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Listen! Why Use Auditory Feedback?


August 3, 2018

Listen!

It is important to listen in order to improve the
 speed, timing, symmetry and rhythm of movements


Tell me and I forget. Teach me and I remember. Involve me and I learn.
Benjamin Franklin

• How effective is the feedback you provide to your clients when helping them learn new movement patterns?

• What is your style of intervention? Telling, teaching, or involving?

• What type of feedback do you provide? Visual, auditory, tactile, or a combination?

• Is your feedback immediate or do you decrease and fade it as a patient progresses?


Why use auditory feedback?

This is an interesting question that can be applied to people of all ages.  For example, watching my two young kids learning new physical skills, I have to decide when is it necessary to step in and when do I let them learn from their mistakes? What strategies help people learn faster and retain new movement patterns?

For our clients, we want to help them learn new movement patterns that are efficient, safe, and effective.  To achieve this, we must consider the type of feedback we provide. We need to connect with them on multiple levels:
  • Involving clients helps them to learn from their mistakes and problem solve to correct their errors/movement patterns.
  • Engaging them promotes cognitive awareness of movements that were previously automatic and unconscious.
  • Highlighting improvements results in better performance and outcomes.
  • Motivating them builds on the eagerness to perform more repetitions and practice! 3,4,6
When designing a program that incorporates feedback there are many influential factors to consider 6-8:
 

 
Today’s discussion will focus on modality, specifically auditory feedback and why you may use auditory vs visual or tactile feedback.  I have used feedforward cues such as a metronome but a limited amount of auditory feedback within my practice due to the limited resources. Audition, the sense of hearing, enables the perception of rhythm and speed. Auditory feedback provides temporal information such as speed and timing. It improves step symmetry and enables the perception of periodicity, rhythm, and cadence.

The study of Ronsse et al. (2011) 5 highlights the importance of choosing the right modality for the intended goal. Two groups of participants acquired a new bimanual coordination pattern. Performers had to continuously move both wrists back-and-forth while maintaining 90°-out-of-phase (a quarter of the cycle) using visual input reflecting coordination as well as auditory pacing to integrate the timing of both hands. Behavioral findings revealed that the visual group became dependent on this augmented feedback performance, whereas the auditory group performed equally well with or without augmented feedback by the end of practice. Functional magnetic resonance imaging results corroborated these behavioral findings. The visual group showed increased neural activity in sensory-specific areas during practice which is indicative of reliance on augmented feedback. Conversely, the auditory group showed decreased neural activity in areas specifically associated with cognitive/sensory monitoring of motor task performance.  This study is one of many that explains the benefits of using auditory feedback for the timing of movements.6 Visual feedback is important for the acquisition of a skill but it is important to gradually decrease visual feedback for effective long-term retention.  Visual feedback also may be better to improve spatial parameters of movement vs temporal parameters (timing of movements).6

The following video demonstrates how auditory feedback (in the forefoot and rearfoot) from the Balance Matters system improves the timing of movements. The individual is blind and could not stand tall with good posture without falling backwards.  He appears to be looking down but his flexed posture was actually stabilizing him. Initially he worked on standing upright using auditory feedback from the footpads under him.  If he started to lose his balance backwards he shifted his weight forward faster to activate the front clickers to prevent a fall.  Once he was able to stand with good posture he progressed with head motions and arm motions and standing on various type of footpads to maintain good postural control. He then progressed to dynamic stepping. Watch as he achieves improved stability and posture after six weeks as he receives auditory feedback to quickly shift his weight forward and improve the speed and timing of his lateral weight shift to sidestep. Although he has improved, he still has goals to continue to improve his postural control and sensory orientation.


   

Reflecting on the verbal cues I provided, it may have been more effective to increase his external focus of attention as I mentioned in my last blog. Instead of “shift your weight to your toes or front part of your foot” being more specific by instructing “when you hear the front clicker of the pads, push through it to make it quiet”.  I could have used another cue to increase his awareness to the sound of the clicker to improve the speed of his weight shifting to discourage losing balance backwards.  I believe our instructions, cues and feedback still needs to be researched further to achieve optimal outcomes in various stages of rehab.
I love how learning is a two-way street and that our clients also teach us how to become better clinicians. This client’s blindness brought to light the degree to which I rely on visual demonstration.  I realized how important auditory and tactile cues are in helping to change movement patterns. Try Balance Matters to improve the timing and symmetry of movements. Stay tuned for another blog and video demonstrating how to use auditory feedback for the timing of weight shifting during sit to stand and stand to sit transfers and how to prevent “plops”.

References
  1. Chiviacowsky, S., & Wulf, G. (2007). Feedback after good trials enhances learning. Research Quarterly for Exercise and Sport, 78, 40–47
  2. Dozza M, Horak FB, Chiari Auditory biofeedback substitutes for loss of sensory information in maintaining stance.Exp Brain Res. 2007 Mar; 178(1):37-48.
  3. Huang, H., Wolf, S. L., & He, J. (2006). Recent developments in biofeedback for neuromotor rehabilitation. Journal of Neuroengineering and Rehabilitation, 3(1), 1–12.
  4. Molier, B., Van Asseldonk, E., Hermens, H., & Jannink, M. (2010). Nature, timing, frequency and type of augmented feedback; does it influence motor relearning of the hemiparetic arm after stroke? A systematic review. Disability and Rehabilitation, 32(22), 1799–1809.
  5. Ronsse, R., Puttemans, V., Coxon, J. P., Goble, D. J., Wagemans, J., Wenderoth, N., & Swinnen, S. P. (2011b). Motor learning with augmented feedback: Modality-dependent behavioral and neural consequences. Cerebral Cortex, 21(6), 1283–1294. 5. Sigrist, R., Rauter, G., Riener, R. et al. Augmented visual, auditory, haptic, and multimodal feedback in motor learning: A review. Psychon Bull Rev (2013) 20: 21.
  6. Sigrist, R., Rauter, G., Riener, R. et al. Augmented visual, auditory, haptic, and multimodal feedback in motor learning: A review. Psychon Bull Rev (2013) 20: 21
  7. Tzetzis, G., Votsis, E., & Kourtessis, T. (2008). The effect of different corrective feedback methods on the outcome and self confidence of young athletes. Journal of Sports Science and Medicine, 7, 371–378
  8. Wulf, G., & Shea, C. H. (2002). Principles derived from the study of simple skills do not generalize to complex skill learning. Psychonomic Bulletin & Review, 9(2), 185–211