Effects of different visual presentation methods on movement procedure learning

Abstract

[Purpose] There is no established learning methods for movement procedures for activities of daily living. Patients with higher brain dysfunction and other disorders encounter challenges with movement procedures. Therefore, as a basic study on the memorization methods for movement procedures, we examined the differences between the effects of two memorization methods on healthy participants. [Participants and Methods] Forty student participants were asked to memorize and recall 10 movement elements. The control condition comprised all presented movements; whereas the intervention method comprised two movement elements (one block) each. The number of sets wherein all 10 movements were recalled and the number of consecutive recalls per set after 7 days were compared between the two conditions. [Results] The intervention method engendered significantly fewer sets that were recalled and significantly more consecutive recalls. [Conclusion] It is suggested that the method of presenting the movement procedure in smaller pieces is a more effective memory method than presenting the entire procedure.

INTRODUCTION

Physical therapy involves the practicing of movements used in daily life. The reason behind movement difficulties is believed to be a decline in motor function, and accordingly, physical training is provided. However, even in participants with the necessary motor functions, they may still make mistakes if not appropriately instructed regarding the movement procedures. For example, a stroke patient with hemiplegia can practice walking with a cane if the physical therapist provides verbal instructions; however, some participants make mistakes without instructions.

Exercise requires not only the necessary physical functions and movement skills but also semantic memory of the movement. However, movement procedures cannot be learned from textbooks, and for patients with dementia or higher brain dysfunction, physical therapists often concede halfway through the rehabilitation, proclaiming, “It’s no wonder they can’t remember the procedures”.

Semantic memory involves the processes of “inscription, retention, and recall”, which are important for learning movements. Retention involves “rehearsal”, which allows for long-term memory transfer. For inscription, instructional methods need to be devised depending on higher brain dysfunction.

Trial-and-error learning¹⁾ produces “learned helplessness” with continuous unsuccessful practice attemps^{2, 3)}, potentially affecting other types of learning. This is also likely to occur with repetitive practice and is often experienced while rehabilitating patients with cerebrovascular disorders. “Errorless discrimination learning” is effective for such problems, and there has been a study using various intervention methods based on the concepts of applied behavior analysis⁴⁾. Previous study have reported that written information input is more effective than verbal instructions for remembering movement procedures⁵⁾; however, most of these studies were based on single-case designs and their results have not been generalized. Furthermore, in these reports, although the intended movement procedure was learned, the cognitive function test results remained unchanged. There are also reported study on efficient memory methods in educational settings⁶⁾. Motor memory interventions are considered an essential strategy to maximize the effectiveness of rehabilitation.

In this basic research on memory methods for movement procedures, the effects of two different memory methods were examined in young healthy individuals. Here we established efficient memorization methods, focusing on a single-case design with actual patients, such as patients with hemiplegia.

PARTICIPANTS AND METHODS

The participants comprised 40 students (20 males and 20 females) who were enrolled in the Department of Physical Therapy at Ryotokuji University, College of Health Sciences. Their ages were 20.4 ± 1.9 years (mean ± standard deviation). Participants were informed orally and in writing regarding the purpose and content of the study and considerations for personal information, and consent was obtained (Ryotokuji University Ethics Review Committee No. 20-16, International University of Health and Welfare Ethics Review Committee No. 21-Ig-183).

The participants performed a memory and recall task involving 10 movement elements; memorizing the movements by looking at pictures of the steps. The task movements comprised 10 standing postures with different upper and lower limb postures. There were two movement types (Movements A and B, Fig. 1) and memorization methods (control and intervention methods). Movements A and B constituted the same 10 movement elements in different orders.

Fig. 1.

Two types of operating procedures and elements.

The procedures of the two memorization methods are shown in Fig. 2. In the control condition, participants memorized the movement elements in order from 1 to 10 while looking at a piece of paper (A3 size) on which the 10 movements were drawn in sequence. In the intervention method, five sheets of paper (A3 size) with the two movement elements drawn in order (10 movements divided into two movements each) were prepared, and participants were asked to memorize them consecutively from 1 to 10 (5 blocks in total). The examiner provided the participants a piece of paper with one block drawn on it and asked them to memorize the movements. Once the participants considered themselves to have memorized the block, the examiner checked the participants’ movements (Check) to determine if they matched those on the paper. If the participants’ movements matched the picture, the examiner would move on to the next block. If the movement was incorrect, participants were asked to memorize the wrong block again.

Fig. 2.

How to proceed with the two memory methods.

*1: The examiner checks whether the participant can perform the block without looking at the presented block. If correct, the next block was presented. If incorrect, the incorrect block is memorized again. *2: Implement the movement elements 1–10 in sequence. *3: Incorrect answers will result in relearning movement elements 1–10. *4: Incorrect answers, learn in order from blocks the block you got wrong.

In both conditions, each test set comprised a 30-second task study, a test to check whether the participants could perform the memorized movement, an evaluation of the movement (video evaluation), and feedback regarding the incorrect movement. The total duration of the test, video evaluation, and feedback was 1 min.

During the test, participants were instructed to perform the entire procedure, and the number of consecutive correct movements from movement element 1 was the primary endpoint. The movements during the test were videotaped, and the movie was viewed by two judges to determine whether the movement was appropriate. The judges, a physical therapist with 10 years of clinical experience and a 21 year-old female student who was enrolled in the physical therapy department, were fully informed of the purpose and methods of the study and asked for their cooperation. By having two examiners, the validity of the test results was considered. In addition, the examiners were selected as those who were not physically or mentally ill and those who understood the main purpose of the study and gave their consent. The movements were judged to be a success if the pictures of the movement elements matched the video images and the movement speed remained constant. The movement speed was confirmed by viewing the movie while listening to the sound of a metronome, using the movement tempo of 80 bpm as a guide. If two examiners who watched the video at the same time judged that the posture and the movement speed were consistent, it was judged as correct, and if either of them judged it to be insufficient, it was judged as incorrect. Following the evaluation, the examiner provided feedback to the participants by indicating the incorrect movement. If there was an incorrect movement in the control condition, participants relearned using a piece of paper with 1–10 movement elements drawn on it. If an incorrect procedure was presented in the intervention method, participants began learning the next task from the block in which the error was made. The task was terminated when the participant was able to correctly recall all the movements in the test in the order of 1–10. A crossover design was used for the study. Stratified randomization was used for memory condition assignment (control condition and intervention method) and movement type (movements A and B) to ensure the equality of movement type and gender. The two conditions were separated every 7 days. The assignments were performed in a private room with minimal external stimuli.

For each set of test results, the movement orders and movement element combinations were recorded. For the intervention method, the block numbers on the participants’ forms were recorded at the beginning and end of each set. The examiners determined the percentage of correct responses per condition, set, movement element, number of consecutive recalls per set, number of sets wherein all 10 movements were recalled, and number of consecutive recalls 7 days after the task was completed.

The Wilcoxon signed rank test was used to compare the difference in the distribution center (median) between the two conditions, number of sets wherein all 10 movements were recalled, number of consecutive recalls per set (up to the set wherein at least one person correctly answered 10 movements), and number of consecutive recalls after 7 days. IBM SPSS Statistics ver. 26 (IBM Corporation, Tokyo, Japan) was used to perform statistical analysis with a significance level of 1%.

RESULTS

The set number and participant number of who were able to recall all movement elements are shown in Table 1. The set number wherein all movement elements were recalled was 11.0 in the control condition and 6.0 in the intervention method; significantly lower in the intervention method than in the control condition (p<0.01).

Table 1. The set number and participant number of who were able to recall all movement elements.

Methods	Set															Median (IQR)
	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15
Control condition	0	0	0	0	0	0	0	0	5	10	6	6	5	5	3	11.0 (10.0–13.0)*
Intervention method	0	0	0	0	13	9	10	5	3	−	−	−	−	−	−	6.0 (5.0–7.0)*

IQR: interquartile range. *Comparison of two conditions; p<0.01.

The movement elements that were recalled in which all participants performed the “task-test” in both conditions and the number of consecutive recall after 7 days are shown in Table 2. Median serial recall was 4.0 for one set, 5.0 for two sets, 5.4 for three sets, 6.0 for four sets, 7.0 for five sets, 6.5 for six sets, 6.8 for seven sets, and 6.6 for eight sets in the control condition. The median number of serial recall in the intervention method was 5.0 for one set, 6.5 for two sets, 7.7 for three sets, 8.5 for four sets, 9.0 for five sets, and 10.0 for six sets and thereafter, significantly lower in the intervention method than in the control condition with each set (p<0.01); 0.6 in the control condition and 6.6 in the intervention method, significantly fewer in the intervention method than in the control condition (p<0.01).

Table 2. Number of consecutive plays of the movement elements in the set, after 7 days.

	n	Control	n	Intervention
1 Set	40	4.0 (3.4–4.8)	40	5.0 (4.0–6.0)*
2 Set	40	5.0 (4.0–5.7)	40	6.5 (6.0–7.0)*
3 Set	40	5.4 (5.0–6.0)	40	7.7 (7.2–8.0)*
4 Set	40	6.0 (5.0–7.0)	40	8.5 (8.1–9.3)*
5 Set	40	7.0 (6.2–7.8)	40	9.0 (8.0–10.0)*
6 Set	40	6.5 (6.0–7.0)	27	10.0 (9.0–10.0)*
7 Set	40	6.8 (6.1–7.5)	18	10.0 (9.2–10.0)*
8 Set	40	6.6 (6.3–7.8)	8	10.0 (9.3–10.0)*
After 7 days	40	5.6 (5.0–6.0)		6.6 (6.0–7.3)*

*Comparison of two conditions; p<0.01. Median (IQR). IQR: interquartile range.

The correct percentage for each condition, set, and movement element are presented in Table 3. The number of sets in the control condition for which the percentage of correct respondents for each movement element was 100% was one set for elements 1–3, nine sets for element 4, 14 sets for element 5, 15 sets for elements 6 and 7, four sets for element 8, 13 sets for element 9, and seven sets for element 10. However, for steps 3 and 4, the percentage of correct responses reached 100%, fell below 100% once, and then returned to 100% again. The set number in which the percentage of correct responses for each procedure reached 100% was one set for elements 1–4, three sets for element 5, eight sets for elements 6 and 7, seven sets for element 9, and four sets for element 10 in the intervention method. The number of blocks presented in the task study was 10 participants up to block 2 and 30 participants up to block 3 in one set, The 13 participants up to block 4 and 27 participants up to block 5 in two sets, and all participants reached set 5 in three sets. The presenting blocks (start to end) for each set were 3–4 for 13 participants in the second set, 3–5 for 27 participants, 3–5 for 35 participants in the third set, and 4–5 for 15 participants in the fourth set (Table 4).

Table 3. Percentage of correct respondents per movement element in the two methods.

Table 4. Percentage of correct responses to the presented blocks and movement elements in the intervention condition (Learning start block−Learning end block).

Arrows indicate blocks from the start of the study to the end of the learning block.

DISCUSSION

This study compared two memory methods results for learning a movement procedure. The two types of movements to be memorized were the same 10 movement elements in different orders. A crossover design was used in the study, with an equal distribution of gender, memory method, and movement type between the two memory methods. These excluded the effects of participant differences, gender, movement difficulty, and the order in which the two memory methods were performed. Thus, differences between the two memory methods affected the results.

The number of consecutive recalls was significantly higher for the intervention method than for the control condition in all cases. The number of sets in which everyone was able to recall the task behavior was significantly less for the intervention method than for the control condition. These results indicate that dividing the movement elements that were to be memorized into smaller sets allowed for more efficient memory. Short-term memory involves a process called rehearsal, in which the information to be remembered is repeated and retained in the mind. The storage capacity of short-term memory is reported to be 4 ± 1 chunks⁷⁾. A chunk is a block of several pieces of information. Chunking stored information has been reported to improve memory efficiency^8,9,10). Rehearsal can be divided into maintenance rehearsal (simply repeating a phrase) and elaboration rehearsal (repeating a phrase while associating it with something or imagining it). Elaboration rehearsals are more likely to be transferred to long-term memory than maintenance rehearsals^11,12,13).

The number of consecutive recalls for each set and 7 days later was higher in the intervention method than in the control condition. This suggested that the rehearsal may have become an elaboration rehearsal or that the movement elements were chunked and remembered in the intervention method. Karpicke et al.¹⁴⁾ reported that repeated testing of recall of all movement elements was effective for memory retention. Both conditions were tested for recall of all movement elements. A block is memorized and the examiner gives a picture of the next block if the participant is able to perform those two movement elements in the intervention method. This block-by-block execution of movement elements and judgment by the examiner could have served as a test of some of the movements.

In this study, participants were told that the number of consecutive recalls from movement element 1 would be the primary record with respect to correct responders per set and movement element. Therefore, it is expected that participants would normally recall from behavior element 1, and that 100% of the correct respondent rate for all participants would also be reached in the order of the movement elements. However, the control condition results showed that after the correct response rate for movement elements 1–3 reached 100% in one set, the correct response rate for behavior element 3 did not stabilize, and did not continue to be 100% until 11 sets later. This indicates that memory retention of movement element 3 requires cumulative learning. Conversely, there was a participant who correctly answered movement element 10 from the first set and maintained a 100% correct rate for movement element10 after the seventh set. Furthermore, many participants correctly answered the movement elements after movement element 3 before the memory of movement element 3 was established. The intervention method results showed that even though the participant was memorizing the last block of 5 movement elements in the learning time in the set, the movement elements in the middle of the sequence were forgotten in the whole-movement test. From these results, it is possible that the first and last ones presented are more likely to be remembered when the whole-movement elements task to be memorized are done. Glanzer and Cunitz¹⁵⁾ found that in word memory, the first and last order in which words are presented have higher recall rates. The results of the present study support the Primacy effect and the Recency effect.

Limitations of this study include method and participant factors. We did not evaluate and record the rehearsal method, number of times, or presence or absence of chunking, so a definitive statement about these factors cannot be made. We have not conducted a condition that would clarify the differences in the method of memorizing each block in the intervention method in combination with a block-by-block test. We cannot examine the effects of attention and arousal. Therefore, it is difficult to determine the effects of rehearsal, chunking, and partial testing, as well as the effects of attention and arousal based on this study alone. As for the participants, the study is limited to college students and it is difficult to generalize the results to healthy elderly, dementia patients, hemiplegic patients, etc. However, it is suggested that if clinical application becomes feasible, movement acquisition can be achieved in a short period, which will have a positive impact on the level of independence in activities of daily living.

Funding

No specific funding was used for this study.

Conflict of interest

There are no conflicts of interest to disclose.