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Pediatric Physical Therapy:
doi: 10.1097/PEP.0b013e3181beb09d
Review Article

The Application of Motor Learning Strategies Within Functionally Based Interventions for Children with Neuromotor Conditions

Levac, Danielle BScPT, MSc; Wishart, Laurie BSc.PT, PhD; Missiuna, Cheryl PhD, OTReg(Ont); Wright, Virginia PT, PhD

Free Access
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Author Information

School of Rehabilitation Science (D.L., L.W., C.M.), Faculty of Health Sciences, McMaster University, Hamilton; and Bloorview Research Institute (V.W.), Toronto, Ontario, Canada

Address Correspondence to: Danielle Levac, Room 402, Institute for Applied Health Sciences, McMaster University, 1400 Main Street West, Hamilton, ON L8S 1C7, Canada. E-mail: levacde@mcmaster.ca

Grant Support: Supported by a Quality of Life Strategic Training Fellowship in Rehabilitation Research from the Canadian Institutes for Health Research Musculoskeletal and Arthritis Institute, a PhD Award in Acquired Brain Injury Research from the Ontario Neurotrauma Foundation, and a Doctoral Award from the Canadian Child Health Clinician Scientist Program (CCHCSP), a Canadian Institutes of Health Research Strategic Training Initiative. (to D.L.). Dr. Wright holds a Career Development Award (2007–2011) with the CCHCSP. Dr. Missiuna holds a Career Rehabilitation Scientist Award funded by the Ministry of Health and Long-Term Care and administrered by The Ontario Neurotrauma Foundation.

Ms. Levac was a PhD candidate in Rehabilitation Science at McMaster University in Hamilton, Ontario, when this study was undertaken.

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Abstract

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.

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INTRODUCTION AND PURPOSE

Learning to accomplish the purposeful motor skills and tasks that enable participation in daily life activities is a primary goal of therapeutic interventions for children and youth with neuromotor conditions.1,2 Although temporary improvements in motor performance during therapy are always encouraging, the ultimate focus of interventions must be to promote motor learning, that is, the relatively permanent differences in motor skill capability that can be transferred and generalized to new learning situations.3 Motor learning theory can be used to organize and structure this interventional focus.1–3 Specifically, the intention of interventions based on dynamic systems theory (DST) is to promote motor learning by encouraging the child to actively explore and problem solve around complex goal-directed tasks in meaningful environments.1,4 This theoretical framework guides many contemporary functionally based intervention approaches in which learning outcomes are considered to emerge through a process of self-organized interaction between the characteristics of the child, the features of the task, and the learning environment.1,5,6

The practical application of motor learning theory within physical therapy interventions can be found in the use of motor learning strategies.6,7 Motor learning strategies, based on theory or evidence, can be actively used by therapists to structure presentation of the task and the learning environment during intervention sessions.1,8 Many motor learning strategies have been outlined for clinicians to consider (see Larin7 for an overview), and several strategies incorporate elements that describe various dimensions of application. In particular, the following elements of 3 motor learning strategies may be relevant within functionally based interventions: giving verbal instructions to provide the learner with relevant task information or direct the learner’s attention to specific aspects of the task; organizing the structure, schedule, and amount of physical practice; and providing frequent or infrequent verbal feedback about task performance or outcome. These strategies are directly applicable to functionally based pediatric physical therapy interventions because they pertain to learning complex motor skills and tasks. Table 1 outlines these strategies and their elements in more detail.

Table 1
Table 1
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Pediatric physical therapists may experience both challenges and benefits when integrating these strategies into clinical practice. Their use in pediatric interventions may be challenging because their underlying assumptions were generated within controlled experimental paradigms involving healthy adults undertaking simple tasks.2 Indeed, although such research has generated evidence-based rules or guidelines with respect to the application of motor learning strategies that are available to clinicians working with adult clients, there is insufficient evidence on which to state that a strategy should be applied in a specific way with pediatric clients. However, the research gap specific to the population of children and youth with disabilities does not diminish the idea that promoting motor learning is the foundation of pediatric therapeutic interventions.

Motor learning strategies may also be perceived by therapists as being overly complicated or lacking in clarity.9 Given that many therapists require direction to incorporate motor learning within their clinical practice,10 the onus is on established intervention approaches to provide much-needed guidance by illustrating the application or adaptation of these strategies to pediatric populations. The use of motor learning strategies is intended to enhance the benefits of therapy sessions, provide a structure to support transfer and generalization of learning, and assist in therapist decision making related to configuration of the task and the environment.1,2

In this study, the motor learning strategies of interest are discussed in the context of functionally based interventions that reflect a philosophical shift away from a traditionally impairment-focused approach in pediatric rehabilitation, long epitomized by neurodevelopmental therapy, which is rooted in hierarchical and neuromaturational theories of motor control.5,11–14 These older theories emphasized the role of the central nervous system in controlling motor behavior.11,13 Neurodevelopmental treatment promotes the use of manual techniques in therapy such as facilitation and inhibition procedures to promote efficient movement patterns.15 Although the theoretical basis of neurodevelopmental treatment is evolving to reflect DST perspectives of motor control,15–17 and the goal of treatment is to promote functional independence,15 the intervention techniques used to achieve this goal can be viewed as child focused. They emphasize promoting movement efficiency and enhancing movement strategies to enhance participation in functional activities.17 There is inconclusive evidence to support the effectiveness or functional impact of this impairment-focused intervention,18,19 and therapists are cautioned that simply incorporating newer theoretical thinking into these older ideas may not help to advance our professions.20,21

A growing acceptance of DST perspectives of motor control (see Darrah and Bartlett22 and Law et al23) in which the central nervous system is considered to be one of the many subsystems within the child that interact with parameters of the learning situation to influence motor behavior, supports a more task and context-focused approach to clinical recommendations in pediatric therapy (as incorporated in recent clinical management guidelines for children with spastic diplegia24).

This debate surrounding the theoretical basis of intervention approaches has been paralleled in the literature specific to developmental coordination disorder (DCD),25,26 a neurodevelopmental condition with prevalence estimates of 5% to 6% of the population.27 Traditional approaches to intervention for DCD, including sensory integration and perceptual motor training, were based in hierarchical and neuromaturational theories of motor control and focused on remediation of the motor impairments and process deficits thought to impact functional performance.25 With inconclusive evidence for the effectiveness of such approaches, functionally based interventions grounded in DST perspectives, which focus on enhancing problem solving and improving skill acquisition, have become more prominent.25

The 4 contemporary functionally based intervention approaches discussed in this article are as follows: cognitive orientation to daily occupational performance (CO-OP),28 neuromotor task training (NTT),29 family-centered functional therapy (FCFT),23 and activity-focused motor interventions (AFMI).1 Table 2 provides details about each of these approaches. CO-OP and NTT are geared toward children and youth with DCD, whereas FCFT and AFMI are applicable to children with neuromotor conditions in general. These approaches were selected because they emphasize the learning of purposeful tasks and not the quality of the movements used to achieve them. Accordingly, it is suitable to undertake an in-depth exploration of the strategies by which therapists can promote motor learning within each intervention approach.

Table 2
Table 2
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The purpose of this study was to undertake a scoping review of the literature to identify and describe the application of selected elements of 3 motor learning strategies (form of verbal instructions, amount, structure and schedule of practice, and frequency and form of verbal feedback) within these 4 functionally based interventions. “Application” is defined as any way in which an element of the motor learning strategy (eg, practice amount or practice schedule; see Table 1 for more details) is operationalized within the scholarly and grey literature (textbooks and unpublished, nonindexed, or nonpeer reviewed) pertaining to the approach. A greater understanding of the application of motor learning strategies within these contemporary intervention approaches may help to increase understanding of how motor learning concepts are being integrated within pediatric clinical practice.

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METHODS

A scoping review is a form of literature review in which the goal is to achieve a greater visualization of the extent, range, and nature of concepts of interest within a broad field of study.30 This type of review uses all sources of information from the full range of literature available and is a useful process to highlight a complex topic in which a diversity of research methodologies present a barrier to traditional systematic review.30 Unlike a systematic review, a scoping review is predominantly descriptive in nature and does not critically appraise the quality of the evidence.30 As such, this study does not aim to review the evidence for each intervention or to establish the “best” way to apply motor learning strategies. Rather, the intent is to describe how the strategies are currently applied within these interventions.

This scoping review is based on the methods outlined by Arksey and O’Malley.30 The scholarly and gray literature was searched for research studies, book chapters, conference proceedings, and review/descriptive articles dating from 1990 to August 2008. The year 1990 was chosen as an approximate reflection of the emergence of DST in the rehabilitation field. The electronic search was structured by first using the names of the intervention approaches as search terms. Finally, a general search combining the terms “physiotherapy” or “physical therapy” and “pediatrics” and “motor learning,” “intervention,” “treatment,” “skill acquisition,” “motor skills,” or “learning theory” was completed.

The electronic search strategy included MEDLINE, EMBASE, CINAHL, AMED, PubMed, Scholars Portal/PSYCHinfo, ProceedingsFirst, and ProQuest Dissertations and Theses. Reference lists of primary articles were hand searched for additional sources that may have been missed by the electronic search. Finally, key authors in the field were contacted and asked for information about additional sources or unpublished studies.

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Data Analyses

All publications were reviewed using a data charting framework30 developed by one of the authors of this article (D.L.). Information was extracted pertaining to authorship, purpose and methods of the study (unless it was a descriptive publication), population, motor learning strategy (or strategies) identified, description of application of motor learning strategy (or strategies), and theoretical basis of the intervention approach. The number and variety of publications for each approach were summarized. A descriptive analytical method as outlined by Arksey and O’Malley30 was then undertaken to identify and describe the application of each motor learning strategy within each approach. Specifically, the information within the charting framework pertaining to application of a motor learning strategy was summarized across all publications within each approach. The application was then placed into a category, created by the author, which described the nature of application of the strategy within the approach. New categories were created when an application was identified that did not fit into an existing category. Finally, similar categories were combined with overall themes. These themes emerged through an iterative process of combining the categories in different ways until the major applications of motor learning strategies became clear.

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RESULTS

A total of 49 publications were reviewed in detail. During this process, 18 publications were excluded because they did not pertain to 1 of the 4 approaches of interest. Thirty-one publications were ultimately included in this scoping review.

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Numerical Summary

This scoping review included 18 references for CO-OP, 6 for NTT, 5 for FCFT, and 2 for AFMI. Three of the 4 approaches (CO-OP, NTT, and FCFT) had empirical data to support their theoretical models. Publications pertaining to CO-OP included review articles, descriptive chapters, case studies, pilot randomized controlled trials, precohort to postcohort studies, a grant proposal, and single-subject research designs. Publications pertaining to NTT included studies with a treatment and nontreatment control group (nonrandom), preintervention to postintervention studies, and correlational studies. The FCFT literature included single-subject research designs (SSRDs), a study protocol and grant proposal for a randomized controlled trial, and a descriptive article, whereas publications for AFMI were limited to descriptive articles that included fictional case studies.

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Themes

Two themes emerged during the descriptive analysis that captured the application of motor learning strategies within the intervention approaches. These themes are described in the following. Within each theme, the presentation of the findings is organized by motor learning strategy to compare and contrast between the different approaches. Although the findings presented are limited to examples from key publications within each approach, they reflect the summary of the application of the motor learning strategy within all of publications pertaining to the approach. A list of all the publications included in this scoping review is given in Table 3.

Table 3
Table 3
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Theme 1: Application of an element(s) of a motor learning strategy is an essential feature of the approach and is clearly outlined in the literature so that it can be followed in clinical practice.

The first theme to emerge from the descriptive analysis was that the application of a motor learning strategy (or strategies) was a central component of the intervention approach.

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Form of Verbal Instructions.

The form of verbal instructions can pertain to providing information about important requirements of the task or directing the learners’ attention toward different aspects of the task (see Table 1 for details). The use of instructions to provide information about task requirements is a central feature of NTT, AFMI, and CO-OP. In NTT, instructions are viewed as commands about what to do, how to do it, and what should be achieved.31 Instructions, considered to be essential to learning, provide information about the nature of the task and the movements required to complete it.31 Although this clearly outlines the use of instructions related to task requirements, no information is provided as to whether instructions should direct the child toward an internal or an external focus of attention. In contrast, the use of verbal instructions within AFMI is to explicitly direct attention externally to aspects of the task and environment, rather than internally to aspects of the movement.1 For example, when the child is learning to climb stairs, therapists are encouraged to instruct the child to focus on the height of the step versus the movement of his or her body.1 In AFMI, information related to instructions pertaining to task requirements is present, although not outlined in detail: instructions should relate to the “relevant cues of the task.”1(p97)

In CO-OP, instructions are essential to provide information about the requirements of the task, as this knowledge is considered to be difficult for children with DCD to acquire independently.28 These instructions are provided through the use of mediational techniques to assist children in problem solving and discovering cognitive strategies related to both successful task performance and learning (see Table 2 for details).

The FCFT literature does not provide information about the application of this motor learning strategy.

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Amount, Schedule, and Structure of Practice.

Physical practice of motor skills or tasks during physical therapy interventions is a motor learning strategy containing, but not limited to, elements relating to structure, scheduling, and amount of practice (see Table 1 for details). Three of the 4 approaches (AFMI, FCFT, and NTT) apply at least one of these elements as a key feature of their interventions. The application of practice structuring is evident in the use of variable/constant practice and part/whole practice. Although AFMI clearly emphasizes the use of variable practice, therapists working with older children are instructed to consider the use of more constant practice in the early stages of learning if the child is having difficulty with the task.1 Variable practice is recommended for infants.32 Part-task practice is encouraged for younger children, who are learning serial tasks, when the parts can be attached to form a target whole task.32 With respect to FCFT, Darrah et al33 stated that “parts of a movement may be worked on in isolation but they should always be put back together into a functional context.”(p82) This refers to the use of both part and whole task practice.

The NTT literature encourages variable practice by clearly stating that therapists should increase the difficulty of task practice over repeated practice trials31,34; for example, therapists can vary elements of the task (such as the size of an object or the distance it is being thrown).31

Proponents of FCFT and AMFI explicitly incorporate the amount of practice in terms of encouraging repetition of practice trials to maximize practice opportunities. Increasing the amount of practice seems to be achieved by incorporating practice into daily routines throughout the day. Although task repetition is highly encouraged (ie, “great amounts”)32(p298) and thus judged to fit within these theme, it is acknowledged that details regarding the exact frequency of practice are not specified in any of these approaches. For example, NTT literature suggests that “the number of practice trials should be maximised”31(p579) but does not provide any further details.

Indeed, many of the elements of this motor learning strategy were insufficiently described or omitted from the intervention approaches. Practice of motor tasks is the clear intention of those who describe CO-OP, but details of the structure, sequencing, or amount of practice are not provided. Although proponents of CO-OP state that “motor learning principles are used during the intervention sessions to organize practice schedules,”35(p45) no further information is given. Overall, the element of practice scheduling (ie, blocked vs random) was not mentioned within any of the intervention approaches.

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Form and Frequency of Verbal Feedback.

Verbal feedback is a motor learning strategy containing multiple elements. The form of verbal feedback can be quantitative: augmented information provided by the therapist to the learner about the performance of the task (knowledge of performance) or the task outcomes (knowledge of results); or qualitative: positive (eg, “good job!”) or negative (eg, “you can do better than that”). Considering the frequency with which verbal feedback is provided is another element of this strategy (see Table 1 for more details).

Three approaches (CO-OP, NTT, and AFMI) emphasize the application of at least one of these elements as a central feature of the interventions. Verbal feedback in CO-OP relates to task performance or task results (ie, knowledge of performance and knowledge of results) using the mediational techniques discussed in the Form of Verbal Instructions section above (see Table 2 for details).28,36,37 When providing feedback, these mediational techniques include the process of questioning in which the child is asked to discover the information about their performance or results, rather than the therapist providing this information.37 Questions used in mediation could include “How is what happened when you tried the task this time different from last time? What do you think worked better this time?”31

NTT proponents consider “motor teaching principles” to be significant components of the intervention.31 Providing or asking for feedback, defined as “tell[ing] the child what was done right [or] wrong during the execution,”31(p576) is 1 of the 3 categories identified within the motor teaching principles of NTT taxonomy. This verbal feedback mostly pertains to task performance (ie, knowledge of performance) but can also involve providing information about movement results (ie, knowledge of results).31 “Sharing knowledge” is a second category within the NTT taxonomy. Sharing knowledge includes explaining the benefits of certain types of movement strategies, explaining task difficulty, and questioning the child about task performance to explore their understanding of the task.31 The taxonomy explicitly outlines options for therapists to verbalize quantitative feedback within these 2 categories.

Lastly, when the approach is applied to older children, those who describe AFMI discuss the use of both knowledge of performance and knowledge of results feedback and urge therapists to use both types of quantitative feedback depending on the child’s individual needs and the type of task that is being practiced.1 Although advocates of AMFI recommend that feedback be infrequent, more information is needed regarding specific frequencies. Information regarding the application of verbal feedback is limited within FCFT. Finally, none of the approaches provide information specific to the form of qualitative feedback that should be given by therapists, although in a description of NTT the authors state that the “motivational . . . functions of feedback are emphasized.”31(p570)

Theme 2: Application of a motor learning strategy (or strategies) within the approach promotes an emphasis on transfer and/or generalization of learning beyond the interventions.

The second theme to emerge from the analysis was that the purpose of applying a motor learning strategy (or strategies) within the approach was considered by the authors of this review to enhance transfer and/or generalization of learning beyond the therapy sessions. Transfer and generalization of learning are important to consider because they differentiate motor performance (the quality of motor activity at an instance in time38) from motor learning (the permanent acquisition of improved movement skills as a result of practice3). Specifically, generalization of learning refers to “the degree that a specific skill, learned in a specific context, can be performed in another context,”35(p32) while transfer is defined as “the degree to which learning one skill influences the learning of another skill.”35(p33) Several elements of the 3 motor learning strategies were applied within CO-OP, AFMI, FCFT, and NTT in this way.

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Form of Verbal Instructions.

The use of verbal instructions promotes generalization and transfer of learning in AFMI and CO-OP. AFMI applies the use of instructions to direct the child’s attention toward features of the task and the environment that are most relevant for transfer and generalization of learning.1 The use of instructions related to task requirements in this way is illustrated when therapists are advised to provide instructions related to the feature of the task that might differ in other environments or in similar tasks; for example, the height of the step when climbing stairs.1

In CO-OP, the goal of the mediational techniques used in instructions was to promote generalization and transfer of learning. For example, bridging is a mediational technique that is used in instructions to link old knowledge to new knowledge in situations when it can be used in future, such as in learning new and similar tasks.37 In addition, one of the key features of CO-OP is giving instructions for homework to the child and parent to practice the task in different situations or practice applying the cognitive strategies to learn new tasks.35 At the beginning of each intervention session, this homework is discussed with the child.

The purpose and form of giving verbal instructions within NTT were viewed to relate primarily in providing information to enhance the child’s understanding of that particular task rather than to promote transfer and generalization of learning.

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Amount, Schedule, and Structure of Practice.

The application of certain elements of this motor learning strategy to promote transfer and generalization of learning was identified in CO-OP, FCFT and AMFI, and NTT. Specifically, proponents of CO-OP, FCFT, and AMFI emphasize both the amount of practice and structure of practice by highlighting the incorporation of multiple variable practice opportunities into daily routines.1,28,32,39 This is achieved by including parents and caregivers in therapy sessions and by educating them about how to practice similar tasks outside of therapy. The emphasis is therefore on practicing identified skills and tasks in different environments (generalization) and also on practicing related tasks and skills (transfer). For example, those who discuss CO-OP describe how parental involvement provides a link between therapy situations and the real world.35 Parent involvement provides more practice opportunities for related tasks in many different environments, potentially enhancing both generalization and transfer of learning.28 In descriptions of FCFT, parent education regarding home programs is provided to increase practice opportunities in meaningful environments.23 AFMI and FCFT were clearly described as using variable practice to promote transfer of learning.

NTT advocates suggest that increasing task difficulty through variable practice will “have a higher transfer to daily activities.”31(p569) The literature also states that the variability of practice implies that the skills that are practiced, and the environment in which they are practiced, must be relevant to daily life situations to promote transfer, which is stated to be the goal of treatment sessions.34

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Form and Frequency of Verbal Feedback.

CO-OP was considered to use verbal feedback to explicitly promote transfer and generalization of learning. In CO-OP, the goal of mediational techniques, the knowledge of performance that verbal feedback provided, was to help children discover cognitive strategies that will allow them to successfully perform the task in different environments and learn new skills.37,40 This mediation is performed to specifically enhance transfer and generalization: learning “how to learn” new skills and how to solve problems in new situations. For example, one of the mediational techniques is transcendence, which is thought to promote the ability to generalize beyond the skill to other situations.37

The motor learning literature is cited as a major influence on the development of the NTT motor teaching principles taxonomy.31 Although both the “sharing knowledge” and “providing and asking for feedback” categories suggest that therapists provide feedback that includes posing questions to the learner, it was not clear whether these questions also encourage the child to think about the requirements of similar tasks or to reflect on performing the task in other environments. Therefore, a focus on transfer and generalization of learning was not determined within the application of this motor learning strategy.

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SUMMARY AND IMPLICATIONS FOR RESEARCH AND CLINICAL PRACTICE

A scoping review is a method of reviewing the literature that explores key concepts of interest in a field of study.30 The purpose of this scoping review was to identify and describe the application of selected elements of 3 motor learning strategies within the body of available literature depicting or evaluating 4 functionally based interventions. Two themes characterizing the nature of application of the strategies emerged through descriptive analysis. Implications of these findings for rehabilitation practice and research are identified, and challenges with respect to applying motor learning strategies within pediatric intervention approaches are discussed.

The application of a motor learning strategy (or strategies) as a central feature of the intervention varies among the approaches. The application of strategies within AFMI, an intervention model first described in 2004, directly reflects the goals of this approach. AFMI is the only approach in which at least one of the 3 motor learning strategies was considered to be a key feature of the intervention. The literature within this approach is unique because it reviews the evidence and assumptions behind each motor learning strategy. This reflects a primary goal of the approach, that is to assist therapists in questioning how to adapt these strategies for use in children and youth with motor impairments.1

The population of interest to the approach has a clear influence on the application of motor learning strategies as key components of the intervention. For example, it is evident that the 2 interventions geared toward older children and youth with DCD (NTT and CO-OP) are more explicit about the application of elements of the verbal motor learning strategies of instructions and feedback. Age, cognition, and the presumed nature of motor learning impairments in children with DCD may influence the emphasis on verbal interactions between the therapist and the client in these approaches.

In addition to retention of learning over extended periods of time, concepts of generalization and transfer are considered to separate motor learning from temporary differences in motor performance. Application of strategies within the second theme identified in this review is based on the perceptions of the authors; therefore, no statement is made as to whether application of these strategies actually results in greater generalization and/or transfer of learning.

Common to the application of the strategies in this theme is a potential emphasis on the role of active problem solving on the part of the child. By practicing the task in a variety of ways, increasing the amount of practice opportunities, and using mediational instructions and feedback in which the discovery of cognitive strategies is encouraged, the child may be required to problem solve on a frequent basis. Improving problem-solving abilities related to learning may play a role in the concept of generalization and transfer of learning.

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Challenges Related to the Application of Motor Learning Strategies

Findings regarding the application of motor learning strategies within the interventions must be interpreted in full consideration of the nature of the available literature. Specifically, the number and type of publication methodologies widely varied among the different approaches. If more details about the intervention were provided by the authors, a greater understanding of application of the motor learning strategies may have been achieved. This need for greater detail was identified in a recent survey of Pediatric Section members of the APTA, who found that 99% of respondents would like more information about motor learning concepts to apply them in practice.10

The goal of the approach and its population of interest may influence a perceived lack of application of a motor learning strategy within an approach. For example, proponents of FCFT do not mention the use of instructions or verbal feedback. As this is an approach in which the therapist’s primary focus is described as structuring the task or the environment to promote learning, strategies focusing on information exchange with the child may not be considered as relevant to this goal. The population of interest to those who advocate FCFT also influences the use of verbal strategies as this approach is geared toward younger children (younger than 4 years of age) who are likely to have more difficulty than older children in processing verbal information.

Although practice of motor skills and tasks is evident within all the intervention approaches, only certain elements of this important motor learning strategy were clearly detailed. This might reflect challenges related to incorporating these elements within pediatric interventions. For example, attention span and behavioral issues in young children may limit planning of practice schedules. Amount of practice, although perceived as a central feature, may be difficult to prescribe within individualistic intervention approaches such as FCFT or AFMI where practice opportunities are incorporated into heterogeneous family routines.

In general, the findings of this scoping review suggest that the intervention approaches, with the exception of AMFI, did not explicitly apply selected elements of motor learning strategies as systematically as they are described in the motor learning literature. A major factor influencing this lack of application may be that developers of the approaches were not comfortable integrating strategies for which there is limited evidence in children with neuromotor conditions. It is well acknowledged that elements of these strategies, many of which have been evaluated and established in adult populations, may not be directly translatable to children for whom developmental factors and motor learning impairments resulting from neuromotor conditions differ from adults.1 Research is required to explore these strategies in pediatrics to inform their application within clinical practice.9 Investigation should explore both the mechanisms by which strategy application may enhance learning of complex tasks within functional environments and their effectiveness when used with children and youth. Given this lack of evidence, it is impossible to identify the effect of the application, or perceived lack of application of these motor learning strategies, on the effectiveness of the interventions approaches.

Because there is limited literature on children and youth with disabilities, it is evident that motor learning strategies may require adaptation to reflect impairments in motor learning and developmental realities that differ from the experimental paradigms in which the strategies were generated. Determining the extent of possible adaptation within these approaches was not the goal of this review. AFMI is unique in that its proponents suggest that adaptation is required and encourage therapists to adapt the strategies to the individual characteristics of their clients.1 To be able to adapt these strategies, therapists are urged to reflect on the assumptions behind the motor learning strategies and to combine this theoretical knowledge with their clinical experience when adapting the strategies for use in practice.1 Clinical experience and patient considerations are the 2 factors within evidence-based practice. Until research in pediatrics is more predominant, therapists will need to integrate evidence from the adult world. Overall, reflecting on how strategies are applied within these structured approaches may assist therapists in integrating motor learning concepts into their clinical practice.

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Limitations

Given that the literature search for a scoping review is not as methodologically rigorous as that for a systematic review, one cannot be certain that all relevant publications were discovered. The 2 themes that emerged from the descriptive analytical process, and the interpretations, were determined solely by the authors; other authors may have discerned other themes that are also relevant to the application of motor learning strategies. Findings are based on the authors’ interpretations; therefore, the question of whether the findings related to each approach are acutely linked with a motor learning theoretical perspective, or are an assumed link made by the authors, is a bias that must be acknowledged. Finally, this study did not include all the motor learning strategies described in the literature (ie, the provision of manual guidance and the use of demonstration or modeling were not explored), nor did it include all the elements of the selected strategies. The nature of the themes and, thus, the findings may have been different if these and other motor learning strategies and their elements had been considered.

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Future Directions

Findings from this scoping review can provide direction for further research in this area. Further scoping reviews could explore the application of other motor learning strategies or compare the application of strategies within functionally based approaches with their application within traditional impairment-focused interventions. It is also important to use observational or descriptive methodologies or qualitative research to evaluate and describe how motor learning strategies are actually used when therapists undertake these approaches in clinical practice. This practical application may be different from what is intended in the literature describing the approach. Ultimately, it is essential to determine the value of using motor learning strategies in practice by investigating the impact of their application on both service provision and functional outcomes. In addition, more information about the content of physical therapy intervention approaches in the literature will facilitate further exploration of the application of motor learning strategies, and more empirical research will provide further evidence on which additional application should be based within interventions.

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CONCLUSION

The goal of therapeutic interventions for children and youth with neurological conditions is to enhance learning of motor skills and tasks.1,2 The processes pertaining to promotion of motor learning within these contemporary intervention approaches have not been detailed. In this study, a scoping review methodology identified and described the application of selected elements of motor learning strategies within functionally based approaches applicable to differing populations of children and youth with neuromotor conditions.

Two themes characterizing the application of motor learning strategies were identified and described. The application of a motor learning strategy can be an essential component that defines the intervention or a means of enhancing generalization and/or transfer of learning beyond the intervention. Additional information is often needed to better characterize the application of motor learning strategies or confirm that the strategy is a component of the approach. Potential clinical and research implications resulting from a greater understanding of the application of motor learning strategies within established intervention approaches have been described. Findings from this study may assist in narrowing the gap between contemporary thinking in pediatric physical therapy and current directions in motor learning theory and research.

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ACKNOWLEDGMENT

The authors acknowledge Nancy Pollock for her helpful feedback on an earlier draft of this manuscript.

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REFERENCES

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Keywords:

human movement system; learning; motor skills; physical therapy/methods; problem solving; psychological feedback; psychological transfer; psychomotor performance

© 2009 Lippincott Williams & Wilkins, Inc.

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