

Patricia S Pohl
Carrie Cardinale

Andrea Green

Carrie Sauber Waters

Physical Therapy . Volume 76 . Number 9 . September 1996

 artial weight bearing (PWB) is a skill that
physical therapists often teach. Despite the
frequency with which physical therapists teach
PWB, little research has focused on what con-
ditions of practice are the most effective for the learning
of this sensorimotor skill, or even, in general, how well
this skill can be learned. Attempts to train individuals in
PWB have been relatively unsuccessful when using forms
of concurrent feedback during For example,
retraining of symmetrical weight bearing was ineffective
in a group of individuals with hemiparesis using an
augmented sensory feedback device that provides an
auditory tone proportional to the magnitude of weight
bearing during walking3 Despite these findings, concur-
rent feedback is still commonly used in clinical practice
for the training of Pb'B. In contrast to results with
concurrent feedback, a recent s t u d p used a form of
postresponse augmented feedback (ie, summary knowl-
edge of results [KR]) during practice and showed good
learning of a PWB skill, with an accuracy at retention of
within 7.2% of body weight.
these two forms of feedback is timing; KR is presented
after the performance of the task, and concurrent feed-
back is presented during the performance of the task.
Across a large repertoire of motor skills, recent work has
focused on the differential performance and learning
effects of practice under conditions of several kinds of
augmented feedback, including KR relative frequency
(proportion of all practice trials for which KR is provid-
ed), summary KR (KR is given only after a set of trials;
these trials are termed the "summary length"), KR delay
(KR is given after a time delay), concurrent feedback,
and presentation trials (movement is made to a physical
block at the target) .7-11 The findings from these studies
suggest that practice in conditions with less immediate,
less frequent, and less guiding augmented feedback is
more detrkmental for immediate performance but more
benPfrial for the long-lasting learning of motor skills than
practice in conditions where augmented feedback is
provided with little delay, more often, or with physical

Augmented feedback is one of the most powerful vari-
ables influencing motor learning.5 Two types of aug-
mented feedback are relevant to this research: KR and
concurrent feedback. Knowledge of results has been
defined as verbal (or verbalizable) , postresponse feed-
back about the outcome of the movement related to the
g o a l . V n contrast, concurrent feedback is a form of
verbal (or verbalizable) augniented feedback about per-
formance relative to the goal that is provided during the
movement. Thus, the fundamental difference between
Common to all these augmented feedback strategies that
promote motor skill learning are opportunities for learn-
ers to engage in problem solving. This problem solving is
not necessarily "cognitive" in nature but emerges as a
function of the interaction between the motor task
"problem" and the conditions of practice. Practice con-
ditions that are less guiding (eg, have less frequent
feedback) allow for the development of critical sensori-
motor transformations, or the generation of solutions to

CJ Winstein, PhD, PT, is Assistant Professor, Department of Biokiriesioloby and Physical Therapy, University of Southern California, 1540 E Alcazar
St, CHP 155, Los Angeles, CA 90033 (USA) (winsteiri@hsc.usc.edu). Address all correspondence to Dr Winstein.

PS Pohl, PhD, PT, is Assistant Scientist, Center on Aging, and Assistant Professor, Department of Physical Therapy Education,
The University of Kansas Medical Center, Kansas City, KS 66160. He was a doctoral candidate and Research Assistant,
Department of Biokinesiology and Physical Therapy, University of Southern California, at the time the study was conducted.

C: Cardinale, PT, is Physical Therapist 11, Seton Medical Center, Dayley City, CA 94015

A Green, PT, is Lead Physical Therapist, Oakridge Care Center, Oakland, CA 9460'2.

1. Scholtz, PT, is Staff Physical Therapist. Fortanasce and Associates, Arcadia, CA 91007.

CS Waters, PT, is Senior Physical Therapist, Imperial Valley Therapy Centers, El Centro, CA 92243.

Ms Cardinale, Ms Green, Ms Scholtz, and Ms Waters were students in the entry-level Master of Physical Therapy degree program. Department of
Biokinesiology ant1 Physical Therapy, University of Southern California, at the time the study was conducted.

This study was approved by the Research Review Committee fbr Professional Staff Association, University of' Southern California School of
Medicine.

Preliminary results of this study were presented at the C:ornhined Sections Meeting of the American Physical Thel-apy Association;
Fehrua~y8-12, 1995; Reno, Nev.

1 7 ~ ~artzclr
s wnc rubmzfted Jub 18 1995, and was accepted Apnl 15, 1996

986 . Winstein et a / Physical Therapy . Volume 76 . Number 9 . September 1996

motor problems, and are strongly associated with
learning. Is-'"
The literature suggests that concurrent feedback is a
strong performance variable but a weak learning vari-
able. Few studies have shown the long-term benefits of
practice with concurrent feedback, yet this type of feed-
back seems to be used often by physical therapists for the
training of sensorimotor skills (eg, balance retraining).
Thus, there appears to be a discrepancy between what
the motor learning literature suggests about the optimal
timing of feedback and what is currently used in prac-
tice. The purpose of this study was to compare the effects
of practice with either postresponse or concurrent feed-
back on the learning of PWB. Based on theoretical
predictions, our hypothesis was that practice under
conditions of postrespo~lsefeedback would be more
detrimental for immediate performance but more ben-
eficial for longer-lasting learning than practice under a
condition of concurrent feedback.
Subjects
Sixty-one volunteers without known impairment of the
neuromu:~culoskeletalsystem, between 20 and 40 years
of age, were quasi-randomly assigned to one of three
feedback practice groups, such that the male-female
ratio was 1:2 for each group. Subjects were assigned
sequentially to each of the three groups until a 1:2
male-female ratio was obtained; thereafter, group assign-
ment was made until each group had at least 18 subjects.
The mean age for all subjects was 26.2 years (SD=3.8),
the mean body weight was 66.2 kg (SD=12.6), and the
mean target weight (30% of body weight) was 19.9 kg
(SD=3.8). Exclusion criteria were (1) use of axillary
crutches within 2 years before the study, (2) a physical or
sensory impairment limiting the subject's ability to use
crutches, or (3) body weight of less than 49.5 kg or
greater than 592 kg. This weight restriction was due to
limitations in the adjustablility of the scale used in the
study. Most of the subjects were physical therapy stu-
dents who had some knowledge of crutch use. Each
subject read the institutionally approved guidelines
regarding the rights of human subjects in medical
experiments and signed an informed consent statement.
Task and Instrumentation
Subjects practiced supporting 30% of their body weight
on their preferred limb on a floor scale with the goal of
being accurate and consistent. The floor scale, with a
readable accuracy of 20.45 kg (the smallest unit of the
scale dial to which the needle could be resolved), was
modified to control the feedback that subjects could
derive from the scale. The increments on the round
scale dial were replicated on paper; however, the num-
Physical Therapy . Volume 7 6 . Number 9 . September 1996
- -TOD Cover
H a l f Cylinder
Open \ 1
Figure 1.
(A) Replicated paper scale dial was slipped over the floor scale dial
face. One unit on the paper scale was equivalent to 4.5 kg ( 1 0 Ib). The
target weight was fixed at 8 units ( 3 6 kg), indicated on the paper dial
with a bold marking. The scale needle starting position has been
adjusted at 2 units for a 90-kg subject in this example. Subjects in the
concurrent feedback condition viewed the replicated paper scale dial
and scale needle directly. (B) The scale with the metal half cylinder that
obstructed the view of the dial from subjects in the two postresponse
feedback conditions. Postresponse feedback was drawn on a replicated
paper scale dial and placed on the top cover in accordance with the
feedback condition.
bers indicating the pounds on the scale were changed,
such that each 4.5-kg (10-lb) increment corresponded to
1 unit (Fig. 1A). The marking at 8 units (36 kg) was
designated the PWB goal for all subjects, with the
number "8" highlighted in green along with a thickened
line at the corresponding hash mark on the paper dial.
This paper dial was placed over the scale dial face but did
not interfere with needle movement. For postresponse
feedback conditions, a metal half cylinder with an
opaque cover over the top end was secured upright to
the scale such that it encircled half of the scale dial
(Fig. 1B). This modification obstructed the view of the
dial from the subject but not from the experimenter.
Wooden platforms were aligned on either side of the
scale such that when subjects stepped onto the scale with
the preferred limb, the contralateral limb and crutches
were level with the top of the scale. The crutches were
adjustable, tubular, aluminum axillary crutches with
hand and axillary cushions. A portable tape player was
used to provide prerecorded verbal cues, as appropriate,
for each trial. All subjects wore rubber-soled shoes to
provide a standard heel height and to prevent slippage
on the scale.
Winstein et al . 987

Procedure
Subjects participated in a practice session, followed
2 days later by a retention test. Subjects were informed at
the beginning of the study that a no-feedback retention
test of 20 trials would follow 2 days later. During the
practice session, subjects performed 80 trials (as deter-
mined from previous research", with a 2-minute break
after the first 40 trials. Prior to each day of data collec-
tion, the scale was calibrated with cast iron weights,
which had been weighed against a known standard. The
scale was read to the nearest 0.45 kg (1 Ib).
Acquisition phase. At the start of the first session,
subjects were asked to hop on one leg three times. The
chosen (preferred) leg was designated the PUB limb.
Each subject was weighed, and the subject's target weight
was then calculated. Because 8 units was the PWB goal
for all subjects, the starting point for the scale needle was
adjusted for each subject (Fig. 1A). The starting point
was calculated by subtracting 30% of the subject's body
weight from the PWB goal of 36 kg (8 units). For
example, a 90-kg subject would have an actual target
weight of 27 kg (6 units). Thus, the starting position for
this subject was set at 9 kg (2 units). When this subject
applied 30% PWB, the scale dial would move from the
starting position of 2 units to the target of 8 units.
The height of the crutches was adjusted to allow a
two-finger-width space below the axilla as the subject
stood erect. Each subject was instructed in a two-point
step-to gait pattern1" and permitted to practice this gait
pattern for a few steps. Thus, the subject simultaneously
advanced both crutches and the PUB limb, and then
advanced the contralateral limb to the line of the
crutches and PWB limb. Subjects were allowed a few
practice trials on the scale prior to data collection. An
experimenter (the same person for all subjects) then
demonstrated three trials of the task with the pre-
recorded commands and explained the procedures for
feedback, depending on the group assignment. Suhject5
were told that the goal was to place a proportion of their
body weight through their lower extremity to reach
8 units on the scale. The goal of 30% of body weight was
not mentioned to control for individual differences in
weight-bearing perception."
There were three practice groups: concurrent feedback
(CF), summary-1-KR (KR-1), and summary-5-KR (KR-5).
During practice, subjects in the KR-1 group received KR
after every trial about the previous trial, those in the
KR-5 group received KR after every fifth trial regarding
the previous five trials, and those in the CF group
received concurrent feedback during every trial.
Each trial was 7 seconds in duration and began with the
subject standing in front of the scale at a starting
988 . Winstein et a1
IA
GO HOLD RELAX RETURN
1 11 1
Post-
DtEy KR
KR
Delay
I Trial Idle Period
Figure 2.
Time line of trial and augmented feedback intervals. (A) Intervals for the
postresponse feedback groups (KR-1 and KR-5). (B) Intervals for the
concurrent feedback group (CF). Tape-recorded verbal cues illustrated
for the time line shown in panel A were the same for all three groups.
position that was indicated by floor tape placed 15 cm
from the scale. After the prerecorded "Go" signal, sub-
jects stepped onto the scale using a two-point step-to gait
pattern. One set of prerecorded verbal cues was used to
instruct the subjects and to control the timing of the
trial, the feedback, and the intertrial intervals across the
three practice conditions (Fig. 2).
After stepping onto the scale, subjects in the CF group
were told to view the scale dial and to adjust their weight
so that the red scale needle was aligned with the "8" on
the modified dial. Subjects in the two postresponse
feedback groups (KR-1, KR-5) were told to look down at
the opaque cover over the top end of the metal cylinder
covering the scale dial during each trial. A "Hold"
comniand was given 7 seconds after the "Go" command.
During this 4second interval, subjects were told to
maintain the assumed weight bearing and the scale
setting was recorded. Following this interval, a "Relax"
command was given and feedback was provided (post-
response feedback groups only). The experimenter
placed the replicated paper dial indicating the subjects'
response on the top end of the metal cylinder. The
subjects' performance (ie, load) on the trial(s) was
represented by a red line(s) referenced to the green
PWB goal. This was designed to inform the subjects
about the level of weight bearing they achieved. Thus, I'
subjects in the KR-1 group saw one red line on the
replicated scale dial after each trial. Subjects in the KR-5
group saw five red lines after every fifth trial, each
labeled with a corresponding trial number (1-5), on the
replicated scale dial. After the 5second "Relax" interval,
I
Physical Therapy. Volume 7 6 . Number 9 . September 1996 '
Table.
Characteristics of Subiects [N=60)

KR-1 Group" (n=21) KR-5 Groupb (n=20) CF Groupc(n= 19)

Variable X SD Range X SD Range X SD Range

Age (Y) 26.5 4.2 23-39 26.0 4.1 23-40 26.1 3.1 22-23
Weight (kg) 63.7 11.2 49.5-83.3 67.5 14.0 49.5-1 02.2 67.7 12.7 52.2-102.2
Target (kg) 19.1 3.4 14.9-25.2 20.3 4.1 14.9-30.6 20.3 3.8 15.8-30.6
" KR-1 group rrreived postresponse ferdback after evety trial.
" KR-5 group received post)-rsponse feedhick after ever). fifth trial
' CF group I-eceivedconcurl-ent fcedback during every trial.

a "Return" command cued subjects to return to the
starting position (Fig. 2).
The intertrial interval was 14 seconds, except after every
fifth trial, when it was 19 seconds. This longer intertrial
interval provided subjects in the KR-5 group with a
10-second KR interval to view feedback regarding their
five preceding trials. The subjects in the KR-1 group
were allowed to view the feedback from the preceding
trial during these longer intertrial intervals, and subjects
in the CF group remained idle. A trial was invalid if the
subject misstepped by not stepping squarely on the scale
or stepped off the scale before a reading could be made
by the investigator. Invalid trials were repeated immedi-
ately. Tht: duration of the acquisition phase was approx-
imately 30 minutes per participant.
Retention phase. Subjects returned 2 days later for a
20-trial, no-feedback retention test. The procedure was
reviewed to reorient the subjects to the task, and subjects
were allowed to practice stepping up and down off the
scale three times with the scale dial covered by the metal
cylinder and opaque cover. Subjects were asked to
accurately and consistently reproduce the PWB goal they
had pract.iced 2 days earlier. All subjects were required to
look down at the scale during each trial; however, the
scale dial remained covered (Fig. 1B).
Data Analysis
Performances were grouped into blocks of 10 trials.
Normalization of dependent measures was necessary for
comparison between subjects because each subject had a
different target (30% of body weight) . Performance
during the acquisition phase (blocks 1-8) and the
retention phase (blocks 9 and 10) was analyzed sepa-
rately, with normalized absolute error ( N M ) and nor-
malized variable error (NVE) as dependent measures. In
addition, performance at the end of the acquisition
phase (block 8) and performance during the retention
phase (blocks 9 and 10) were included in a single
analysis. Normalized absolute error, a measure of accu-
racy, is he absolute difference between the applied
weight and the target weight, expressed as a percentage
of the target weight. Thus, NAE represents the magni-
tude of error without regard to the direction of error (ie,
undershooting or overshooting the target). It was calcu-
lated using equation 1, where R is the scale reading, B is
the initial scale setting (36 kg - 30% of body weight), W
is the weight applied, and T is 30% of body weight:
Normalized variable error (NVE), a measure of consis-
tency, represents the within-subject variability about the
subject's mean for a block of 10 trials. It was calculated
using equation 2,- where n is the number of trials in a
block (10) and NAE is the normalized absolute error
block mean score:
(2) [SQRT NAE - m)'h]
X 100 = NVE%
Separate two-factor mixed-model analyses of variance,
with group as the between-subject factor and trial block
as the within-subject factor (repeated measures), were
performed for NAE and NVE using BMDP statistical
software.lg A Greenhouse-Geisser adjusted F was used
for the repeated-measures factor. Post hoclinear contrasts
using a Bonferroni correction were performed to deter-
mine the locus of any significant effects. Significance was
set at P<.05.
Results
Sixty-one volunteers participated in the acquisition
phase. One subject, however, was unable to participate
in the retention phase due to a lower-extremity injury
that was incurred the day after the practice session.
Thus, the results are reported on a total of 60 subjects
(Table). Forty-two subjects used their right lower
extremity and 18 subjects used their left lower extremity
as the PWB limb. Only 11 invalid trials (less than 1%)
* BMDP Statistical Software Inc, 1440 Sepulveda Blvd, Suite 316, 1.0s Angeles. CA
90025.

Physical Therapy . Volume 76 . Number 9 . September 1996 Winstein et al . 989

 -*- KR-1 15 -
-0- KR-1

20 -
-.-
-a- KR-5
CF
10 - a -.-
-A- KR-5

CF

s
W
a
Z
12

-,-~.,.,.' \
.a
/,. A
s
W
>
Z 5 8 , -0
.

\.-.-.-.-.-.-.
k4=,-aqZ=, 4-X

4 -

0
-.-..-. - 4 . .
Y-
1 2 3 4 5 6 7 8 9
Acquisition Retention
(1 0-trial blocks)
Figure 3.
Group block means for normalized absolute error (NAE % target) for the
acquisition phase (blocks 1-8) and the retention phase (blocks 9
and 101.
were repeated out of the total of 6,000 trials recorded
during the acquisition and retention phases.
Acquisition Phase
Accuracy (NAEJ. Figure 3 illustrates the mean NAE by
block for each group. Across all groups, error scores
decreased from 9.8% in block 1 to 4.4% in block 8. This
change in performance resulted in a significant improve-
ment across blocks (1;=31.92; df=7,399; Pc.0001).
Over blocks, there were differences in performance
between groups (F=69.25; df =2,57; Pc.0001). Subjects
in the CF group had a mean NAE of 1.4%. Subjects in
the postresponse feedback groups performed less accu-
rately, with means of 6.4% and 8.2% for the KR-1 and
KR-5 groups, respectively. In addition, the performance
of the three groups was different across blocks for NAE
(F=9.68;df=14,399; P<.0001). Post hocanalyses revealed
that subjects in the CF and KR-1 groups showed no
further improvement in performance accuracy after
block 1. In contrast, subjects in the KR-5 group contin-
ued to show improvement after the first block (F=3.99;
(lf=6,114; Pc.006).
Consistency (NVE). With practice, subjects in all groups
became more consistent in their performance. Across
groups, the NVE decreased from 7.3% in block 1 to 3.2%
in block 8 (Fig. 4). This improvement in consistency over
practice was significant (F=32.83; df =7,399; Pc.0001).
In addition, there were differences in variability across
practice blocks between groups. Subjects in the KR-1 and
KR-5 groups had an average NVE of 5.0% and 5.3%,
respectively. The average NVE for subjects in the CF
0
1 2 3 4 5
Acquisition
6 7 8
7-
9 10
Retention
10 (10-trial blocks)
Figure 4.
Group block means for normalized variable error (NVE %target) for the
acquisition phase (blocks 1-8) and the retention phase (blocks 9
and 10).
group was 1.2%. This difference in variability between ,
groups was significant (F=83.18; df =2,57; Pc.0001).
The consistent performance of the subjects in the CF
group over practice contrasted with the marked
improvements in consistency in the postresponse feed-
back groups (Fc4.61; df = 14,399; Pc.001). Post hoc anal-
yses within each group across blocks did not reveal a
locus for this interaction.
Retention Phase
Overall, subjects performed less accurately over the two
blocks of retention (right side, Fig. 3 ) . This decreased
performance accuracy across blocks for NAE was signif-
icant (F=5.85; df=1,57; Pc.02). Subjects in the CF
group had the largest NAE, with a mean across the two
blocks of 11.3%, as compared with means of 7.9% and
7.5% for subjects in the KR-1 and KR-5 groups, respec-
tively. This difference between groups was significant
(F=3.42; df =2,57;Pc.04). Post hocgroup mean contrasts
for NAE, collapsed across the two retention blocks,
between the CF group mean and the mean from the two
KR groups, which were not different from each other,
revealed that the CF group performed with the largest
error (F=6.88; df = 1,58; Pc.02).
For mean NAE, there were differences between groups
across blocks (F=3.74; df=2,57; Pc.03). Performance
accuracy for subjects in the KR-1 group remained rela- ,
tively stable over the two retention blocks, however, 1
performance accuracy for subjects in the other groups
declined slightly. Post hoc contrasts within each group
across blocks did not reveal a locus for this interaction.
In the retention phase, all groups demonstrated a simi-
lar level of response consistency (NVE), with an average

990 . Winstein et al .
Physical Therapy Volume 76 . Number 9 . September 1996
of 4.6% (right side, Fig. 4). Analysis revealed no
differences.
Lost Acquisition -Retention
A comparison across groups from the end of the acqui-
sition phase, where augmented feedback was available
(block 8 ) , through the retention phase, where aug-
mented feedback was not available, showed an overall
deterioration in performance. This deterioration across
blocks was statistically significant (F=36.40; df =2,114;
P<.OOOl).
Although all groups performed less accurately in the
retention phase compared with the acquisition phase,
the magnitude of deterioration depended on the prac-
tice condition (Fig. 3 ) . The accuracy of performance of
subjects in the postresponse feedback groups declined
approxinlately 1.8% from the last block of acquisition to
retention. In contrast, the accuracy of performance of
subjects in the CF group declined nearly 11.3%. This
difference between groups across blocks was statistically
significant for NAE (1;=12.84; df =4,114; P<.0001).
Indeed, within-group post hoc contrasts revealed a dif-
ference across blocks for only the CF group (F=50.13;
df=1,18; P<.OOOl).
Overall, across blocks from the end of acquisition
through retention, the subjects' performance becarne
more variable as evidenced by NVE (F=17.89; df =2,114;
1'<.0001). More importantly, there was a difference
between groups across blocks (F=10.47; df=4,114;
P<.0001). Similar to the results for accuracy, there was a
marked decrease in response consistency by subjects in
the CF group (F=124.42; df=1,18; P<.0001). In con-
trast, subjects in the two postresponse KR groups per-
formed with a similar level of response consistency at the
end of a~cquisitionand retention (Fig. 4 ) .
Discussion
This study provided a direct comparison between the
effectivei~essof concurrent feedback and postresponse
feedback. on the learning of PWB in young adults
without known neuromusculoskeletal impairment. The
results demonstrated that for learning this skill, post-
response feedback was more effective than concurrent
feedback.. Although the subjects in the CF group per-
formed more accurately and consistently during practice
compared with the subjects in the postresponse feed-
back groups, subjects in the CF group performed less
accurately than the subjects in the other two groups
when they had to reproduce the PWB task 2 days later in
the no-feedback retention test. There were no group
differences, however, in performance consistency in
retention. Thus, the results of this study demonstrate
that corkcurrent feedback is a powerful performance
variable in that it promotes both accuracy and consis-
Physical Therapy . Volume 76 . Number 9 . September 1996
tency of performance when it is available but that this
type of feedback is a poor learning variable in that
performance accuracy does not persist when it is not
available. In contrast, the results suggest that post-
response feedback is a more effective learning variable
for the training of this PWB skill. The acquisition-
retention design commonly used in motor learning
research provides an inherent test of reliability. In
addition, repeated measures over the acquisition phase
provide a further test of reliabilit).. Because performance
measures plateaued for all groups over practice, we
believe that test-retest reliability can be assumed.
The detrimental learning effects of practice with concur-
rent feedback are consistent with the findings of previ-
ous studies of PWB tasks and other motor skill^.'^^^^,^^
Warren and Lehmann2 used concurrent feedback train-
ing methods over 100 practice trials of a PWB task and
reported errors with magnitudes greater than 50% of the
target loads during retention tests. These findings and
those of Bohannon and colleaguesL7suggest that PWB
skills cannot be learned with any degree of accuracy.
Subjects in the postresponse feedback groups in our
study, however, demonstrated a minimum error in the
retention test of 17% of the 30% of body weight goal, or
about 5% of body weight. Thus, PWB can be learned
with a reasonable degree of accuracy when practice
conditions that promote learning are used.
Conditions of practice promote certain information-
processing operations, including storage, retrieval, and
recall. For motor learning, these operations may not be
conscious or declarative in nature, but instead are
implicit and procedural in nature.Z0 Recent theories in
motor learning and memoly in general suggest that the
"...act of retrieval is itself a potent learning e ~ e n t . " ' ~ ( ~ ~ ~ )
Thus, conditions of practice that promote the active
retrieval of an action plan should be more beneficial for
learning than conditions of practice where the pi-escrip-
tion for the action is provided. For example, in condi-
tions where feedback is immediate (eg, concurrent), the
feedback can be used as a direct guide to the solution to
the motor problem. In contrast, in conditions where
feedback is not immediate (eg, postresponse), the feed-
back does not provide a direct solution to the motor
problem and thus the learner must engage in active
retrieval to solve the problem.
One subject in the CF group was able to overcome the
detrimental effects on learning of concurrent feedback.
During practice, the accuracy scores of this individual
were similar to the CF group mean. In the retention
phase, however, there was little change in the accuracy of
this subject's response. Postexperiment debriefing
revealed that this participant utilized a unique strategy
during the last 40 trials of practice. During the "Relax"
Winstein et al . 991
interval, this individual concentrated o n the feeling that
was associated with the target weight. Thus, self-directed
strategies could be used to facilitate motor learning even
when concurrent feedback is used during practice.
Other researchXz1 suggests that practice with concurrent
feedback juxtaposed with a period of no feedback may
be effective for motor learning where a simple recalibra-
tion is needed. Students in a physical therapy program
practiced a vertebral joint mobilization skill without
feedback for three 30-second bouts. After the first prac-
tice session, concurrent feedback was provided, using an
oscilloscope that displayed force production relative to a
target force for one 45second bout. Subjects showed
improved accuracy in producing the target force o n a
1-week retention test." Similarly, Wannstedt and Her-
man3 observed symmetrical weight bearing 1 month
after a short training period in a group of patients with
hemiparesis using the augmented sensory feedback
device described earlier. Interestingly, like the students
in the joint mobilization all successf~llsubjects in
Wannstedt and Herman's study3 corrected limb loading
almost immediately in the first session using the aug-
mented sensory feedback device. Thus, practice condi-
tions that provide some guidance (eg, concurrent feed-
back),juxtaposed with opportunities for active problem
solving (eg, no-feedback bouts), can be beneficial for
motor learning when a simple sensorimotor calibration
is required.I0
Caution must be taken in generalizing our findings. The
motor task was essentially static and limited to one target
goal. Extending these findings to dynamic PWB tasks o r
to target goals other than 30% of body weight must be
made with certain considerations. We would expect the
accuracy to be lower in dynamic PWB tasks than in our
static PWB task. Indeed, slightly lower accuracy scores
than those reported here were found in a similar study
that examined the learning of PWB during gait.l Fur-
ther, for rapid force production tasks, variability
increases linearly as the target force increases u p to
approximately 65% of maximum."." Thus, we might
predict that accuracy and consistency of PWR under
conditions with target goals greater than 30% of body
weight would follow a similar rule.
The participants in this study were all young adults
without known neuromusculoskeletal impairment.
Although there is n o evidence to suggest that the
processes underlying the learning of these types of
motor skills are different in older individuals o r in
individuals with disability, tests of such claims are
needed. Previous work examining the effects of aug-
mented feedback for motor learning in older ad~lts23.2~
and individuals with stroke'" has revealed a similar
pattern of improvement with practice when compared
992 . Winstein et al
with younger adults and age-matched control subjects,
respectively. Differences were revealed in the absolute
magnitude of best performance but not in the rate of
improvement. Thus, we would predict that if this study
were conducted with older individuals or individuals
with impairment, the same pattern of results would
emerge but the magnitude of error would be greater.
Conclusion
The results of this study showed that practice conditions
with postresponse feedback were more effective for
learning a PWB skill, as measured by a 2-day retention
test, than was a practice condition with concurrent
feedback. Further, provided with conditions of practice
that facilitated active problem solving, young adults
without known neuromusculoskeletal impairment were
able to learn this static PWB skill quite well (ie, accuracy
to within 5% of body weight). These results are consis-
tent with a more general hypothesis that conditions of
practice (eg, concurrent feedback) that provide a direct
prescription for action may be beneficial for immediate
performance but detrimental for long-term learning. In
contrast, conditions of practice (eg, postresponse feed-
back) that promote active problem solving such as the
development of specific sensorimotor transformations
may be relatively detrimental for immediate perfor-
mance but beneficial for longer-lasting motor learning.
References
1 Baxter ML, Allington RO. Koepke GH. Weight-distribution variable
in the use of crutches and canes. PIA?, 'l'hn. 1969;49:360-365.
2 Warren CG, Lehmann JF. Training procedures and biofeedback
methods to achieve controlled partial weight bearing: an assessment.
Arch Phys Med Rehabzl. 1975;56:449-45.5.
3 Warinstedt GT, Herman RM. Use of sugmcnted sensory feedback to
achieve symmetrical standing. Wiys T h n . 1978:58:553-559.
4 Winstein CJ, Christensen S. Fitch N. Effects of summary knowledge
of results on the acquisition and retention of partial weight bearing
during gait. Phwical Thetap? Pmctice. 1993;2:40-51.
5 Salnioni AW, Schmidt RA, Walter CB. Knowledge of results and
motor learning: a review and critical reappraisal. Pvrhol Bull. 1984;95:
355-386.
6 Winstein CJ. Knowledge of results and motor learning: implications
for physical therapy. Phys Ther. 1991;71:140-148.
7 Schmidt RA, Young DE, Swinncn S, Shapiro DC. Summary knowl-
edge of results for skill acquisition: support for the guidance hypoth-
esis. J Exp Psychol Learn hfem C o p . 1989;3 5352-359.
8 Swinncn SP, Schmidt RA. Nicholson DE, Shapiro 1)C. lriformation
feedback for skill acquisition: instantaneous knowledge of results
degrades learning. J Exp Psychol Learn hfem Cogr~.1990;16:706-716.
9 Vander Linden DW. Cauraugh JH, Greene TA. The effect of fre-
!
quency of kinetic feedback on learning an isometric force production
task in nondisabled subjects. Phys Ther. 1993;73:70-87.
[
i
10 MTinsteinCJ, Pohl PS, Lewthwaite R. Effects of physical guidance
and knowledge of results on motor learning: support for the guidance
hypothesis. Res Q Exerc Sport. 1994;65:316-323.
Physical Therapy . Volume 76 . Number 9 . September 1996
 11 U'instein CJ* Schmidt RA. Reduced frequency of knowledge of 19 Annett J. Learning a pressure under conditions of immediate and
results enhances motor skill learning. J Exp Pryrhol Learn Mem C o p . delayed knowledge of results. QJExp Psychol. 1959;11:3-15.
1990;16:677.-691.
20 Squire LR. h f e m q and Brain. NewYork, NY Oxford Lrniversity Press
12 Bjork RA., Bjork EL. A new theo~yof disuse and an old theory of Inc; 1987: chap I I.
stimulus fluctuation. In: Healy AF, ksslyn SM, Shiffrin RM, eds. From
21 Lee M, Moseley A, Refshauge K. Effect of feedhack on learning a
Learning Processes to C o p i t i w Processes: E.s.says in Honor of William K Estes,
vertebral joint mobilization skill. Phys Ther. 1990;70:97-104.
Vohtm 2. Hillsdale, NJ: Lawrence Erlbaum Associates Inc; 1992:35-67.
22 Schmidt RA, Sherwood DE. At1 inverted4 relation hetween spatial
13 Schmidt RA. FI-equent augmented feedhack can degrade learning:
error and force requirements in rapid limb movements: further
evidence and interpretations. In: Stelmach GE, Requin J , eds. Tutorials
e\idence for the impulse-variability model. J Exp Psycho1 Hum Percqt
in hlotor K?uroscience. Dordrecht, the Netherlands: Kluwer- Group;
Pofurm. 1982;8:158-170.
1991:59-75.
23 Schmidt RA, Zelaznik HN, Hawkins B, et al. Motor-output variabil-
14 Schmidt RA, Bjork RA. New conceptualizations of practice: com-
ity: a theory for the accuracy of rapid motor acts. Psychol RCIJ.1979;86:
mon principles in three paradigms suggest new concepts of training.
415-451.
Psychological Srience. 1992;3:207-217.
24 Swanson LR, Lee TD. Effects of aging and schedules of knowledge
15 Singer R.N, Pease D. Effect of guided vet-sus discove~ylearning
of results on motor learning. J Gerontol. 1992;47:P406-P411.
strategies on learning, retention, and transfer of a serial motor task.
Rm Q. 1976:,47:788-796. 25 Behrman AL, Vander Linden DW, Cauraugh JH. Relative frequency
knowledge of results: older adults learning a force-time modulation
16 Minor MA, Minor SD. Patient Carp Skilk. Reston, Va: Reston Pub-
task. Journal of Human Movement Studics. 1992;23:233-250.
lishing; 198,4.
26 Merians A, Winstein CJ, Sullivan K, Pohl PS. Effects of feedhack for
17 Bohannon RW, Waters G, Cooper J. Pel-ception of unilateral lower
motor skill learning in older healthy subjects and individuals post
extremity weightbearing during bilateral upright stance. Perccpt Mot
stroke. Neurology Report. 1995;19:23-25.
Skills. 1989;liS:H75-880.
18 B W Statistical Softr~~ar Manual, Rplease 7. Los Angeles, Calif:
Llnivcrsity of California Press; 1992.

Physical Therapy . Volume 76 . Number 9 . September 1996 Winstein et a1 . 993

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