Motor Learning Principles Research Articles

Visual Perturbation to Enhance Return to Sport Rehabilitation after Anterior Cruciate Ligament Injury: A Clinical Commentary.

Anterior cruciate ligament (ACL) tears are common traumatic knee injuries causing joint instability, quadriceps muscle weakness and impaired motor coordination. The neuromuscular consequences of injury are not limited to the joint and surrounding musculature, but may modulate central nervous system reorganization. Neuroimaging data suggest patients with ACL injuries may require greater levels of visual-motor and neurocognitive processing activity to sustain lower limb control relative to healthy matched counterparts. Therapy currently fails to adequately address these nuanced consequences of ACL injury, which likely contributes to impaired neuromuscular control when visually or cognitively challenged and high rates of re-injury. This gap in rehabilitation may be filled by visual perturbation training, which may reweight sensory neural processing toward proprioception and reduce the dependency on vision to perform lower extremity motor tasks and/or increase visuomotor processing efficiency. This clinical commentary details a novel approach to supplement the current standard of care for ACL injury by incorporating stroboscopic glasses with key motor learning principles customized to target visual and cognitive dependence for motor control after ACL injury.Level of Evidence5

Promoting Generalized Learning in Balance Recovery Interventions.

Recent studies have shown balance recovery can be enhanced via task-specific training, referred to as perturbation-based balance training (PBT). These interventions rely on principles of motor learning where repeated exposure to task-relevant postural perturbations results in more effective compensatory balance responses. Evidence indicates that compensatory responses trained using PBT can be retained for many months and can lead to a reduction in falls in community-dwelling older adults. A notable shortcoming with PBT is that it does not transfer well to similar but contextually different scenarios (e.g., falling sideways versus a forward trip). Given that it is not feasible to train all conditions in which someone could fall, this limited transfer presents a conundrum; namely, how do we best use PBT to appropriately equip people to deal with the enormous variety of fall-inducing scenarios encountered in daily life? In this perspective article, we draw from fields of research that explore how general learning can be promoted. From this, we propose a series of methods, gleaned from parallel streams of research, to inform and hopefully optimize this emerging field where people receive training to specifically improve their balance reactions.

Effects of game-based rehabilitation on upper limb function in adults within the first six months following stroke: protocol for a systematic review and meta-analysis.

To evaluate and summarize the level of evidence for the immediate, short-term, and long-term effects of game-based rehabilitation on upper limb function in adults within the first six months following stroke. A game-based intervention is a valuable therapeutic tool for incorporating principles of motor learning and neuroplasticity in the rehabilitation of upper limb function post-stroke. Most of the existing reviews on game-based rehabilitation are focused on the chronic phase of stroke. However, as maximum upper limb motor recovery occurs in the first six months after stroke, further exploration of the effects of game-based rehabilitation in this phase is necessary. We will include randomized clinical trials assessing the immediate, short-term, and long-term effects of game-based rehabilitation on upper limb function in adults within the first six months following stroke. The systematic review will follow the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) checklist and JBI methodology for systematic reviews of effectiveness. A database-specific search strategy will be used in CINAHL, PubMed, Scopus, Web of Science, ProQuest, PEDro, OT Seeker, and Ovid MEDLINE to identify studies in the English language with no date limit. Two reviewers will independently screen, extract data from, and assess risk of bias in the eligible studies. Meta-analysis and publication bias evaluation will be done when adequate data are available. If a meta-analysis is precluded, then a narrative synthesis will be done. The Grading of Recommendations Assessment Development and Evaluation (GRADE) criteria will be used to assess the certainty of evidence for the outcome measures of interest. PROSPERO CRD42020190100.

Perceptual and Acoustic Effects of Dual-Focus Speech Treatment in Children With Dysarthria.

Purpose Children with dysarthria secondary to cerebral palsy may experience reduced speech intelligibility and diminished communicative participation. However, minimal research has been conducted examining the outcomes of behavioral speech treatments in this population. This study examined the effect of Speech Intelligibility Treatment (SIT), a dual-focus speech treatment targeting increased articulatory excursion and vocal intensity, on intelligibility of narrative speech, speech acoustics, and communicative participation in children with dysarthria. Method American English-speaking children with dysarthria (n = 17) received SIT in a 3-week summer camplike setting at Columbia University. SIT follows motor-learning principles to train the child-friendly, dual-focus strategy, "Speak with your big mouth and strong voice." Children produced a story narrative at baseline, immediate posttreatment (POST), and at 6-week follow-up (FUP). Outcomes were examined via blinded listener ratings of ease of understanding (n = 108 adult listeners), acoustic analyses, and questionnaires focused on communicative participation. Results SIT resulted in significant increases in ease of understanding at POST, that were maintained at FUP. There were no significant changes to vocal intensity, speech rate, or vowel spectral characteristics, with the exception of an increase in second formant difference between vowels following SIT. Significantly enhanced communicative participation was evident at POST and FUP. Considerable variability in response to SIT was observed between children. Conclusions Dual-focus treatment shows promise for improving intelligibility and communicative participation in children with dysarthria, although responses to treatment vary considerably across children. Possible mechanisms underlying the intelligibility gains, enhanced communicative participation, and variability in treatment effects are discussed.

Effect of boost articulation therapy (BArT) on intelligibility in adults with dysarthria.

BackgroundThe articulatory accuracy of patients with dysarthria is one of the most affected speech dimensions with a high impact on speech intelligibility. Behavioural treatments of articulation can either involve direct or indirect approaches. The latter have been thoroughly investigated and are generally appreciated for their almost immediate effects on articulation and intelligibility. The number of studies on (short‐term) direct articulation therapy is limited.AimsTo investigate the effects of short‐term, boost articulation therapy (BArT) on speech intelligibility in patients with chronic or progressive dysarthria and the effect of severity of dysarthria on the outcome.Methods & ProceduresThe study consists of a two‐group pre‐/post‐test design to assess speech intelligibility at phoneme and sentence level and during spontaneous speech, automatic speech and reading a phonetically balanced text. A total of 17 subjects with mild to severe dysarthria participated in the study and were randomly assigned to either a patient‐tailored, intensive articulatory drill programme or an intensive minimal pair training. Both training programmes were based on the principles of motor learning. Each training programme consisted of five sessions of 45 min completed within one week.Outcomes & ResultsFollowing treatment, a statistically significant increase of mean group intelligibility was shown at phoneme and sentence level, and in automatic sequences. This was supported by an acoustic analysis that revealed a reduction in formant centralization ratio. Within specific groups of severity, large and moderate positive effect sizes with Cohen's d were demonstrated.Conclusions & ImplicationsBArT successfully improves speech intelligibility in patients with chronic or progressive dysarthria at different levels of the impairment. What this paper addsWhat is already known on the subject Behavioural treatment of articulation in patients with dysarthria mainly involves indirect strategies, which have shown positive effects on speech intelligibility. However, there is limited evidence on the short‐term effects of direct articulation therapy at the segmental level of speech. This study investigates the effectiveness of BArT on speech intelligibility in patients with chronic or progressive dysarthria at all severity levels. What this paper adds to existing knowledge The intensive and direct articulatory therapy programmes developed and applied in this study intend to reduce the impairment instead of compensating it. This approach results in a significant improvement of speech intelligibility at different dysarthria severity levels in a short period of time while contributing to exploit and develop all available residual motor skills in persons with dysarthria. What are the potential or actual clinical implications of this work? The improvements in intelligibility demonstrate the effectiveness of a BArT at the segmental level of speech. This makes it to be considered a suitable approach in the treatment of patients with chronic or progressive dysarthria.

Identifying Clinical Behaviors Using the Motor Learning Classification Framework: A Pilot Study

Although differences in clinical interactions with patients between students and experienced clinicians are well described, differences in therapeutic training behaviors have not been explored, especially in relation to motor learning principles. This pilot study compared clinical behaviors between speech language pathology (SLP) students and experienced SLPs in a voice therapy task, using prepractice variables in the Motor Learning Classification Framework (MLCF). Using a quasi-experimental design, five final-year undergraduate SLP students and four experienced SLPs with a voice therapy caseload taught a standardized patient to produce a vocal siren. Two trained raters categorized the clinicians' behaviors using the MLCF. High intrarater reliability (91.9%, 92.3%) and interrater reliability (89.6%, 82.1%) were shown across both raters. Both clinician groups used the same percentage of behaviors classified as verbal information but differed in the subtypes of these behaviors. Experienced clinicians used behaviors categorized as problem-solving and only experienced clinicians used repeated behavior sequences that included perceptual training. Both groups used significantly more talking behaviors than doing behaviors. The MLCF can be reliably used to identify prepractice behaviors during client interactions in voice therapy. Students and experienced clinicians showed similarities in behaviors, but experienced clinicians used more problem solving and perceptual training behaviors than students. These differences have implications for student training. The greater use of talking behaviors than doing behaviors warrants further investigation into whether this impacts the subsequent quality of practice engaged by the client and ultimately treatment effectiveness.

Current Physical Therapy Practice in Norway for Children With Cerebral Palsy.

To investigate to what degree functional physical therapy approaches are implemented in Norway when promoting gross motor skill acquisition in children with cerebral palsy. It was a national survey about current practice among Norwegian pediatric physical therapists. The physical therapists chose between 5 predefined approaches developed through practice descriptions by a convenience sample of 55 physical therapists. The distribution of the main approaches were: functional training based on principles of motor learning, training of body functions and structures, manual stimulation of position and movements, addressing environmental factors, and conceptual methods. Working in the North and having more experience predicted less chance of using functional approaches. Most physical therapists frequently used other approaches as a supplement to the main approach, but not conceptual methods. Functional training based on principles of motor learning has become the method of choice in Norway.

Motor-learning based activities may improve functional ability in adults with severe cerebral palsy: A controlled pilot study.

Cerebral palsy (CP) is a neurodevelopmental disturbance characterized by impaired control of movement. Function often decreases and 15% of adults are classified as severely affected (Gross Motor Function Classification Scale III-V). Little is known about interventions that aim to improve functional abilities in this population. To evaluate a 12-week intervention based on motor learning principles on functional ability in adults with severe CP. 16 adults (36±10 years, GMFCS III-V) were enrolled and divided into an intervention group (Active group) and a standard care group (Control group). Primary outcome measure was Gross Motor Function Measure (GMFM-88). Secondary measures were neurological status. The Active group were measured at baseline, after the intervention and at one-month follow-up. The Control group were measured at baseline and after one month. Analysis showed statistically significant improvement in GMFM-88 for the Active group from baseline to post assessment compared with the Control group (group difference: 5 points, SE 14.5, p = 0.008, CI: 1.2 to 8.7). Improvements were maintained at follow-up. Results from the neurological screening showed no clear tendencies. The study provides support that activities based on motor learning principles may improve gross motor function in adults with severe CP.

Learning Gait Modifications for Musculoskeletal Rehabilitation: Applying Motor Learning Principles to Improve Research and Clinical Implementation.

Gait modifications are used in the rehabilitation of musculoskeletal conditions like osteoarthritis and patellofemoral pain syndrome. While most of the research has focused on the biomechanical and clinical outcomes affected by gait modification, the process of learning these new gait patterns has received little attention. Without adequate learning, it is unlikely that the modification will be performed in daily life, limiting the likelihood of long-term benefit. There is a vast body of literature examining motor learning, though little has involved gait modifications, especially in populations with musculoskeletal conditions. The studies that have examined gait modifications in these populations are often limited due to incomplete reporting and study design decisions that prohibit strong conclusions about motor learning. This perspective draws on evidence from the broader motor learning literature for application in the context of modifying gait. Where possible, specific gait modification examples are included to highlight the current literature and what can be improved on going forward. A brief theoretical overview of motor learning is outlined, followed by strategies that are known to improve motor learning, and finally, how assessments of learning need to be conducted to make meaningful conclusions.

The Augmented Movement Platform For Embodied Learning (AMPEL): development and reliability

Balance and gait impairments are highly prevalent in the neurological population. Although current rehabilitation strategies focus on motor learning principles, it is of interest to expand into embodied sensori-motor learning; that is learning through a continuous interaction between cognitive and motor systems, within an enriched sensory environment. Current developments in engineering allow for the development of enriched sensory environments through interactive feedback. The Augmented Movement Platform for Embodied Learning (AMPEL) was developed, both in terms of hardware and software by an inter-disciplinary circular participatory design strategy. The developed device was then tested for in-between session reliability for the outcome measures inter-step interval and total onset time. Ten healthy participants walked in four experimental paths on the device in two different sessions, and between session correlations were calculated. AMPEL was developed both in terms of software and hardware, with three Plug-In systems (auditory, visual, auditory + visual). The auditory Plug-In allows for flexible application of augmented feedback. The in-between session reliability of the outcomes measured by the system were between high and very high on all 4 walked paths, tested on ten healthy participants [mean age 41.8 ± 18.5; BMI 24.8 ± 6.1]. AMPEL shows full functionality, and has shown between session reliability for the measures of inter-step-intervals and total-onset-time in healthy controls during walking on different paths.

Practical Training Strategies to Apply Neuro-Mechanistic Motor Learning Principles to Facilitate Adaptations Towards Injury-Resistant Movement in Youth

Youth may be particularly responsive to motor learning training strategies that support injury-resistant movement mechanics in youth for prevention programs that reduce injury risk, injury rehabilitation, exercise performance, and play more generally (Optimizing Performance Through Intrinsic Motivation and Attention for Learning Prevention Rehabilitation Exercise Play; OPTIMAL PREP) One purpose of the present manuscript was to provide clinical applications and tangible examples of how to implement the proposed techniques derived from OPTIMAL theory into PREP strategies for youth. A secondary purpose was to review recent advances in technology that support the clinical application of OPTIMAL PREP strategies without extensive resources/programming knowledge to promote evidence-driven tools that will support practitioner feedback delivery. The majority of examples provided are within the context of anterior cruciate ligament (ACL) injury rehabilitation, but we emphasize the potential for OPTIMAL PREP strategies to be applied to a range of populations and training scenarios that will promote injury resistance and keep youth active and healthy.

Effects of Practice Variability on Second-Language Speech Production Training

Background: Mastering the phonetics of a second language (L2) involves a component of speech-motor skill, and it has been suggested that L2 learners aiming to achieve a more native-like pronunciation could benefit from practice structured in accordance with the principles of motor learning. Participants and Methods: This study investigated the influence one such principle, high versus low variability in practice, has on speech-motor learning for Korean adults seeking to acquire native-like production of English rhotics. Practice incorporated a commercially available intraoral placement device (“R Buddy,” Speech Buddies Inc.). In a single-subject across-behaviors design, 8 participants were pseudorandomly assigned to practice rhotic targets in a low-variability (single word) or high-variability (multiple words) practice condition. Results: The hypothesized advantage for high-variability over low-variability practice was observed in the short-term time frame. However, long-term learning was limited in nature for both conditions. Conclusion: These results suggest that future research should incorporate high-variability practice while identifying additional manipulations to maximize the magnitude of long-term generalization learning.

Examining Conductive Education: Linking Science, Theory, and Intervention

Recognized in many European countries and Canada as a valid form of therapeutic and educational rehabilitation, conductive education (CE) emphasizes cognitive and motor learning principles for movement reeducation. This article illustrates how CE incorporates motor control and motor learning theories in conjunction with unique facilitation concepts, including rhythmic intention, task series, tailored low-tech equipment, and traditional facilitation concepts such as developmental sequence, manual facilitations, and multimodal interventions.Uniquely, CE brings together task series practice and learning, including a lying program, sitting program, standing program, and walking program, along with activities of daily living within a group treatment model. The conductor uses cadence and rhythmic intention to encourage movement exploration in a scripted plan of care. The participants are active learners and use CE slatted equipment to help support movements. Full participation, to the best of the learners’ ability, is realized with activity modifications made by the conductor.Increased motor control arises through repetition, practice, functional context, and sensory feedback that provide guidance for intention and voluntary movement. Motor control and motor learning theories are foundational principles of CE. Individuals with neurologic injuries, including cerebral palsy, stroke syndrome, Parkinson disease, and traumatic brain injury, can benefit from CE. To date, although research studies cannot objectively compare one person’s movement skills with another’s, new research surrounding motor control and motor learning illustrates and supports the principles and practice of CE. CE is an educational therapy model for teaching and developing new movement skills for individuals with neurologic impairments. This article connects the current science of movement and describes the unique principles involved with CE delivery as an intervention for individuals with neurologic impairments.

Rapid Syllable Transition Treatment—A Treatment for Childhood Apraxia of Speech and Other Pediatric Motor Speech Disorders

Purpose Childhood apraxia of speech (CAS) is a speech disorder that many generalist speech-language pathologists feel underqualified to treat. For children with CAS, this may result in ad hoc interventions resulting in slower progress. Research evidence for various CAS treatments is primarily limited to single-case experimental design studies; however, two treatments (Rapid Syllable Transition Treatment [ReST] and the Nuffield Dyspraxia Programme, Third Edition) have been compared in a single randomized controlled trial. Conclusion This tutorial describes one of those treatments: ReST which was designed to address the three consensus core features of CAS simultaneously: consistency and accuracy of sounds, sequencing, and prosody. The treatment uses nonwords to help children build and store accurate motor plans and programs using principles of motor learning. Treatment data are described, and commonly reported clinical issues are discussed. Recommendations for which children may be suitable for ReST and for evidence-based practice are described.

How the Study of Speech Motor Control Can Inform Assessment and Intervention in Childhood Apraxia of Speech

Purpose The study of speech motor control has led to great advancements in the current understanding of childhood apraxia of speech (CAS). There remains a significant need to bridge the gap between theory and practice to fully understand the clinical implications of past research. Method This review article reviews the speech motor control research in CAS and discusses how these works have offered key information about the underlying motor deficits (Grigos et al., 2015; Terband et al., 2019), the influence of structured practice on speech performance (Case & Grigos, 2016; Grigos & Case, 2018), and the role of task complexity (Case, 2019; Case & Grigos, 2016; Grigos & Case, 2018). We highlight salient points from this existing literature and clinical implications to the assessment and treatment of CAS. Conclusion The study of speech motor control has shed light on a number of key factors related to CAS. Even within perceptually accurate speech, children with CAS display differences in movement patterning and timing control. Assessment must aim to more directly tax speech motor skills to obtain a thorough and accurate illustration of production deficits. Intervention is challenged with the task of not only improving production accuracy but also facilitating more efficient motor planning and programming. Motor-based intervention that applies motor learning principles and introduces variability across motor, phonetic, and prosodic contexts is believed to achieve this goal, though research is needed to better understand changes in speech motor control with treatment.

The Effect of Motor Learning Theory to Speech of an ESL Student: A Single-Subject Study

Purpose : The purpose of the current research was to explore whether a motor learning theory-based protocol that emphasized specific practice structures and feedback schedules would be more effective in improving English pronunciation of a nonnative English speaker.<BR>Methods : The protocol consisted of six sessions over a five-week period and trained eight sets of stimuli that included 10 items for each set.<BR>Results : Results revealed improvement in the participant’s English pronunciation abilities. The one-way repeated analysis of variance showed statistically significant mean differences among pre-treatment, treatment, and post-treatment. Both intelligibility and naturalness during pre-treatment to treatment and pre-treatment to post-treatment measures was significant. Treatment to post-treatment scores were not significant for both intelligibility and naturalness. The participant yielded better intelligibility and naturalness scores after the treatment and once treatment was removed, suggesting that the use of motor learning principles may be a possible intervention method for managing or improving an accent in nonnative speakers.<BR>Conclusions : The study indicated significant differences between the three treatment groups in speech intelligibility and speech naturalness, but not substantial enough to reach a generalization effect as there was a small sample size. Further research is needed to examine significant differences. Given the single-subject design, the findings are unable to reach a generalization effect. Future investigations in a broad-spectrum of nonnative English-Second language speakers are needed to further validate these findings.

Motor Learning, Neuroplasticity, and Strength and Skill Training: Moving From Compensation to Retraining in Behavioral Management of Dysphagia.

Purpose Learning a motor skill and regaining a motor skill after it is lost are key tenets to the field of speech-language pathology. Motor learning and relearning have many theoretical underpinnings that serve as a foundation for our clinical practice. This review article applies selective motor learning theories and principles to feeding and swallowing across the life span. Conclusion In reviewing these theoretical fundamentals, clinical exemplars surrounding the roles of strength, skill, experience, compensation, and retraining, and their influence on motor learning and plasticity in regard to swallowing/feeding skills throughout the life span are discussed.

The Use of Dynamic Weight Support with Principles of Infant Learning in a Child with Cerebral Palsy: A Case Report

Aims Typical infant movement is characterized by a high degree of motor exploration, error, and variability. However, children with cerebral palsy (CP) often cannot create these experiences due to their neuromotor impairments. The purpose of this case study is to describe a 6-month course of physical therapy (PT) incorporating principles of infant motor learning using dynamic weight support (DWS) in a child with CP. Methods The child was a 27-month-old girl with diplegic CP who functioned at Gross Motor Function Classification System Level IV. The child received 68 PT sessions over a six-month period. DWS was used during therapy to encourage motor practice. The therapy area was arranged to encourage active exploration, motor variability, and error experience. Gross motor function, postural control, parent perception of performance, and parent satisfaction were measured before, during, and after the course of therapy. Results Gross motor function increased during the treatment beyond the level predicted from natural progression. Postural control fluctuated and demonstrated no appreciable improvement. Parent-perceived performance and satisfaction improved on three of four goals. Conclusions Using DWS to incorporate principles of infant learning may have facilitated the development of gross motor skills in a child with diplegic CP.

Pedagogy for Effective Learning of Clinical Skills: An Integrated Laboratory Model

Background and Purpose. The teaching, learning, and assessment of clinical skills is a critical component of entry-level physical therapy education. The intention of this article was to describe a successful model for teaching clinical skills in the context of the patient and client management model across the domains of physical therapist education with emphasis on motor learning principles, experiential learning, and clinical reasoning. Method/Model Description and Evaluation. The model describes a cohesive laboratory learning environment that integrates skills from the clinical science courses that coincide each semester. A laboratory director coordinates with faculty teaching clinical sciences in a given semester to ensure the necessary psychomotor content is included, creates experiential learning opportunities that integrate skills across content areas, and promotes clinical reasoning in the context of the patient and client management model. Success of this model was measured through student outcomes on skills competency tests (SCTs), Clinical Competence Performance Examinations (CCPEs), American Physical Therapy Association (APTA) Clinical Performance Instrument (CPI) benchmarks, and the National Physical Therapy Examination (NPTE). Outcomes. Each student passed SCTs administered during semesters 1–6 given a maximum of 3 trials. Every student passed the CCPE administered at the end of each semester in one of 3 trials except for one student in semester 6. Each student met expectations for performance as measured on the CPI for 4 clinical education experiences including entry-level performance for the final 2terminal experiences. All students were successful on the NPTE. Discussion and Conclusion. Implementation of this model has prepared students for authentic physical therapy practice by promoting integration of curriculum content and has fostered faculty collaboration. While initial student and curricular outcomes have been positive, assessment of the model is ongoing.

The design and evaluation of electromyography and inertial biofeedback in hand motor therapy gaming

ABSTRACT This article details the design of a co-created, evidence-based biofeedback therapy game addressing the research question: is the biofeedback implementation efficient, effective, and engaging for promoting quality movement during a therapy game focused on hand gestures? First, we engaged nine young people with Cerebral Palsy (CP) as design partners to co-create the biofeedback implementation. A commercially available, tap-controlled game was converted into a gesture-controlled game with added biofeedback. The game is controlled by forearm electromyography and inertial sensors. Changes required to integrate biofeedback are described in detail and highlight the importance of closely linking movement quality to short- and long-term game rewards. After development, 19 participants (8–17 years old) with CP played the game at home for 4 weeks. Participants played 17 ± 9 min/day, 4 ± 1 day/week. The biofeedback implementation proved efficient (i.e. participants reduced compensatory arm movements by 10.2 ± 4.0%), effective (i.e. participants made higher quality gestures over time), and engaging (i.e. participants consistently chose to review biofeedback). Participants found the game usable and enjoyable. Biofeedback design in therapy games should consider principles of motor learning, best practices in video game design, and user perspectives. Design recommendations for integrating biofeedback into therapy games are compiled in an infographic to support interdisciplinary knowledge sharing.