Motor learning: A practical framework for paediatric physiotherapy

Development and content validation of the Upper Limb-Motor Learning Strategy Tool for cerebral palsy

PURPOSE

To describe the development and content validation of the Upper Limb-Motor Learning Strategy Tool (UL-MLST) that aims to guide clinicians on how to implement and document the motor learning strategies used in the upper limb therapy approaches for children with cerebral palsy.

METHODS

The study consists of two main stages (1) item generation and development and (2) content validation and refinement. The UL-MLST Online Training Program, Manual and Checklist were developed by the authorship group in stage one. In stage 2, two experts evaluated the UL-MLST regarding the Relevance, Coherence, and Significance of the individual strategies and whether the tool is Relevant, Comprehensive, and Clinically useful.

RESULTS

Of sixty-two strategies included in the UL-MLST, 52 strategies were rated as being either "Moderately" or "Highly" Relevant, Coherent, and Significant. Ten strategies did not achieve mutual agreement; however, they did not meet the criteria for deletion and were revised according to expert feedback. Overall, the UL-MST was judged to be Relevant, Comprehensive, and Clinically useful.

CONCLUSIONS

The UL-MLST provides a valid tool to support clinicians in the implementation of the motor learning strategies for children with cerebral palsy.IMPLICATIONS FOR REHABILITATIONThe Upper Limb- Motor Learning Strategy Tool (UL-MLST) Online Training Program, Manual, and Checklist provide a comprehensive package of resources to support the application of motor learning strategies in upper limb therapy for children with cerebral palsy.The UL-MLST provides clinicians with a valid tool for self-appraising the implementation of motor learning-based therapies.The tool has the potential to improve fidelity, enhance the quality, and ensure consistency of evidence-based, task-focused approaches of therapy.

Development of a Play-Based Motor Learning Approach (A.MO.GIOCO) in Children with Bilateral Cerebral Palsy: Theoretical Framework and Intervention Methodology

The early intervention of motor training based on specific tasks and parent empowerment represents the new paradigm for the rehabilitation of children with Cerebral Palsy (CP). However, most published studies address the problem of the effectiveness of rehabilitation intervention without describing the treatment methodology or briefly mentioning it. The purpose of the study is to illustrate the development of a play-based motor learning approach titled A.MO.GIOCO (Apprendimento MOtorio nel GIOCO) and its systematization. Fifteen children aged between 2 and 6 years with bilateral CP will be enrolled and treated for 6-8 weeks (48 h). Motor Teaching methods applied by senior therapists have been extensively described, starting from rehabilitation goals and proposed therapeutic play activities, tailored to the functional profile of each child. This child-friendly rehabilitative approach (A.MO.GIOCO) refers to the systemic cognitive model of learning and movement control and is implemented in the context of spontaneous play activities and in the therapist-child-family interaction. In this study the theoretical framework of the approach and the process followed by the therapists to transfer it into rehabilitative practice are highlighted. As a result, an operational guide has been created. Further studies will explore the efficacy of the proposed standardized approach.

Are they really motor learning therapies? A scoping review of evidence-based, task-focused models of upper limb therapy for children with unilateral cerebral palsy

PURPOSE

To identify the specific motor learning (ML) theories underpinning evidence-based, task-focused upper limb models of therapy for children with unilateral cerebral palsy; and to document the strategies used in the operationalisation of these theories.

MATERIAL AND METHOD

This scoping review searched for relevant studies using eight electronic databases. A list of 68 ML strategies and accompanying definitions was developed for data extraction. Three classifications; adequate, inadequate or not described were used to rate the description of ML strategies. A corresponding colour-coding system was used to provide a visual summary.

RESULTS

There is a limited description of the ML theories and strategies used to operationalise these theories in existing models of evidence-based upper limb therapy. Of 103 therapy protocols included, only 24 explicitly described the guiding ML theory. When described, there was significant variation in the underlying theories, leading to significantly different focus and content of therapy. Of the 68 ML strategies, only three were adequately described.

CONCLUSIONS

To support treatment fidelity and the implementation of evidence-based, task-focused models of upper limb therapy in clinical practice, future research needs to provide explicit details about the underlying theories and strategies used in the operationalisation of these theories.Implications for rehabilitationEvidence-based models of upper limb therapy purport to be based on motor learning theory, however, most provide a very limited description of the theories and strategies used.Dosage of practice is only one element that is specific to a therapy approach and other elements guided by the principles of type of task and type of feedback should be considered.To support the implementation of evidence-based approaches in clinical practice, and improve treatment fidelity, it is important for researchers to define the theories that guide therapy approaches and explicitly describe the strategies used to operationalise these theories.

Exploring Physiotherapists' Use of Motor Learning Strategies in Gait-Based Interventions for Children with Cerebral Palsy

Aim: This study investigated physiotherapists' experiences using motor learning strategies (MLS) in gait-based interventions for children with cerebral palsy (CP). The objectives were to explore how child characteristics, physiotherapist decision-making, and treatment approach influenced intentional MLS use.Methods: Semi-structured interviews were conducted with eight physiotherapists who provided gym- and/or Lokomat-based treatment to children with CP. Interviews were analyzed using directed content analysis and a modified constant comparison method.Results: Three themes described their experiences: (1) MLS use is driven by the unique aspects of the child, physiotherapist, and intervention; (2) The use and description of motor learning content varies among physiotherapists; and (3) The Lokomat is "the same but different." Child characteristics were at the forefront of MLS selection in both interventions. The terminology used to describe MLS use varied considerably among therapists. They used similar clinical decision-making in gym- and Lokomat-based interventions.Conclusions: Conscious reflection on the factors affecting MLS use could facilitate related clinical decision-making in physiotherapy interventions for children with CP. Increased awareness of MLS and use of a structured framework for reporting MLS are required to promote intentional MLS use and generate CP-specific evidence-based MLS research.

From Motor Learning Theory to Practice: A Scoping Review of Conceptual Frameworks for Applying Knowledge in Motor Learning to Physical Therapist Practice

BACKGROUND

The importance of motor learning knowledge for physical therapist practice is well known; however, its application is lacking. Conceptual frameworks that place motor learning knowledge within a clinical context are a potential mediator to overcome this gap.

PURPOSE

This study aimed to conduct a scoping review of the literature to identify and describe the content of such conceptual frameworks in physical therapy/rehabilitation, including the approaches taken in their development and the "elements" or building blocks of motor learning-based interventions within each conceptual framework.

DATA SOURCES

The data sources used were PubMed, CINAHL, and PsychInfo databases.

STUDY SELECTION

Articles that were selected had a primary focus on motor learning and its application in physical therapy/rehabilitation and were published between 2000 and 2017.

DATA EXTRACTION

Twelve of 62 relevant articles met the inclusion criteria.

DATA SYNTHESIS

Papers attempted to translate theoretical knowledge into a coherent, clinically accessible conceptual framework via 3 main approaches: synthesizing selected motor learning elements into original new conceptual frameworks, mapping motor learning elements in current clinical practices, and assembling selected motor learning elements. The elements of motor learning that were common across papers included theoretical concepts (such as "meaningful goal setting" and "active involvement"); practice variables (including the type, frequency, and timing of feedback; the focus of instructions; task breakdown; and the amount, variability, and order of practice); and intervention strategies (task specific and mental practice). Psychological aspects related to self-efficacy and motivation were also considered integral.

LIMITATIONS

Papers published before the year 2000 were excluded.

CONCLUSION

The scoping review revealed that the presentation of motor learning elements in a coherent framework encompassed very diverse approaches and used different categorization systems. In addition, to fully grasp the complexity of clinical practice, motor learning should be coupled with other fields of knowledge.

Implementation of motor learning principles in physical therapy practice: Survey of physical therapists' perceptions and reported implementation

INTRODUCTION

The field of motor learning (ML) plays a pivotal role in physical therapy (PT), and its implementation has been shown to improve intervention outcomes. The objective of this study was to assess physical therapists' ML-related self-efficacy, self-reported implementation, and environmental workplace factors. An additional aim was to report the psychometric properties of a questionnaire that was developed to assess the above-mentioned constructs.

METHODS

An observational, cross-sectional survey was completed by 289 physical therapists (average age: 38.7 (9.7), with 11.3 (9.7) years of experience and 74% female). Construct validity, internal consistency, and test-retest reliability were tested. The main outcome measures were the scores of the three scales of the questionnaire, referring to self-efficacy in ML, implementation of ML principles, and workplace environment features.

RESULTS

The questionnaire had sound psychometric qualities. Respondents perceived ML as an integral part of PT. ML-related self-efficacy and implementation of ML principles were moderate (2.95/5 (0.7) and 3.04/5(0.8), respectively). PT practice had a significant effect on ML-related self-efficacy (p = 0.035) and implementation (p = 0.0031). Respondents who had undergone ML training in their graduate program reported higher ML-related self-efficacy (p = 0.007). Respondents who had postgraduate training in ML reported significantly more extensive implementation (p = 0.024). Lack of knowledge and lack of time were perceived as the major barriers to implementation.

CONCLUSIONS

Level of self-efficacy might be insufficient to support the systematic implementation of ML principles in practice. Addressing impeding individual- and organizational-level factors might facilitate ML self-efficacy and implementation. Postgraduate education facilitates ML implementation.

Client Perceptions of Task-Oriented Training at Home: “I Forgot I Was Sick”

Task-oriented training is a contemporary intervention based on behavioral neuroscience and recent models of motor learning. It can logically be guided by the theory of occupational adaptation. This report presents the perceptions of four participants who underwent task-oriented training at home (TOTE Home) for upper extremity hemiparesis following a stroke. Guided by principles of motor learning and the theory of occupational adaptation, a directed content analysis was used with field notes recorded during the TOTE Home. Three themes emerged: salience of the activity within context, desire for mastery by creating the just right challenge, and adapted self-perception of abilities. While motor learning principles informed the method of task practice and feedback, it was the person’s desire to perform meaningful, relevant activities that drove the adaptive process. This study provided insight in the perceptions and experiences of participants undergoing TOTE Home.

Changes in performance over time while learning to use a myoelectric prosthesis

BACKGROUND

Training increases the functional use of an upper limb prosthesis, but little is known about how people learn to use their prosthesis. The aim of this study was to describe the changes in performance with an upper limb myoelectric prosthesis during practice. The results provide a basis to develop an evidence-based training program.

METHODS

Thirty-one able-bodied participants took part in an experiment as well as thirty-one age- and gender-matched controls. Participants in the experimental condition, randomly assigned to one of four groups, practiced with a myoelectric simulator for five sessions in a two-weeks period. Group 1 practiced direct grasping, Group 2 practiced indirect grasping, Group 3 practiced fixating, and Group 4 practiced a combination of all three tasks. The Southampton Hand Assessment Procedure (SHAP) was assessed in a pretest, posttest, and two retention tests. Participants in the control condition performed SHAP two times, two weeks apart with no practice in between. Compressible objects were used in the grasping tasks. Changes in end-point kinematics, joint angles, and grip force control, the latter measured by magnitude of object compression, were examined.

RESULTS

The experimental groups improved more on SHAP than the control group. Interestingly, the fixation group improved comparable to the other training groups on the SHAP. Improvement in global position of the prosthesis leveled off after three practice sessions, whereas learning to control grip force required more time. The indirect grasping group had the smallest object compression in the beginning and this did not change over time, whereas the direct grasping and the combination group had a decrease in compression over time. Moreover, the indirect grasping group had the smallest grasping time that did not vary over object rigidity, while for the other two groups the grasping time decreased with an increase in object rigidity.

CONCLUSIONS

A training program should spend more time on learning fine control aspects of the prosthetic hand during rehabilitation. Moreover, training should start with the indirect grasping task that has the best performance, which is probably due to the higher amount of useful information available from the sound hand.

Reliability of the motor learning strategy rating instrument for children and youth with acquired brain injury

PURPOSE

To evaluate reliability and feasibility of the Motor Learning Strategy Rating Instrument (MLSRI) in children with acquired brain injury (ABI). The MLSRI quantifies the extent to which motor learning strategies (MLS) are used within physiotherapy (PT) interventions.

METHODS

PT sessions conducted by ABI team physiotherapists with a convenience sample of children with ABI (4-18 years) were videotaped and independently scored later by two raters trained in MLSRI use. Intraclass correlation coefficients (ICCs) and 95% confidence intervals (CIs) estimated intra- and inter-rater reliability.

RESULTS

Eighteen PT sessions were evaluated. Intra- and inter-rater reliability ICCs for total score were 0.86 (95% CI: 0.66-0.94) and 0.50 (95% CI: 0.08-0.78), respectively. MLSRI category ICCs were 0.56-0.86 (intra-rater) and 0.16-0.84 (inter-rater).

CONCLUSIONS

Intra-rater reliability of MSLRI total score was excellent. Moderate inter-rater reliability may partially be due to inconsistent item interpretation between raters. Revisions and further reliability testing are required before recommending the MLSRI for clinical and research use.

Documenting the content of physical therapy for children with acquired brain injury: development and validation of the motor learning strategy rating instrument

BACKGROUND

A goal of physical therapy interventions for children and youth with acquired brain injury (ABI) is the learning and relearning of motor skills. Therapists can apply theoretically derived and evidence-based motor learning strategies (MLSs) to structure the presentation of a task and organize the environment in ways that may promote effective, transfer-oriented practice. However, little is known about how MLSs are used in physical therapy interventions for children with ABI.

OBJECTIVE

The purpose of this study was to develop and validate an observer-rated Motor Learning Strategy Rating Instrument (MLSRI) quantifying the application of MLSs in physical therapy interventions for children with ABI.

DESIGN

A multi-stage, iterative, item generation and reduction approach was used.

METHODS

An initial list of MLS items was generated through literature review. Seven experts participated in face validation to confirm item comprehensiveness. In a content validation process, 12 physical therapists with pediatric ABI experience responded to a questionnaire evaluating feasibility and importance of items. Six physical therapy sessions with clients with ABI were videotaped at a children's rehabilitation center. The 12 physical therapists participated in a session where they: (1) rated session videos to test the MLSRI and (2) provided verbal feedback.

RESULTS

Revisions were made sequentially to the MLSRI based on these processes.

LIMITATIONS

The MLSRI was scored during videotape observation rather than being given a live rating, which may be onerous in certain settings and may influence therapist or child behavior.

CONCLUSIONS

Further reliability investigations will determine whether the 33-item MLSRI is of help in documenting strategy use during intervention, as an evaluation tool in research, and as a knowledge transfer resource in clinical practice.

Modified constraint-induced movement therapy or bimanual occupational therapy following injection of Botulinum toxin-A to improve bimanual performance in young children with hemiplegic cerebral palsy: a randomised controlled trial methods paper

Background

Use of Botulinum toxin-A (BoNT-A) for treatment of upper limb spasticity in children with cerebral palsy has become routine clinical practice in many paediatric treatment centres worldwide. There is now high-level evidence that upper limb BoNT-A injection, in combination with occupational therapy, improves outcomes in children with cerebral palsy at both the body function/structure and activity level domains of the International Classification of Functioning, Disability and Health. Investigation is now required to establish what amount and specific type of occupational therapy will further enhance functional outcomes and prolong the beneficial effects of BoNT-A.

Methods/Design

A randomised, controlled, evaluator blinded, prospective parallel-group trial. Eligible participants were children aged 18 months to 6 years, diagnosed with spastic hemiplegic cerebral palsy and who were able to demonstrate selective motor control of the affected upper limb. Both groups received upper limb injections of BoNT-A. Children were randomised to either the modified constraint-induced movement therapy group (experimental) or bimanual occupational therapy group (control). Outcome assessments were undertaken at pre-injection and 1, 3 and 6 months following injection of BoNT-A. The primary outcome measure was the Assisting Hand Assessment. Secondary outcomes included: the Quality of Upper Extremity Skills Test; Pediatric Evaluation of Disability Inventory; Canadian Occupational Performance Measure; Goal Attainment Scaling; Pediatric Motor Activity Log; modified Ashworth Scale and; the modified Tardieu Scale.

Discussion

The aim of this paper is to describe the methodology of a randomised controlled trial comparing the effects of modified constraint-induced movement therapy (a uni-manual therapy) versus bimanual occupational therapy (a bimanual therapy) on improving bimanual upper limb performance of children with hemiplegic cerebral palsy following upper limb injection of BoNT-A. The paper outlines the background to the study, the study hypotheses, outcome measures and trial methodology. It also provides a comprehensive description of the interventions provided.

Trial Registration

ACTRN12605000002684

Effects of intensive physiotherapy in infants newly diagnosed with cerebral palsy

PURPOSE

This study was designed to examine effects of blocks of daily physiotherapy in 5 infants with cerebral palsy.

METHODS

A single-subject design was used. Intervention consisted of two 4-week periods of daily physiotherapy, interrupted by 8 weeks of physiotherapy as usual. The children were assessed every 4th week using the Gross Motor Function Measure. Results were visually analyzed, and statistical significance of Gross Motor Function Measure-66 scores was established with the 2 SD band method.

RESULTS

Compliance was high. All infants showed gross motor progress compared with baseline, but separating effect of daily physiotherapy from physiotherapy as usual was inconclusive. Parents preferred the intensive treatment alternative.

CONCLUSION

Blocks of intensive therapy can be an alternative to regular dosage of physiotherapy, but until further studies are conducted, the physiotherapy intervention, intensity, and frequency should be tailored to meet the needs of each individual infant and family.

The application of motor learning strategies within functionally based interventions for children with neuromotor conditions

PURPOSE

To identify and describe the application of 3 motor learning strategies (verbal instructions, practice, and verbal feedback) within 4 intervention approaches (cognitive orientation to daily occupational performance, neuromotor task training, family-centered functional therapy, and activity-focused motor interventions).

METHODS

A scoping review of the literature was conducted. Two themes characterizing the application of motor learning strategies within the approaches are identified and described.

RESULTS

Application of a motor learning strategy can be a defining component of the intervention or a means of enhancing generalization and transfer of learning beyond the intervention. Often, insufficient information limits full understanding of strategy application within the approach.

CONCLUSIONS

A greater understanding of the application, and perceived nonapplication, of motor learning strategies within intervention approaches has important clinical and research implications.

Are teaching principles associated with improved motor performance in children with developmental coordination disorder? A pilot study

BACKGROUND AND PURPOSE

Physical therapists' teaching skills often are disregarded in research studies. We examined whether the use of different teaching principles during neuromotor task training was associated with treatment effects.

SUBJECTS

Nineteen children (mean age=7 years 5 months, range=5-10 years) who had developmental coordination disorder and who performed below the 15th percentile on the age-related Movement Assessment Battery for Children (M-ABC) and 11 physical therapists participated in the study.

METHODS

One intervention session for each child was videotaped. The frequency of the use of principles included in the motor teaching principles taxonomy (Niemeijer et al, 2003) was correlated with changes in motor performance on the M-ABC and the second edition of the Test of Gross Motor Development.

RESULTS

Providing clues on how to perform a task, asking children about a task, and explaining why a movement should be executed in a certain way were related to better movement performance.

DISCUSSION AND CONCLUSION

Teaching principles may be associated with success in therapeutic situations.

Improving the use of hands in daily activities: aspects of the treatment of children with cerebral palsy

Effective treatment for children with cerebral palsy requires a careful analysis of the behavior taking into consideration the complex issue of using the hands. In addition, it is important that the treatment is grounded in well-defined theories and methods. With the assistance of the International Classification of Functioning, the ICF, examples are provided of the effect of treatment on the level of Body Function. On the Activity Level, examples are given of treatment that applies recent knowledge of motor control and principles of motor learning. This paper is not intended to be a review of the literature, but rather, a set of examples from basic science, clinical practice and studies of intervention that highlight the possibilities of improving the usefulness of the hands in daily life.

Effect of sensory-level electrical stimulation of the tibialis anterior muscle during physical therapy on active dorsiflexion of the ankle of children with cerebral palsy

PURPOSE

The aim of the study was to determine whether add-on electrical stimulation (ES) at the sensory level improves ankle dorsiflexion in children with cerebral palsy.

METHOD

Seventeen children (three to nine years of age) with spastic hemiplegia or diplegia with weak or absent active ankle dorsiflexion received ES therapy applied to the tibialis anterior muscle during ordinary scheduled physical therapy sessions for one month. The ES was given at the sensory level alone with the aim of increasing the child's sensory awareness of the voluntary movement of the ankle.

RESULTS

Statistically significant improvement occurred in active ankle dorsiflexion with the knee flexed and extended between the first (pre) test and the subsequent tests (zero, two, and nine months later). Active toe flexion and extension and active inversion and eversion of the feet improved significantly.

CONCLUSION

ES at the sensory level combined with physical therapy improves active and passive motion of the ankle and foot that persists months after stimulation component is removed.