1. Intro p 151
   1. • The child needs to be an active learner to problem solve how to accomplish a specific task, given his or her constraints • Such task oriented approaches are becoming predominant type of Tx in adult therapy • Important difference among children w/disabilities is that unlike adults, children are rarely trying to regain function, & thus a do not have a motor image of how the task should be performed. Rather, they are learning must occur in the context of development, whereby age-appropriate skills must be learned for the very first time • CP=most common type of pediatric physical disability
2. Motor Learning Principles p 151
   1. Intro
   2. Basic Assumptions p 151
      1. Gen Influences on Learning of Motor Skills
         1. 3 characteristics that influence learning or relearning a motor skill & the effectiveness of therapeutic intervention strategies:
            1. 1. Person
            2. 2. Task (Skill/Activity)
            3. 3. Environment
      2. Categories & Taxonomies of Motor Skills p 152
         1. • the key characteristics of motor skills can be understood through the use of taxonomies =Gentile’s taxonomy of Motor skills • this taxonomy is based on the view that certain characteristics of motor skills placed different types & quantities of attention & motor control demands on the person • there are 4 general characteristics of skills (will discuss 3) • 1st 2= concerning the environmental context (all components of the location & situation which the scale is performed such as supporting surface, objects & other people)
         2. The 1st deals with Whether the Skill's REgulatory Conditions are STATIONARY OR IN MOTION
            1. • REGULATORY CONDITIONS – features of the environmental context that specify the specific movement characteristics needed to achieve the skill’s performance/action goal • b/c a person can achieve a specific performance goal with different movement characteristics, the regulatory conditions specified the movement characteristics required to achieve the performance goal in a specific situation • In different situations involving the motor skill of walking, the regulatory conditions of performance environment (walking on the sidewalk vs sand; walking around objects vs moving people) influence walking behavior in considerably different ways, depending on the specific characteristics of the regulatory condition & whether or not the regular condition is stationary or in motion • CLOSED SKILLS– skills for which regulatory conditions are stationary • OPEN SKILLS – skills for which the regular conditions are in motion
         3. The 2nd deals with Whether the regulatory conditions are the same or different on successive repetitions of performing the skill IINTERTRIAL VARIABILITY)
            1. NO: INTERTRIAL VARIABILITY
            2. • If the REGULATORY CONDITIONS are the SAME = skill has no intertrial variability; i.e. walking up steps were each step is the same height • Reqs the person to simply repeat each trial’s movement characteristics
            3. YES: INTERTRIAL VARIABILITY
            4. • In REGULATORY CONDITIONS are DIFFERENT = skill has intertrial variability; i.e. drinking a glass of water, each drink/rep changes the amount of water in the glass on each trial • Reqs the person to adjust specific movement characteristics on each rep
         4. The 3rd Deals with whether or not an OBJECT must be MANIPULATED when performing the skill
         5. Gentile's Taxomony of Motor Skills
            1. It's Usage:
            2. A guide for evaluating a patient's movement capabilities & limitations
            3. A guide for systematically selecting a progression of activities to improve a child's functional capabilities
      3. Types of Knowledge Acquired During Learning p 153
         1. Learning of motor skills involves the acquisition of 2 types of knowledge:
            1. Explicit/Declarative Knowledge (EXPLAIN)
            2. • The verbal description of a skill • If have difficulty giving verbal description, it can be concluded that you do not have the knowledge of how to do the task
            3. Implicit/Procedural Knowledge (DO)
            4. • Nonverbal/physical performance of a skill
            5. • These types of knowledge are distinguished on the basis of how accurately a person can verbally describe the knowledge; for example if asked to provide evidence that you know how to do something you could verbally describe it or you could physically do it
      4. Stages of Learning p 153
         1. • People go through distinct stages/phases as they learn (a motor skill)
         2. Gentile's Model of Skill Learning:
            1. Initial Stage
            2. • Involves learners attempting to attain some degree of success at achieving the performance goal of the skill • Person develops movement characteristics that match the regulatory conditions of the skill • Person acquires a movement coordination pattern that results in successful achievement of the skills performance goal, although this achievement will be inconsistent from trial to trial • Learner produces movement characteristics that often match, but sometimes don’t match requirements of the regulatory conditions • This stage is characterized by both successful & unsuccessful attempts • Eventually, the learner develops a movement coordination pattern that allows a reasonable amount of performance goal achievement, although the pattern is rather crude & inefficient
            3. Later Stages
            4. Learner needs to acquire 3 Gen characteristics:
            5. The capability of ADAPTING MOVEMENT PATTERNS acquired in the initial stage to specific demands of any performance situation involving that skill
            6. CONSISTENCY in achieving the performance goal of the skill on EACH ATTEMPT at performing the skill
            7. Efficiency of performance in terms of reducing the energy cost of performing the skill to a level that allows an "economy of effort"
            8. The learning goals depend on whether the skill being learned is closed or open
            9. CLOSED SKILL-FIXATION
            10. • CLOSED SKILLS require FIXATION of the basic movement coordination pattern acquired in the first stage • This means that the learner must refine this pattern so that he/she can consistently achieve action goal with little if any conscious effort & a minimum of physical energy
            11. OPEN SKILL-DIVERSIFICATION
            12. • OPEN SKILLS require DIVERSIFICATION of the basic movement coordination pattern acquired in the first stage • This means that the movement pattern is to be adaptable to the ever-changing spatial & temporal characteristics of the open skill performance context
            13. Another characteristic of Gentile’s learning stages model is the involvement of EXPLICIT & IMPLICIT learning processes in the 2 stages • Although both types of learning processes occur in both stages, 1 type predominates over the other at each stage
            14. Initial stage = EXPLICIT learning processes predominate
            15. Later stages = IMPLICIT learning processes predominate
   3. Practice Conditions Considerations p 154
      1. Generalization: From Clinic to Everyday Experience p 154
         1. PT's pick interventions that allow Pts to fnx in everyday world=aka Generalization/Transfer of Learning
         2. Factors that Influence Generalization/Transfer of Learning
            1. • Generalization occurs because it is due to the SIMILARITY BTWN the components of the SKILLS or PERFORMANCE CONTEXTS involved • More generalization occurs with increased amounts of skill or context similarity • The context in which a skill or activity is performed also must be considered especially if the generalization involves performing a skill/activity in the clinic & then in the daily living environment • The greatest amount of generalization of skill performance from a clinic environment to the child’s everyday living environment would occur when all the characteristics of the patient’s everyday living environments are included in the intervention strategies, wherever they take place
         3. 2 Implications for PT Practice using the Generalization/Transf of Learning View:
            1. Use of simulations in the clinic of a patient's daily living environment
            2. Use of simulations of children performing functional daily living skills in their own home or workplace
      2. Presenting Instructions About HOw To Perform Skill: Demo & Verbal Instructions p 154
         1. Intro
            1. • Instructions can be simple as a verbal description of the goal of the activity which works well for motor skills the child can already perform • But for the person is not familiar with a skill or activity or does not know how to perform it, then some other type of instruction must be provided
            2. 2 most common ways PT’s provide instructions are by:
            3. 1. Demonstrating the skill/activity
            4. 2. Verbally describing what to do to perform the skill/activity
         2. Demo p 155
            1. • Is esp effective when the skill or activity involves many movements that must be coordinated or sequenced in a way that the child has not experienced before or if he or she would have difficulty following a long verbal description of the sequence of movements
            2. MIRROR NEURONS IN BRAIN:
            3. • Most researchers agree that observation of another person performing an activity engages a part of the brain that involves “MIRROR NEURONS” which are ACTIVATED BY VISION as a person watches the activity being performed • When engaged in observing an activity, the visual system detects specific movement related features of the activity that do not change from one performance of the activity to another • These features specify the coordinated movement patterns underlying performance of the activity • The combination of the mirror neurons registering the activity & vision detecting the specific movement pattern associated with the activity allows the observer to form a type of blueprint on which to base his/her own attempt to perform the activity
            4. NOVICE LEARNERS OBSERVE OTHER NOVICE LEARNERS:
            5. • Researchers are shown that learning benefits occur when novice learners observe other novice learners which appears to be due to the cognitive problem-solving activity in which the observer engages while watching the novice practice the activity • This means that the observer sees what not to do as well as what to do to achieve the goal of the activity • One strategy that implements this demonstration is the pairing/grouping of children where 1 of the pair or group practices the activity while the other observed him • This is consistent with the philosophy of conducting intensive therapies such as constraint induced movement therapy in group or day camp settings
         3. Verbal Instructions p 155
            1. 2 Important Influential Factors of VI:
            2. The amount of instruction given must be within the limits of the person's capacity to remember & think about them when he/she attempts to perform the activity
            3. Instruction should be fewer number & concise in presentation
            4. Where the instructions focus the person's attention while performing the activity (the movements (internal focus) vs intended movement outcome (external forces)
            5. This is typically better for learning
            6. TYPICALLY BETTER LEARNING OCCURS WITH AN EXTERNAL FOCUS WHEN A PERSON'S ATTENTION IS DIRECTED TO THE INTENDED MOVEMENT OUTCOME
            7. USE OF VISUAL METAPHORIC IMAGE:
            8. • Is another way to use VI about how to perform a skill/activity which involves picturing in the mind what the skill or activities like, rather than the skill itself • Ex: Hopping: tell child to move from one place to another “like a bunny would move”=metaphoric image the child can use to determine how to hop
         4. Presenting Feedback During Practice p 155
            1. 2 Gen Feedback Distinctions:
            2. Augmented, External or Extrinsic Feedback
            3. Feedback/information the PT provides during or after the performance of an activity
            4. Visual, Auditory or Tactile Feedback
            5. Feedback that is naturally available through the various sensory systems
            6. Feedback Provided by PT can refer to:
            7. KNOWLEDGE OF RESULTS (KR)
            8. Outcome of performing the skill
            9. "you were 2 in short of grasping cup"
            10. KNOWLEDGE OF PERFORMANCE (KP)
            11. MOVEMENT CHARACTERISTICS that led to the performance outcome
            12. "your elbow wasn't extended enough to allow you to reach the cup"
            13. 2 Roles of FB in Motor Skill Learning:
            14. To facilitate achievement of the skill's performance goal
            15. • B/c FB provides info about the degree of success achieved while performing a skill (errors made or what was done correctly), the learner can determine whether what he/she is doing is appropriate, & what he/she should do differently to successfully perform the skilled • here FB can help the person achieved successful performance of the skill more quickly or easily than could occur without the feedback
            16. Motivation
            17. • Feedback and motivate the child to continue striving toward a specific performance goal • Here the child uses FB to compare his/her own performance to a specified performance goal • Person must then decide to continue to pursue the goal, to change the goal, or to stop performing the activity
         5. Feedback About Errors Vs Correct Aspects of Performance p 155
            1. Both types of information=valuable, esp b/c each is related to a different role of feedback
            2. Choosing ERROR INFO:
            3. is more effective for FACILITATING SKILL LEARNING
            4. Choosing INFO ABOUT CORRECTLY PERFORMED ASPECTS OF ACTIVITY:
            5. serves to inform the person that he/she IS ON TRACK IN LEARNING the skill or activity, which should ENCOURAGE the person to KEEP TRYING
         6. Selecting the Skill or Activity Component for Feedback p 156
            1. How Much FB Should I Give?
            2. • Should be kept within memory & attention limits • Focus on only 1 aspect or component of the child’s performance
            3. Of The Many Errors Observed, Which One Should I Give FB on?
            4. • Focus on the part of the skill that is most critical for achieving the performance goal of the skill • Additional errors to be corrected would be based on a priority list of errors that are most critical for successfully performing the skill • Ie: stepping over an object. Most critical Part=looking at the object.
         7. Frequency of Giving Feedback p 156
            1. • Research shows that giving error correction feedback during or after every practice trial (100% frequency) is not optimal for learning motor skills • Less than 100% frequency optimizes skill learning, at least in healthy adults
            2. Guidance Hypothesis:
            3. states that the learner use the feedback to guide his or her performance to achieve success which occurs rather quickly
            4. CON: Positive guidance benefit experienced during practice creates a dependency on the availability of feedback which results in performance without feedback that is poorer than if the feedback were available; thus FB=a crutch
            5. FB given less frequently than on every practice attempt=learner engages in more active learning strategies on trials when no feedback is available
            6. Various Techniques that REDUCE the FB Frequency to <100%:
            7. Fading Technique
            8. Systematically reduces the frequency from high to low as a person progresses in learning the skill
            9. Self-Selection Technique
            10. • Involves the patient receiving feedback only when he/she requests it • Research found that when novice learners were allowed to request your correction feedback whenever they wanted they requested it at a frequency less than 100%
            11. Interspersing of Motivational & Error Correction FB during practice
            12. the optimal ratio for the interspersing of these 2 types of feedback is unknown
      3. Practice Structure p 156
         1. Intro
            1. • Selecting specific activities • Scheduling the sequence of those activities
         2. Practice Variability p 156
            1. A practice structure characteristic that increases the chance for future performance success is the variability of the learners experiences (person, task/skill, environment) while he or she practices= PRACTICE VARIABILITY
            2. BENEFITS:
            3. • Primary benefit a learner derives from practice experiences that promote movement & context variability is an increased capability to perform a skill/activity in some future situation thus the pt is able to perform the practice skill/activity and adapt to performance context conditions that he/she may not have actually experienced before
            4. WAYS TO INCORP PRACTICE VARIABILITY IN PRACTICE SESSIONS:
            5. Directly requiring the child to perform multiple variations of a skill that require different movement patterns or sequences to achieve the same action goal (using diff movement pstrats for reaching, grabbing a cup: different shapes, locations, full vs empty)
            6. Vary the characteristics of the context in which the skill or activities performed (using different types & sizes of cups or different types of content in the cup)
         3. Organizing Practice Variability p 157
            1. Should each variation be practice separately with a sufficient amount of time or number of practice trials for the person to demonstrate a desired amount of improvement? Or should each variation be practice in a way that all variations are experienced within each session?
            2. Research shows that each variation should be practiced in a way that all variations are experienced with then each session = best 4 learning
            3. CONTEXTUAL INTERFERENCE (CI) EFFECT
            4. • Contextual interference – the interference (i.e. memory or performance disruption) that results from performing variations of skills or activities within the context of a practice session • CI Effect– is that higher amounts of CI during practice results in better learning that occurs with lower amounts • In terms of variable practice schedules, this effect translates into schedules that involve more interspersing of skill or activity variation within a practice session, which results in better learning that occurs with schedules that involves less interspersing of variations
            5. COMMON PRACTICE SCHEDULES:
            6. 1. BLOCKED
            7. Creates the LEAST AMT OF CI by engaging the learner in NONREPEATED sets of practice trials (or amounts of time) for each skill/activity variation
            8. 2. RANDOM
            9. Creates the HIGHEST AMT of CI by engaging the learner in performing all skill/activity variations in RANDOM ORDER throughout the practice session
            10. Which is Better?
            11. Typically people perform the skills/activities better during blocked practice schedules but an opposite result occurs on transfer test when people who followed a random practice schedule during practice showed superior performance
         4. Practice Specificity p 157
            1. • It emphasizes the need for comparable/similar conditions in both practice & future performance situations • Researchers have found that practice specificities especially applicable to the sensory/perceptual characteristics of practice & future performance contexts • Because people use & rely on visual feedback when it is available, it can become a potential problem in practice settings; i.e. the use of mirrors as a source of visual feedback to help people learn to move in specified ways can lead to a dependency on the mirrors for performing the skill/activity ; so the visual feedback from the mirrors becomes part of what is learned during practice
            2. PRACTICE SPECIFICITY & PRACTICE VARIABILITY:
            3. • Both hypotheses proposed the practice conditions can create a dependency on the availability of certain conditions during practice & future performance situations: the more specific the conditions during practice, the more dependent the person becomes on the availability of those conditions • Both hypotheses propose that varying conditions during practice can break this potential dependency
      4. Massed & Distributed Practice p 157
         1. • Deals with the amount of time devoted to various activities within & across sessions; The length of each session; the amt of active engagement in each activity w/in a session; the amt of rest btwn activities w/in & btwn sessions • The terms refer to the amount of time in which a person actively practices & rest between & during practice sessions
         2. Massed vs Distributed
            1. MASSED PRACTICE INVOLVES LONGER ACTIVE PRACTICE & SHORTER REST PERIODS THAN DISTRIBUTED PRACTICE
         3. The APPLICATION of massed & distributed practice:
            1. Relates to the Length & Distribution of Practice Session
            2. If a specified amount of time (or number of practice trials) should be devoted to practicing a skill/activity, is it better to schedule longer (& fewer) practice sessions or shorter (& more) practice sessions?
            3. EVIDENCE: SHORTER & MORE PRACTICE SESSIONS ARE PREFERRED TO LONGER & FEWER SESSIONS
            4. Relates to the Length of the Rest Intervals Btwn Trials
            5. If a child is supposed to perform 10 repetitions of an activity, how much time should the patient rest between repetitions to maximize the benefit of the repetitions?
            6. WHEN TO CHOOSE MASSED:
            7. • EVIDENCE: MASSED practice is better for DISCRETE SKILLS such as reaching & grasping, & limb positioning (ROM Exercises) • Massed creates FATIGUE problems for continuous skills more than for discrete skills
            8. WHEN TO CHOOSE DISTRIBUTED:
            9. EVIDENCE: DISTRIBUTED practice is better only for the learning of CONTINUOUS SKILLS such as locomotion, cycling & swimming activities
      5. Whole & Part Practice p 158
         1. Intro
            1. One way to determine the answer to practicing a skill in parts on in its entirety is to analyze the skill in terms of its complexity & organization characteristics
            2. COMPLEXITY:
            3. • Refers to the number of parts of the skill, as well as the amount of attention demanded by the performance • Complexity increases as the number of parts & the amount of attention demanded increases
            4. ORGANIZATION:
            5. • Is determined by the temporal & spatial relationships of the parts of the scale • Motor skills in which the PARTS ARE relatively INDEPENDENT in terms of temporal & spatial relationships between parts are considered to be LOW IN ORGANIZATION • Skills in which the BETWEEN-PARTS relationships are temporally & spatial the INTERDEPENDENT have a HIGH LEVEL OF ORGANIZATION
            6. NAYLOR & BRIGGS COMPLEXITY-ORGANIZATION MODEL:
            7. • Skills that ARE LOW IN COMPLEXITY & HIGH IN ORGANIZATION should be practiced as a WHOLE SKILLS • Skills that are HIGH IN COMPLEXITY & LOW IN ORGANIZATION should be PRACTICED IN PARTS • In PT, most skills practiced are complex meeting they should be practiced in parts before they are practiced as a whole skill
            8. WHICH PARTS SHOULD BE PRACTICED SEPARATELY & WHICH SHOULD BE COMBINED?
            9. • Those parts that are temporarily & spatially interrelated should be grouped together as a natural unit within the skill
            10. A STRATEGY FOR ENGAGING PEOPLE IN PRACTICING INDIVIDUAL PARTS = PROGRESSIVE PART METHOD:
            11. • Rather than have people practiced each part of the skill separately before performing the whole skill, the progressive part method involves practicing the skill in increasing sizes of sequences of parts • The first part is practiced separately until a certain level of success is achieved & in the second part is added so that the first & second part of practiced as 1 unit • Each part then gets progressively added until the whole skill is performed
         2. Reducing Difficulty of a Skill p 158
            1. 2 Step process to practicing a modified version of the whole skill rather than practicing the skill by parts:
            2. 1. Practicing the simplified version of the skill
            3. 2. 'Followed by practicing the actual skill without the modification
            4. Strategies to Effectively Reduce a Skill's Difficulty:
            5. Reduce the speed at which the skill is normally performed to a pace that allows attention to be given to the movement patterns
            6. Reduce the difficulty of the object that must be manipulated while performing the skilled or activity
            7. Reduce the attention demands required by the skill, such as by using the BWSS for performing gait skills
            8. • The use of virtual reality & simulators
      6. Mental Practice p 159
         1. • Refers to be cognitive or mental rehearsal of a physical skill in the absence of overt physical movement • People may think about the cognitive or procedural aspects of the skill or activity, or they may engage in visual &/or kinesthetic imagery in which they see &/or feel themselves actually performing the skill or activity • Research has estab’d its effectiveness in facilitating skill acquisition and adults & as a means of preparation just before performing a skill/activity • Is most effective when combined with actual physical practice of the skill/activity; • The inclusion of mental practice can reduce the need for physical practice by 25% – 50% therefore 50 physical practice trials combined with 50 mental practice trials are as effective for learning a skill as 100 physical practice trials according to some research • So visualize it then perform it
         2. WHY IS MENTAL IMAGERY EFFECTIVE FOR AIDING MOTOR SKILL LEARNING & PERFORMANCE PREP?
            1. NEUROMUSCULAR HYPOTHESIS:
            2. states the imaging or visualizing of motor skill performance creates electrical activity in the nerves & musculature involved in performing the scale (it doesn’t reach a level of intensity that would produce the kind of muscle activity needed to produce observable movement)
            3. THE BRAIN ACTIVITY HYPOTHESIS
            4. • Involves a similar notion of internal activity that simulates activity that occurs when the skill is actually performed • Is based on the results of brain imaging studies, when a person imagines moving a body part, the brain activity similar to what occurs when a person physically moves
            5. THE COGNITIVE HYPOTHESIS:
            6. • Proposes that mental practice engages the person in the type of cognitive processes in which a person engages before, during, & after physically performing and motor skill • These processes may include cognitive activities such as decision-making for developing strategies to correct performance errors
3. Motor Learning in Typically Developing Kids p 159
   1. Intro
      1. • Not only do children undergo motor learning repeatedly, but this occurs as cognition & physical constructs of their bodies change • It's important to consider learning in the context of motor development of age appropriate skills
   2. Kids Aren't Simply Little Adults p 159
      1. Intro
         1. ADULTS:
            1. Person, task & environment affect adult learning
            2. • Have amazing cognitive processing capabilities, but these emerge slowly throughout development
         2. CHILDREN:
            1. Maturation of physical & neuronal structures & environmental cues & practice influence each other & guide development in children
            2. • As changes in body mass & limb length occur, the dynamic required to produce code action also change. Therefore learning activities must be planned & occur continually in the context of the developing child & motor learning at one time point may not directly transferred to another • Children are known to have decreased information processing capabilities compared with adults which limits the amount & type of information they can process • Children are slower processing such information & have decreased selective attention to do so • Limited processing & reduced object recognition capabilities affect their ability to copy images • Higher-level attentional focus, spatial working memories, & verbal learning & memories all differ between children & adults which means that the amount of information that children can process & the rate at which they may do so may be limited & many of the principles of motor learning discussed may need to be adjusted according to age expectations, as well as any cognitive limitations
      2. Feedback Schedules p 160
         1. ADULTS:
            1. Adults benefit from intermittent FB
            2. Feedback fading is beneficial in adults
         2. CHILDREN:
            1. CHILDREN BENEFIT FROM FB PROVIDED AFTER EVERY TRIAL
            2. Fading of FB beyond a critical point may be detrimental to learning in children
            3. There may be a critical point in HR skill where feedback reduction interferes, & feedback may need to be withdrawn more gradually
            4. Practice in children can be made more effective with feedback with optimal information without guiding to outcome so PT’s need to monitor how feedback is influencing performance & modified the frequency accordingly
         3. WHY IS REDUCING FB LESS BENEFICIAL IN KIDS & THEY NEED MORE FB?
            1. • Reduced feedback and children resulted in more air which could be due to their reduced attentional capabilities but it may relate to the fact that children have increased error & movement variability, whereby they are signal – two – noise becomes much higher & intrinsic feedback is washed out • Children are known to rely more on online adjustments during movement & increased feedback may help calibrate these adjustments • Children may require increased feedback to update internal representations, which may interact with information processing
      3. Types of Practice Schedules
         1. • The organization of practice variability to modulate contextual interference may differ between children & adults • The type of practice schedule that is most beneficial may depend on age, task complexity & skill level
         2. MIXED EVIDENCE
            1. Organizing Practice Variability: BLOCKED VS RANDOM
            2. ADULTS:
            3. Random practice is better for learning
            4. CHILDREN:
            5. RANDOM:
            6. Random practice is better for learning & retention (ie hand writing retention in elementary school kids was found to be better during random practice)
            7. BLOCKED:
            8. • Blocked or mixed practice may be better for some tasks & age groups • Blocked may be better for younger/less skilled learners for complex tasks ( because random practice schedules may overload the system with too much information, given the reduced & slower information processing)
            9. Other studies suggest no difference and practice schedules
      4. Learning Occurs Over Considerable Time & Practice p 161
4. Motor Learning in Pediatric Rehab p 161
   1. Practice Makes Better p 161
      1. CP
         1. CEREBRAL PALSY=MOST COMMMON TYPE OF CHILDHOOD NEUROLOGIC DISABILITY & The topic on which the majority of research in pediatric motor learning has been focused on
         2. • CP is a developmental disorder of movement & posture that causes limitations in activity & deficits in motor skills • Is attributed to nonprogressive disturbances in the developing fetal or infant brain • MOST COMMON SUBTYPE=SPASTIC HEMIPLEGIA – characterized by motor impairments mainly affecting 1 side of the body; accounting for 30% – 40% of new cases • Through much of the 20th century, the motor impairments, especially in the UE are thought to be static with little potential for habilitation; early work studying prehensile force control reinforced this view suggestion that children with CP pertain infantile coordination strategies; BUT subsequent studies found these impairments not to be static and instead improved with sufficient practice
      2. 2 LINES OF EVIDENCE SUGGESTING MOTOR IMPAIRMENTS AREN’T STATIC AND ACTUALLY IMPROVE WITH SUFFICIENT PRACTICE:
         1. • STUDIES HAVE SHOWN THAT MOTOR FUNCTION DOES IMPROVE OVER THE COURSE OF DEVELOPMENT; GROSS & FINE MOTOR FUNCTIONS DO DEVELOPED, ALTHOUGH THESE 2 GENERAL TYPES OF SKILLS SEEM TO DEVELOP & REACH PLATEAUS DIFFERENTLY • – studies found that bimanual proficiency improves during the course of development, but that the developmental rate & the subsequent plateau depends on the initial score at 18 months • –Kids with hemiplegia with higher bimanual function in early childhood developed by manual skills faster & reached their limit earlier than children with lower bimanual function • –The development of bimanual UE use differs from that of gross motor activities and CP, where milder children reach their limit later • –A follow-up study found that hand function in children with CP improves with age
         2. • Studies have demonstrated that motor performance can indeed improve with practice • – although motor learning was considerably slower than in typically developing children, impairments in fine manipulative capabilities & force regulation during grasp were partially ameliorated with this extended practice; suggesting that the initial impaired performance, at least in part, may be due to lack of use & that many impairments and motor control P previously documented may be due to the fact that insufficient practice was provided (i.e. early stages of motor learning rather than motor control capabilities were captured) • –In-hand manipulation has been shown to improve with practice • –other findings suggest intensive practice may provide a window of opportunity for improvement – found benefit of intensive training and postural control and children w/CP • –functional or task oriented approaches & physical conditioning provided with sufficient intensity have the potential to improve motor function in CP • –CP kids may benefit from more concrete instructions than from movement outcome information; so provide careful FB on knowledge of performance, as well as cognitive strats to achieve better performance levels
      3. WHAT TYPE OR PRACTICE SCHEDULE IS BEST FOR CP?
         1. • A study basically found that children with CP can form & retain internal representations of novel objects for anticipatory control, irrespective of the type of practice schedule employed • It is unknown whether 1 form of practice is more beneficial than the other although random or mixed practice may resemble naturalistic learning to a greater extent • INTENSITY OF PRACTICE MATTERS IN REHAB • CHILDREN WHO REQ LESS REDIRECTION OF FOCUS IMPROVED TO A GREATER EXTENT THAN THOSE WHO REQ’D A LOT OF REDIRECTION
         2. BLOCKED SCHEDULING
            1. • Some studies found after blocked practice over several sessions, CP kids retain the ability to grade isometric grip force (using online visual feedback) after a 5 day delay • With a single session of extended blocked practice, CP kids with to meet lesion improve their ability to scale fingertip forces to the weight & texture of novel objects • Like adults, blocked practice resulted in better acquisition of force scaling to the grip of novel objects in children with CP than did random practice; but both practice schedules resulted in similar retention • Force scaling is a form of parameter learning as opposed to learning a new skill; so research findings are in line with the hypothesis that random practice would not provide an advantage over blocked practice for parameter learning
5. Task-Oriented Training p 164
   1. Intro
      1. • Task-Oriented Training=Is a top – down approach that focuses on activity limitations rather than on remediation of impairments or correction of movement patterns • Can be considered a motor learning or goal – directed approach to rehab which is based on integrated models of motor learning & control & behavioral neuroscience focusing on participation & skill acquisition • The associated behavioral demands of the task & motor skill training may result in cortical reorganization underlying concurrent functional outcomes
      2. WHAT’S NEEDED FOR OPTIMAL EFFICACY?
         1. • – must be challenging • – must progressively increased behavioral demands • – must involve active participation • Must have salience to the performer to influence the person – task – environment triad • Time on task may be less important than what is practiced
      3. EVIDENCE: IMPORTANCE OF TASK-ORIENTED APPROACHES FOR CP:
         1. a study compared functional PT (consisted of estab of fnxal goals, repetitive practice of problematic motor abilities in meaningful environment, active problem solving, & involvement of caregivers in goal setting, decision making & implementation on daily life) versus a reference group whose therapy was based on the principle of movement normalization (including some aspects of neurodevelopmental treatment [NDT] & Vojta method) FOUND no differences in improvement in basic gross motor abilities but when examining functional skills in daily situations they found that children in the functional therapy group improved more than children and the movement normalization group; therefore functional training had the additional benefit of improving motor abilities in the daily environment identified to be important to caregivers
         2. Treadmill Training=type of Functional Training
            1. Functional Training that focuses on massed practice of locomotor behaviors=not clear as to whether it’s efficacious in CP
            2. FOR DOWN SYNDROME=YES
            3. it is well established in the efficacy of DOWN SYNDROME
      4. 2 TYPES OF CONTEMPORARY TASK-ORIENTED APPROACHES:
         1. CONSTRAINT-INDUCED MOVEMENT THERAPY (CIMT)
         2. FUNCTIONAL BIMANUAL TRAINING
   2. Constraint-Induced Therapy p 165
      1. Intro
         1. • The idea that “residual (masked) capability” could potentially be tapped into by forced use of the deafferentated or impaired limb (if forced by restraint of the contralateral unaffected UE) drove the development of intensive practice-based therapies in humans • Some colleagues applied force use and some others added in structured activities using principles of behavioral psychology (shaping) – involves approaching motor activities in small steps by successive approximation to the movement goal &/or grading of task difficulty based on the pt’s capabilities; which is similar to PART PRACTICE • The active intervention involving restraint plus structured practice = constraint induced movement therapy (CIMT) • Here functional arm use is promoted more than skill • A study that used an animal model of hemiplegia (1 hemisphere of motor cortex was transiently inactivated & the cat wore a restraint on the unimpaired limb w/no training or received traning for 1 hr/day, 5 days/wk for 4 wks, along w/the restraint) found that despite both groups of cats being forced to use the affected limb, only cats that received active skill training had normalization of functional & synaptic plasticity; therefore the ingredients of training matter
      2. Constraint-Induced Therapy in Kids w/Hemiparesis p 165
         1. • Often the duration of restraint where must be modified along with the type of restraint because children are not as easily motivated to perform ADLs or part practice for sustained periods of time in the way that adults are • Although the evidence is not yet conclusive, all of the studies have reported positive outcomes; so CIMT can be considered a promising therapeutic approach for use with children with hemiplegia • No evidence suggest that 1 type of restraint is more effective than another so comfort & safety should be a key factor in selection • Improvements in UE performance in young children have been noted with just 2 hours per day 3 times per week • CIMT is just a task oriented method to induce intensive practice; it can be considered as part of a child’s long-term pediatric rehabilitative care; there’s no advantage to maintaining the potentially invasive schedule & restraints; & instead, one could administer it through repeated & less intensive bouts
         2. CIMT UTILIZES A NUMBER OF MOTOR LEARNING PRINCILES:
            1. • Use of both part & hold practice • Modifying tasks to ensure success & progression of difficulty as success is achieved • Active problem-solving • Optimal practice & feedback schedules • The need to generalize learning to performance in everyday environments
         3. PROBLEMS WITH APPLYING CIMT TO CHILDREN
            1. CIMT was developed to overcome learned nonuse and adults with hemiplegia & to promote use over skill; children must overcome developmental disuse, whereby they may have never learned how to effectively use their more affected extremity during many tasks & may need to learn how to use it for the first time; so treatment must be developmentally focus & must take into account the principles of motor learning
            2. Restraining a child’s less affected extremity is potentially psychologically & physically invasive, & therefore should not be performed on young or severely impaired children with the same intensity as in adults; remember that the use of the less affected side is still developing and children; therefore a study on kittens found that there may be a substantial risk of damage to the less affected UE if it is restrained for long periods at two early an age; a greatly modified protocol is required in young children
            3. CIMT focuses on Unimanual impairments, which do not greatly influence functional independence & QOL and that children with hemiplegic have a well functioning (dominant) hand; training it as a dominant hand while restrained likely will improve manual dexterity, although it lacks specificity of training for how the hand will be used once the restraint is removed for example, as a nondominant assisting hand during bimanual activities
            4. Children with hemiplegic have impairment in spatial & temporal coordination of the 2 hands as well as global impairments and motor learning so constrained therapies can’t address these problems and thus generalization of training may not apply
   3. Unconstraining The Constraint: Bimanual Training p 167
      1. Development of UE control is the consequence of activity-dependent competition between the 2 hemispheres with the more active side winning out over the less active (damaged) side
      2. Ways to balance activity of the 2 hemispheres:
         1. Using repetitive transmagnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS)
            1. Both inhibit activation of ipsilateral pathways & enhance activation of contralateral pathways
         2. From a functional perspective, principles of practice specificity was suggest that the best way the balance activity of the cerebral cortices & achieve improved by manual control would be to directly practice bimanual coordination
         3. A child appropriate form of task oriented intensive functional training called hand-arm bimanual intensive therapy (HABIT) aims to improve the amount & quality of involved UE use during bimanual tasks
            1. • It retains the 2 main elements of pediatric CIMT ( intensive structured practice & child friendliness) & similarly engages the child in bimanual activities 6 hours per day for 10 – 15 days in a day camp setting; bimanual UE coordination is elicited by modifying the environment • It involves task oriented training to achieve meaningful goals but it’s intensity is much greater, practice is far more structured, & children problem solved & focus on how the UE performs at the end point of the movement; no effort to normalize movement is provided • A small study provided preliminary evidence that task oriented approaches directed at both UEs can improve bimanual UE use & coordination • Another study results support the notion of training specificity & suggest that bimanual training may be more beneficial for improving spatial & temporal aspects of by manual control
6. Salience of Motor Activities p 168
   1. • Must make activities meaningful & enjoyable, including video gaming which on average is played in 8 hours/wk • Actual immersion in a video/virtual environment can potentially allow individuals to produce movements that are not feasible in the real world as a result of their motor impairments; this possibility may have novel intriguing consequences & may enhance learning for functional training, as it is therefore possible to provide positive KR for appropriate efforts • Currently there is insufficient evidence of the efficacy of gaming by itself therefore it is just one means of engaging task oriented training, but one that is potentially beneficial in maintaining motivation & providing reward = important for motor learning & enhancing plasticity • B/C children often are ready engage in video gaming at home, simply continue to perform what they do at home may be neither rewarding or specific enough to elicit movement changes & improvement in gaming ability so PT’s must be creative
   2. THE CHOICE OF VIDEOGAME PLATFORMS, CONSOLES & SOFTWARE NEED TO TAKE INTO ACCOUNT:
      1. The initial abilities of the performer
      2. The specific motor impairments targeted
      3. The extent to which therapy is directed to 1 or both UEs
      4. The ability to attain progress in movement difficulty
      5. The age & interest of the performer
   3. 2 GENERAL APPROACHES TO INCORPORATING VIDEO-BASED OR VIRTUAL REALITY (VR) TRAINING INTO PEDIATRIC REHAB PROTOCOLS:
      1. To develop game platforms that target specific impairments or elicit certain movements which may be useful for eliciting successful movements by altering the gain of required movement to virtual movement provided as feedback; therefore specific impairments could be targeted by creating games requiring such movement, again adjusting the gain of required to display to movement
      2. To use or modify commercially available gaming systems (Nintendo Wii); major limitation is that those devices were not created to elicit specific movements that are necessarily impaired and children with disabilities & may not have sensors that are sensitive enough to translate subtle movement improvements into increases in game performance; during free play, kids are likely to choose games or consoles they can be performed with 1 (nonparetic) UE or require minimal (stabilization) movement of the affected UE
7. Considerations p 169