Motor Evoked Potential Amplitude in Motor Behavior-based Transcranial Direct Current Stimulation Studies: A Systematic Review.

Motor evoked potential amplitude (MEPamp) is frequently measured in transcranial direct current stimulation (tDCS) studies that target the primary motor cortex (M1), and a subset of these studies involve motor behavior. This systematic review explored the role of MEPamp as an indicator of neural change in M1-targeted tDCS studies involving motor behavior (i.e., motor practice and/or evaluation of motor performance) in healthy individuals, and examined the association between changes in motor performance and MEPamp. We executed our search strategy across four bibliographic databases. Twenty-two manuscripts met eligibility criteria. While anodal tDCS combined with motor practice frequently increased MEPamp, MEPamp outcomes did not necessarily align with changes in motor performance. Thus, MEPamp may not be the most appropriate indicator of neural change in tDCS studies that aim to improve motor performance.

Integrating Transcranial Direct Current Stimulation into an Existing Inpatient Physiotherapy Program to Enhance Motor Learning in an Adolescent with Traumatic Brain Injury: A Case Report.

PURPOSE: Describe how transcranial direct current stimulation (tDCS) was incorporated into an inpatient physiotherapy program for an adolescent with severe traumatic brain injury (TBI), detail the motor learning focus of the physiotherapy sessions, and summarize gross motor progress. METHOD: This case report describes an adolescent who received 20 minutes of anodal tDCS immediately prior to 16 physiotherapy sessions over four weeks. Potential side effects were tracked pre/post tDCS. Gross motor outcomes were measured pre-intervention, post-intervention, and three months post-intervention. Physiotherapy session content was analyzed using therapist documentation and the Motor Learning Strategies Rating Instrument. RESULTS: The youth tolerated tDCS well. The primary side effect was itchiness under the electrodes during tDCS sessions. His mobility progressed from wheelchair use pre- 'tDCS + physiotherapy' to ambulation with a walker post-intervention. His Gross Motor Function Measure score increased 33.1% points pre/post intervention. Session tasks often had several foci (e.g., skill acquisition, strength, and balance) with task focus changing as the youth progressed. Various motor learning strategies were layered within tasks to support performance and learning. CONCLUSIONS: tDCS was successfully integrated into an existing inpatient physiotherapy program for an adolescent with TBI. This protocol provides a structure for implementing, monitoring, and measuring tDCS + physiotherapy in pediatric rehabilitation.

Gross motor change after inpatient rehabilitation for children with acquired brain injury: A 10-year retrospective review.

AIM: To estimate gross motor change in inpatient school-aged children with subacute acquired brain injury (ABI), identify factors associated with gross motor change, and describe inpatient physiotherapy focus. METHOD: This retrospective chart review involved inpatient children (5-18 years) with subacute ABI who had either two Gross Motor Function Measure (GMFM-88) assessments or one GMFM-88 with another pre/post gross motor outcome measure. Outcome change scores and Goal Attainment Scaling (GAS) T scores were calculated. Regression analyses examined factors predicting gross motor change. GAS goal areas were analysed to determine physiotherapy focus. RESULTS: Of the 546 charts screened, 266 (118 female) met study criteria. The GMFM-88 was generally administered first, followed by other measures. GMFM-88 (n = 202), Community Balance and Mobility Scale (n = 89), and Six-Minute Walk Test (6MWT) (n = 98) mean change scores were 18.03% (SD 19.34), 17.85% (SD 10.77), and 142.3 m (SD 101.8) respectively. The mean GAS T score was 55.06 (SD 11.50). Lower baseline scores and increased time between assessments were most predictive of greater GMFM-88 change (r ≥ 0.40). Twenty-five percent of GAS goals were ambulation-based. INTERPRETATION: Appropriate outcome measure selection is integral to detecting gross motor change in pediatric inpatient ABI rehabilitation. Mean change score estimates can be used to compare standard inpatient rehabilitation with new treatment approaches.

Impact of the COVID-19 pandemic on therapy service delivery and functioning for school-aged children with disabilities in the United States.

BACKGROUND: The COVID-19 pandemic caused wide-scale disruptions to therapy services for children with disabilities in the United States. OBJECTIVE/HYPOTHESIS: We evaluated changes in therapy service delivery during the first four months of the pandemic, examined the impact of these changes on children's functioning, and analyzed factors predicting the loss of in-person services and receipt of teletherapy services. METHODS: We undertook an anonymous cross-sectional online survey of parents/caregivers of children with a disability aged 5-17 years. Changes in therapy service delivery and children's functioning were descriptively summarized. Logistic regressions examined individual and contextual predictors of loss of therapy services or receipt of teletherapy services. RESULTS: 402 parents of children aged 5-17 years old with one or more disabilities participated; 42% of children lost access to all therapy services, and 34% of children received at least one therapy service via telehealth. Children receiving a greater number of services pre-COVID and having access to more technological devices pre-COVID were significantly more likely to receive teletherapy. Over 40% of parents attributed declines in their child's motor, behavior, social, and communication skills to changes in therapy services; this impact was greater for children with multiple diagnoses. CONCLUSIONS: Findings underscore the negative impact of therapy service disruptions on children with disabilities.

Performance Variability During Motor Learning of a New Balance Task in a Non-immersive Virtual Environment in Children With Hemiplegic Cerebral Palsy and Typically Developing Peers.

Background: Motor impairments contribute to performance variability in children with cerebral palsy (CP) during motor skill learning. Non-immersive virtual environments (VEs) are popular interventions to promote motor learning in children with hemiplegic CP. Greater understanding of performance variability as compared to typically developing (TD) peers during motor learning in VEs may inform clinical decisions about practice dose and challenge progression. Purpose: (1) To quantify within-child (i.e., across different timepoints) and between-child (i.e., between children at the same timepoint) variability in motor skill acquisition, retention and transfer in a non-immersive VE in children with CP as compared to TD children; and (2) To explore the relationship between the amount of within-child variability during skill acquisition and learning outcomes. Methods: Secondary data analysis of 2 studies in which 13 children with hemiplegic CP and 67 TD children aged 7-14 years undertook repeated trials of a novel standing postural control task in acquisition, retention and transfer sessions. Changes in performance across trials and sessions in children with CP as compared to TD children and between younger (7-10 years) and older (11-14 years) children were assessed using mixed effects models. Raw scores were converted to z-scores to meet model distributional assumptions. Performance variability was quantified as the standard deviation of z-scores. Results: TD children outperformed children with CP and older children outperformed younger children at each session. Older children with CP had the least between-child variability in acquisition and the most in retention, while older TD children demonstrated the opposite pattern. Younger children with CP had consistently high between-child variability, with no difference between sessions. Within-child variability was highest in younger children, regardless of group. Within-child variability was more pronounced in TD children as compared to children with CP. The relationship between the amount of within-child variability in performance and performance outcome at acquisition, retention and transfer sessions was task-specific, with a positive correlation for 1 study and a negative correlation in the other. Conclusions: Findings, though preliminary and limited by small sample size, can inform subsequent research to explore VE-specific causes of performance variability, including differing movement execution requirements and individual characteristics such as motivation, attention and visuospatial abilities.

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

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

Learning and transfer of complex motor skills in virtual reality: a perspective review.

The development of more effective rehabilitative interventions requires a better understanding of how humans learn and transfer motor skills in real-world contexts. Presently, clinicians design interventions to promote skill learning by relying on evidence from experimental paradigms involving simple tasks, such as reaching for a target. While these tasks facilitate stringent hypothesis testing in laboratory settings, the results may not shed light on performance of more complex real-world skills. In this perspective, we argue that virtual environments (VEs) are flexible, novel platforms to evaluate learning and transfer of complex skills without sacrificing experimental control. Specifically, VEs use models of real-life tasks that afford controlled experimental manipulations to measure and guide behavior with a precision that exceeds the capabilities of physical environments. This paper reviews recent insights from VE paradigms on motor learning into two pressing challenges in rehabilitation research: 1) Which training strategies in VEs promote complex skill learning? and 2) How can transfer of learning from virtual to real environments be enhanced? Defining complex skills by having nested redundancies, we outline findings on the role of movement variability in complex skill acquisition and discuss how VEs can provide novel forms of guidance to enhance learning. We review the evidence for skill transfer from virtual to real environments in typically developing and neurologically-impaired populations with a view to understanding how differences in sensory-motor information may influence learning strategies. We provide actionable suggestions for practicing clinicians and outline broad areas where more research is required. Finally, we conclude that VEs present distinctive experimental platforms to understand complex skill learning that should enable transfer from therapeutic practice to the real world.

Reliability of the Motor Learning Strategies Rating Instrument in physiotherapy intervention for children with cerebral palsy.

AIM: To evaluate the reliability of the Motor Learning Strategies Rating Instrument (MLSRI-20) in gait-based, video-recorded physiotherapy interventions for children with cerebral palsy (CP). METHOD: Thirty videos of 18 children with CP, aged 6 to 17 years, participating in either traditional or Lokomat-based physiotherapy interventions were rated using the MLSRI-20. Physiotherapist raters provided general and item-specific feedback after rating each video, which was used when interpreting reliability results. RESULTS: Both interrater and intrarater reliability of the MLSRI-20 total score was good. The interrater reliability intraclass correlation coefficient (ICC) was 0.78 with a 95% confidence interval (CI) of 0.53-0.89 and a coefficient of variation (CV) of 11.8%. The intrarater reliability ICC was 0.89 with a 95% CI of 0.76-0.95 and CV of 7.8%. Rater feedback identified task delineation and interpretation of therapist verbalizations as sources of interrater reliability-related scoring challenges. INTERPRETATION: The MLSRI-20 is a reliable tool for measuring the extent to which a physiotherapist uses motor learning strategies during a video-recorded intervention. These results have clinical and research implications for documenting and analyzing the motor learning content of physiotherapy interventions for children with CP. WHAT THIS PAPER ADDS: The Motor Learning Strategies Rating Instrument (MLSRI-20) is reliable for use by trained physiotherapist raters. Measuring motor learning strategies can identify active 'ingredients' in physiotherapy interventions for children with cerebral palsy. The MLSRI-20 promotes a common language in motor learning.

FIABILIDAD DEL INSTRUMENTO DE CLASIFICACIÓN DE LAS ESTRATEGIAS DE APRENDIZAJE MOTOR EN FISIOTERAPIA: OBJETIVO: Evaluar la fiabilidad del Instrumento de Clasificación de las Estrategias de Aprendizaje Motor (Motor Learning Strategies Rating Instrument, MLSRI-20, siglas en inglés,) en intervenciones fisioterapéuticas basadas en la marcha y grabadas en vídeo para niños con parálisis cerebral (PC). METODOLOGÍA: Se clasificaron 30 vídeos de 18 niños y niñas con PC, de edades comprendidas entre los 6 y 17 años y participando en intervenciones de Fisioterapia tradicionales o basadas en el Lokomat, usando el MLRSI-20. Los evaluadores fisioterapeutas proporcionaron retroalimentación general y específica de los ítems después de clasificar cada vídeo, el cual fue usado al interpretar los resultados de fiabilidad. RESULTADOS: Tanto la fiabilidad inter-observador de la puntuación total del MLSRI-20 como la fiabilidad intra-observador fueron buenas. El coeficiente de correlación intraclase (CCI) de la fiabilidad inter-observador fue de 0,78 con un intervalo de confianza del 95% (IC) de 0,53-0,89 y la variación del coeficiente (VC) del 11,8%. EL CCI de la fiabilidad intra-observador fue 0,89 con un IC95% de 0,76-0-95 y un CV de 7,8%. La retroalimentación del evaluador identificó la delineación de la tarea y la interpretación de las verbalizaciones del terapeuta como fuentes de desafío para puntuar la fiabilidad inter-observador. INTERPRETACIÓN: El MLSRI-20 es una herramienta fiable para medir en qué grado los fisioterapeutas usan estrategias de aprendizaje motor durante una intervención grabada en vídeo. Estos resultados tienen implicaciones clínicas y de investigación para documentar y analizar el contenido de aprendizaje motor en las intervenciones fisioterapéuticas en niños con PC.

CONFIABILIDADE DO INSTRUMENTO DE PONTUAÇÃO DAS ESTRATÉGIAS DE APRENDIZAGEM MOTORA NA INTERVENÇÃO DE FISIOTERAPIA PARA CRIANÇAS COM PARALISIA CEREBRAL: OBJETIVO: Avaliar a confiabilidade do Instrumento de Pontuação das Estratégias de Aprendizagem Motora (Motor Learning Strategies Rating Instrument, MLSRI-20) em intervenções de fisioterapia para crianças com paralisia cerebral (PC) baseadas na marcha e registradas por vídeo. MÉTODO: Trinta videos de 18 crianças com PC, com idades de 6 a 17 anos, participando ou em intervenções de fisioterapia baseada no Lokomat foram pontuadas usando o MLSRI-20. Os examinadores fisioterapeutas forneceram uma avaliação geral e item-específica após pontuar cada vídeo, o que foi usado para interpretar os resultados de confiabilidade. RESULTADOS: Tanto a confiabilidade inter-examinador quanto intra-examinador do MLSRI-20 foi boa. O coeficiente de correlação intraclasse (CCI) da confiabilidade inter-foi 0,78 com intervalo de confiança (IC) a 95% de 0,53-0,89 e coeficiente de variação (CV) de 11,8%. O CII da confiabilidade intra-examinador foi 0,89 com CI a 95% de 0,76-0,95 e CV de 7,8%. A avaliação dos examinadores identificou o delineamento da tarefa e as verbalizações dos terapeutas para interpretação como fontes de desafios na pontuação da confiabilidade inter-examinadores. INTERPRETAÇÃO: O MLSRI-20 é uma ferramenta confiável para mensurar a extensão em que um fisioterapeuta usa estratégias de aprendizagem motora durante uma intervenção gravada em video. Os resultados têm implicações clínicas e científicas para a documentação e análise do conteúdo de aprendizagem motora em crianças com PC.

Does Narrative Feedback Enhance Children's Motor Learning in a Virtual Environment?

Augmented feedback has motivational and informational functions in motor learning, and is a key feature of practice in a virtual environment (VE). This study evaluated the impact of narrative (story-based) feedback as compared to standard feedback during practice of a novel task in a VE on typically developing children's motor learning, motivation and engagement. Thirty-eight children practiced navigating through a virtual path, receiving narrative or non-narrative feedback following each trial. All participants improved their performance on retention but not transfer, with no significant differences between groups. Self-reported engagement was associated with acquisition, retention and transfer for both groups. A narrative approach to feedback delivery did not offer an additive benefit; additional affective advantages of augmented feedback for motor learning in VEs should be explored.

Usability of the 'Kinect-ing' with Clinicians Website: A Knowledge Translation Resource Supporting Decisions About Active Videogame Use in Rehabilitation.

Objective: Commercially available active videogames (AVGs) are promising rehabilitation options, but lack of familiarity with game options may limit clinical integration. We evaluated content and format usability of the 'Kinect-ing' with Clinicians (KwiC) website, an online tool that characterizes commercially available games to support clinical decision-making about Kinect™ game use for rehabilitation. Materials and Methods: This study is a cross-sectional online survey of physical therapists (PTs). Participants selected a case scenario and reviewed the KwiC resource for information about five Kinect games. Based on this interaction, participants selected two games that would meet case scenario goals and answered Likert scale and open-ended questions about KwiC usability and usefulness of the content in guiding game selection for clinical case scenarios. Results: Twenty-five PTs participated, six of whom had previous AVG experience. All KwiC items achieved prespecified consensus of 80% "agree" or "strongly agree" on statements evaluating ease of understanding, usefulness, and format usability. There were no differences in ratings between those with and without AVG experience. Participants most appreciated the videos illustrating game play. Eighty-four percent strongly agreed that the KwiC helped them to make a decision about their case scenario. Participants suggested improving the KwiC by including more information about game use with rehabilitation populations. Conclusions: Positive usability feedback supports continued KwiC development efforts to add additional games, expand information about use specific to clinical populations, and broaden the online format to allow opportunities for clinicians to provide feedback and suggestions. We will then evaluate utility of the KwiC in clinical practice.

Promoting Therapists' Use of Motor Learning Strategies within Virtual Reality-Based Stroke Rehabilitation.

PURPOSE: Therapists use motor learning strategies (MLSs) to structure practice conditions within stroke rehabilitation. Virtual reality (VR)-based rehabilitation is an MLS-oriented stroke intervention, yet little support exists to assist therapists in integrating MLSs with VR system use. METHOD: A pre-post design evaluated a knowledge translation (KT) intervention incorporating interactive e-learning and practice, in which 11 therapists learned how to integrate MLSs within VR-based therapy. Self-report and observer-rated outcome measures evaluated therapists' confidence, clinical reasoning and behaviour with respect to MLS use. A focus group captured therapists' perspectives on MLS use during VR-based therapy provision. RESULTS: The intervention improved self-reported confidence about MLS use as measured by confidence ratings (p <0.001). Chart-Stimulated Recall indicated a moderate level of competency in therapists' clinical reasoning about MLSs following the intervention, with no changes following additional opportunities to use VR (p = .944). On the Motor Learning Strategy Rating Instrument, no behaviour change with respect to MLS use was noted (p = 0.092). Therapists favoured the strategy of transferring skills from VR to real-life tasks over employing a more comprehensive MLS approach. CONCLUSION: The KT intervention improved therapists' confidence but did not have an effect on clinical reasoning or behaviour with regard to MLS use during VR-based therapy.

Integrating virtual reality video games into practice: clinicians' experiences.

The Nintendo Wii is a popular virtual reality (VR) video gaming system in rehabilitation practice and research. As evidence emerges related to its effectiveness as a physical therapy training method, clinicians require information about the pragmatics of its use in practice. The purpose of this descriptive qualitative study is to explore observations and insights from a sample of physical therapists (PTs) working with children with acquired brain injury regarding practical implications of using the Wii as a physical therapy intervention. Six PTs employed at a children's rehabilitation center participated in semi-structured interviews, which were transcribed and analyzed using content analysis. Two themes summarize the practical implications of Wii use: 1) technology meets clinical practice; and 2) onus is on the therapist. Therapists described both beneficial and challenging implications arising from the intersection of technology and practice, and reported the personal commitment required to orient oneself to the gaming system and capably implement this intervention. Findings include issues that may be relevant to professional development in a broader rehabilitation context, including suggestions for the content of educational initiatives and the need for institutional support from managers in the form of physical resources for VR implementation.

When is virtual reality "therapy"?

The use of virtual reality (VR) systems within physical rehabilitation clinical practice and research is rapidly developing, highlighting the need for consensus as to the meaning and relevance of the label "VR therapy." The purpose of this communication is to argue that explicit examination of the inferences underlying this label and discussion regarding the role of clinicians in VR implementation are required. In this vein, we propose what we consider to be a more relevant label and discuss the need for evidence to support knowledge translation initiatives for therapists interested in integrating VR systems within clinical practice.

Partnering for change: an innovative school-based occupational therapy service delivery model for children with developmental coordination disorder.

BACKGROUND: Developmental coordination disorder (DCD) is a common, chronic health condition that is poorly recognized and understood in school settings. Without appropriate support, children with DCD are at increased risk of depression, decreased fitness, and obesity. Evidence shows that occupational therapy intervention needs to shift from remediation of impairment to chronic disease management. PURPOSE: This paper describes Partnering for Change (P4C), an innovative, empirically derived school health service delivery model for children with DCD. KEY ISSUES: The model emphasizes the partnership of the occupational therapist with educators and parents to change the life and daily environment of a child. The P4C partnership focuses on capacity building through collaboration and coaching in context. The model uses a tiered approach which includes whole class instruction, dynamic performance analysis, and monitoring response to intervention. IMPLICATIONS: P4C is a model that responds to the needs of this population, addresses issues identified in research, and provides a continuum of services designed to build capacity.

Facilitating clinical decision-making about the use of virtual reality within paediatric motor rehabilitation: application of a classification framework.

AIM: Multiple virtual reality (VR) systems are used to improve motor function in children and youth with neurological impairments. Galvin and Levac developed a classification framework to facilitate clinical decision-making about VR system use. This paper applies the classification framework to identify its strengths and limitations. METHOD: The classification framework is applied to three case studies where therapists may consider using VR with children involved in paediatric rehabilitation programmes. RESULTS: The classification framework identified VR systems that met each child's individual needs. The relevance of each category to clinical decision-making varied depending on each child's goals. Categories requiring further development and suggestions for additional categories are discussed. CONCLUSIONS: The classification framework facilitates child-centred decision-making about the use of VR as a therapeutic intervention. It has shown initial utility but requires further validation with clinicians working in a variety of clinical settings and with a range of client populations.