Motor Learning Principles for Pediatric PTs

I recently travelled to Cincinnati to attend the annual conference of the Academy of Pediatric Physical Therapists. It was an exceptional few days filled with camaraderie and excellent programming.

My interest in motor learning drew me to a course called “Applying the Science of Motor Learning! Motor Learning Principles for Pediatric Therapists. ” It was presented by Carlo Vialu, former Director of PT for the NYC Department of Education. I found the course exceptionally good--research-based, informed and practical—and worth sharing more widely. My take-away points:

1. Motor learning is only motor learning if the changes to motor skills are permanent. This means acknowledging that there is a difference between merely acquiring the skill during the practice session and retaining that same skill at a later time. This includes generalization of the skill or transferring and applying the skill to different tasks. Practice and experience drive true motor learning.

2. Specific research discusses how to apply motor learning principles to promote improved levels of learning. Although this research is often done with able-bodied adults, even athletes, there were examples from the population of children with special needs as well.

• Practice is important and there are times when this may occur in short periods of intense practice spaced by intervals of time (distributed) or with repetitions in a longer, “massed” practice session. It is currently accepted that distributed practice results in better retention of complex tasks. (Moulton et al, 2006)


• Verbal instructions can be internal or external.  Internal instruction focuses the individual’s attention to their own body’s movement. For example, “shift your weight onto your right foot” or “think about the position of your shoulder, elbow and wrist as you throw the ball.” External instruction focuses the individual’s attention on the surroundings connected to the outcome/effect of their movement. For example, “feel the ground against the bottom of your right foot and push against the ground” or “focus on the ball as you throw it toward the target.” Research shows that external verbal instructions result in better skill performance, retention and transfer. (Chiviacowsky et al, 2013)


• Verbal feedback influences motor learning. Interestingly, when this feedback describes the person’s trait such as “you are fast,” less learning occurs. However, when this feedback refers to a process and describes the individual’s effort in performing the task (“when you held it that way, you moved faster”), then more motor learning occurs.
  
  It is also necessary to consider the amount of feedback. For adults, too much feedback can foster dependence and discourage the intrinsic process of trial and error. Children are different and Carlo encouraged us to consider the child’s age, motivation level and nervousness or competence with the task.(Avila et al, 2012)


• In athletes skill demonstration is cautioned against as this may interfere with the individual’s own problem solving in the context of their abilities. (Williams & Hodges, 2005) However, there is evidence for motor learning benefits through modeling by peers, for so-called “observational practice.” (Wulf & Pfeiffer, 2005)


• The way practice sessions are organized is also an important piece of the motor learning puzzle. Constant practice, for instance, results in better performance at the time of practice, but it does not result in better retention or skill transfer. Variable practice, because it requires continual adjustment to achieve movement solutions to meet the changing parameters, promotes skill generalization.
  
  Then, for children, practice that is too easy or practice that is too hard will prevent learning. So in the initial phases of learning, blocked practice, or practicing the task over and over again, has its place. However, as the research with children with CP shows, it is best to follow up with random practice to optimize skill generalization. (Prado et al, 2017)


• Another area of motor learning research involves motor imagery or mental rehearsal prior to task performance. In children, running and then throwing a ball toward a target can improve significantly with mental practice only. Carlo Vialu suggested that in school-based practice, we should consider having a student mentally rehearse the task before physical performance of the task. Research shows that for individuals with CP, both mental practice and physical practice have the same results for skill retention although physical practice is slightly better for skill transfer. (Sharif et al, 2015)


• Most motor learning principles rely on implicit learning or subconscious learning guided by focusing on the task at hand. This means we need to structure the environment to encourage the child to perform and purposefully practice the motor skills needed to achieve the task.

Avila LT, Chiviacowsky S, Wulf G, Lewthwaite R. (2012) Positive social-comparative feedback enhances motor learning in children. Psychology of Sport and Exercise, 13(6):849-853. Abstract

Chiviacowsky S, Wulf G, Avila LT. (2013) An external focus of attention enhances motor learning in children with intellectual disabilities. Journal of Intellectual Disability Research, 57(7):627-634. Full Text

Moulton CA, Dubrowski A, Macrae H, Graham B, Grober E, Reznick R. (2006) Teaching surgical skills: what kind of practice makes perfect?: a randomized, controlled trial. Annals of surgery. 244(3):400-409. Full Text

Prado MT, Fernani DC, da Silva TD, Smorenburg AR, de Abreu LC, and de Mello Monteiro CB. (2017). Motor learning paradigm and contextual interference in manual computer tasks in individuals with cerebral palsy. Research in Developmental Disabilities. 64:56-63. Abstract

Sharif MR, Hemayattalab R, Sayyah M, Hemayattalab A, Bazazan S. (2015) Effects of Physical and Mental Practice on Motor Learning in Individuals with Cerebral Palsy. Journal of Developmental and Physical Disabilities, 27(4):479-487. Full Text

Williams AM, Hodges NJ. (2005) Practice, instruction, and skill acquisition in soccer: Challenging tradition. Journal of sports sciences, 23(6):637-650. Full Text

Wulf G, Paupach M, Pfeiffer F. (2005) Self-controlled observational practice enhances learning. Research Quarterly for Exercise and Sport, 76(1):107-111. Full Text