Physical Therapists Talk Too Much!

“Physical therapists talk too much.”

This was how my professor started the presentation. The class was “Principles of Motor Learning and Motor Control” and the presentation was on feedback. After this statement, our professor then gave us a task. He asked us to go to a physical therapy gym and just close our eyes and listen. What did we hear? Who did we hear? What were they saying? He argued that in most instances you’d hear the physical therapist talking and probably talking too much.

To understand why therapists should talk less, we need to review the principles of feedback in motor learning. There is task-intrinsic feedback that the performer receives themselves through their sensory systems, and then there is augmented feedback that is additional information, usually provided verbally by the therapist (although there are other methods of providing feedback including visual and kinesthetic). In most instances, verbal feedback should be minimal in order to maximize learning and skill acquisition.

Too much feedback can overwhelm the individual. When learning a new task or exercise, a significant amount of the person’s attention is devoted to performing the task. If too much attention is devoted to interpreting verbal instructions and feedback, the individual’s ability to internally process and learn how to complete the task is impaired. Additionally, an individual may become dependent on verbal cues. In this circumstance, the performance of the task may improve, but retention and transfer to similar tasks are worse.

Why do physical therapists still tend to talk too much and provide too much instruction and feedback? We want it to seem like we are providing skilled services. We want to show this for the patient, for the insurance companies, and even for ourselves. Sometimes we fall for the trick of seeing an improvement in performance of the skill or exercise during that session, but this doesn’t necessarily transfer to improved retention of the skill later on or transfer to similar skills. Also, we feel pressure from the insurance companies to demonstrate skilled and necessary services. I remember in one of my clinical-internships writing, “PT provided 75% verbal cues throughout gait training for step length and heel strike” (or something of that nature). In retrospect, providing that much cueing while a person was walking seems absurd. Last but not least, as therapists (and humans) we have a desire to feel like we are important and needed. Intuitively, it seems that the more instructions and feedback we provide, the more we can help the patient. However, based on the research and what we’ve been taught, this isn’t the case. There are many other effective ways to use our skills and knowledge to optimally help our patients.

By limiting feedback and instructions to only the vital key components, you allow the individual to be active in learning the skill and allow internal processing and learning to occur. There are a variety of ways to limit the amount of verbal feedback and instruction you provide. Let’s briefly review a couple of the different ways to provide feedback…

• Continuous: providing feedback the whole time. We want to avoid this for the reasons stated above.
• Concurrent: providing feedback during the task performance. This can overwhelm the individual or the individual may become dependent on it.

Here are some ways to limit feedback and improve learning and retention:

• Delayed: provide feedback after the trial and after a brief pause. The pause allows time for the individual to internally process any task-intrinsic feedback
• Faded: start by providing a lot of feedback and then decrease the amount over time
• Intermittent: provide feedback only after some trials. Examples of this are summary feedback or averaged feedback that is provided after a number of trials are completed
• Bandwidth: provide feedback only when the amount of error falls outside a certain amount or percentage. For example, you only provide feedback if there is 5% error or greater.
• Self-selected: the individual determines when they want feedback and can ask for it specifically

Transitional: therapist asks leading questions that help the individual internally process their mistakes and make appropriate corrections. The person can verbally describe to the therapist what they think they did wrong.

What are the characteristics of good verbal instructions, feedback, or cues? They should be short, concise, and draw attention to only the critical elements of the task or exercise. They should be limited in quantity and focused on the strategies for achieving the goal of the task. It should be timely to allow for internal processing. As Richard Magill writes, “verbal instructions should present the minimum amount of information necessary to communicate what a person needs to do to perform a skill. Providing too much information in verbal instructions can be like providing no verbal instructions at all.”

Verbal feedback and instructions are a critical aspect of physical therapy and learning (or re-learning) different skills, exercises, and movements. In fact, feedback can be absolutely necessary when learning a skill, especially if the individual has sensory or perceptual impairments. However, too much feedback and verbal bombardment can interfere with the normal internal processes of motor learning and skill acquisition.

Don’t throw the baby out with the bathwater. Verbal feedback and instruction is important and still can be utilized…just don’t talk too much!

via Luke Pedersen, PT, DPT

Reference

Textbook: Motor Learning and Control: Concepts and Application By Richard A. Magill

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