Knowledge Translation Task Force for core measures clinical practice guideline: a short report on the process and utilization.

BACKGROUND: As part of the 2018 Clinical Practice Guideline (CPG): A Core Set of Outcome Measures for Adults with Neurologic Conditions Undergoing Rehabilitation, a Knowledge Translation (KT) Task Force was convened. The purpose of this short report was to (1) demonstrate the potential impact of a CPG KT Task Force through a practical example of efforts to implement a CPG into neurologic physical therapy practice and (2) describe the process to convene a KT Task Force and develop products (KT Toolkit) to facilitate implementation of the CPG. METHODS: To describe the process used by the KT Task Force to develop and review a KT Toolkit for implementation of the CPG. RESULTS: Utilizing the Knowledge-To-Action Cycle framework, eight tools were developed as part of the KT Toolkit and are available with open access to the public. Findings indicate that the Core Outcome Measures Homepage, which houses the KT Toolkit, has had greater than 70,000 views since its publication. CONCLUSIONS: This short report serves as an example of the efforts made to implement a CPG into physical therapy practice. The processes to facilitate KT and the tools developed can inform future implementation efforts and underscore the importance of having a KT Task Force to implement a CPG. Moving forward, KT Task Forces should be convened to implement new or revised guidelines. TRIAL REGISTRATION: N/A.

Personalized practice dosages may improve motor learning in older adults compared to "standard of care" practice dosages: A randomized controlled trial.

Standard dosages of motor practice in clinical physical rehabilitation are insufficient to optimize motor learning, particularly for older patients who often learn at a slower rate than younger patients. Personalized practice dosing (i.e., practicing a task to or beyond one's plateau in performance) may provide a clinically feasible method for determining a dose of practice that is both standardized and individualized, and may improve motor learning. The purpose of this study was to investigate whether personalized practice dosages [practice to plateau (PtP) and overpractice (OVP)] improve retention and transfer of a motor task, compared to low dose [LD] practice that mimics standard clinical dosages. In this pilot randomized controlled trial (NCT02898701, ClinicalTrials.gov), community-dwelling older adults (n = 41, 25 female, mean age 68.9 years) with a range of balance ability performed a standing serial reaction time task in which they stepped to specific targets. Presented stimuli included random sequences and a blinded repeating sequence. Participants were randomly assigned to one of three groups: LD (n = 15, 6 practice trials equaling 144 steps), PtP (n = 14, practice until reaching an estimated personal plateau in performance), or OVP (n = 12, practice 100% more trials after reaching an estimated plateau in performance). Measures of task-specific learning (i.e., faster speed on retention tests) and transfer of learning were performed after 2-4 days of no practice. Learning of the random sequence was greater for the OVP group compared to the LD group (p = 0.020). The OVP (p = 0.004) and PtP (p = 0.010) groups learned the repeated sequence more than the LD group, although the number of practice trials across groups more strongly predicted learning (p = 0.020) than did group assignment (OVP vs. PtP, p = 0.270). No group effect was observed for transfer, although significant transfer was observed in this study as a whole (p < 0.001). Overall, high and personalized dosages of postural training were well-tolerated by older adults, suggesting that this approach is clinically feasible. Practicing well-beyond standard dosages also improved motor learning. Further research should determine the clinical benefit of this personalized approach, and if one of the personalized approaches (PtP vs. OVP) is more beneficial than the other for older patients.

How Common Is the Exponential Decay Pattern of Motor Skill Acquisition? A Brief Investigation.

Motor performance is classically described as improving nonlinearly with practice, demonstrating rapid improvements early in practice with stabilization later, which is commonly modeled by exponential decay functions. However, retrospective analyses of our previously collected data challenge this theoretical model of motor skill acquisition, suggesting that a majority of individual learners actually demonstrate patterns of motor improvement different from this classical model. A convenience sample of young adults, older adults, and people with Parkinson disease trained on the same functional upper-extremity task. When fitting three-parameter exponential decay functions to individual participant data, the authors found that only 13.3% of young adults, 40.9% of older adults, and 66.7% of adults with Parkinson disease demonstrated this "classical" skill acquisition pattern. Thus, the three-parameter exponential decay pattern may not well-represent individuals' skill acquisition of complex motor tasks; instead, more individualized analysis methods may be warranted for advancing a theoretical understanding of motor skill acquisition.

The feasibility and efficacy of a serial reaction time task that measures motor learning of anticipatory stepping.

BACKGROUND: Motor learning has been investigated using various paradigms, including serial reaction time tasks (SRTT) that examine upper extremity reaching and pointing while seated. Few studies have used a stepping SRTT, which could offer additional insights into motor learning involving postural demands. For a task to measure motor learning, naïve participants must demonstrate a) improved performance with task practice, and b) a dose-response relationship to learning the task. RESEARCH QUESTION: Is a stepping SRTT feasible and efficacious for measuring motor learning? METHODS: In this prospective study, 20 participants stood on an instrumented mat and were presented with stimuli on a computer screen. They stepped to the corresponding positions on the mat as quickly as possible. Presented stimuli included random sequences and a blinded imbedded repeating sequence. Three days after completing the randomly assigned practice dose [high dose group (n = 10) performed 4320 steps; low dose group (n = 10) performed 144 steps], a retention test of 72 steps was performed. Feasibility was measured as the proportion of participants who completed the assigned practice dose without adverse events. Efficacy was measured as within-group performance improvement on the random sequences and on the repeating sequence (paired t-tests), as well as a dose-response relationship to learning both types of sequences (independent t-tests). RESULTS: All participants (mean age 26.8 years) completed all practice sessions without adverse events, indicating feasibility. High dose practice resulted in performance improvement while low dose did not; a dose-response relationship was found, with high dose practice resulting in greater learning of the task than low dose practice, indicating efficacy. SIGNIFICANCE: This stepping SRTT is a feasible and efficacious way to measure motor learning, which could provide critical insights into anticipatory stepping, postural control, and fall risk. Future research is needed to determine feasibility, efficacy, and optimal practice dosages for older and impaired populations.

Dopamine replacement improves motor learning of an upper extremity task in people with Parkinson disease.

BACKGROUND: Dopamine replacement medication has positive effects on existing motor skills for people with Parkinson disease (PD), but may have detrimental effects on the learning of motor skills necessary for effective rehabilitation according to the dopamine overdose hypothesis. OBJECTIVES: This study aimed to determine whether dopamine replacement medication (i.e. levodopa) affects: learning of a novel upper extremity task, decrements in skill following withdrawal of practice, the rate of learning, and the transfer of movement skill to untrained upper extremity tasks compared to training "off" medication, in people with PD. METHODS: Participants with mild-moderate PD (Hoehn and Yahr stage 2) were randomized to train "on" (n = 12) or "off" (n = 11) levodopa medication. Participants practiced 10 blocks of five trials of a functional motor task with their non-dominant upper extremity over three consecutive days (acquisition period), followed by a single block of five trials two and nine days later. Participants were also assessed "on" levodopa with two transfer tasks (the nine-hole peg test and a functional dexterity task) prior to any practice and nine days after the end of the acquisition period. RESULTS: Participants who practiced "on" levodopa medication learned the upper extremity task to a greater extent that those who practiced "off" medication, as determined by retained performance two days after practice. Skill decrement and skill transfer were not significantly different between groups. Rate of learning was unable to be modelled in this sample. CONCLUSIONS: Levodopa medication improved the learning of an upper extremity task in people with mild-moderate PD.

Predicting Motor Sequence Learning in People With Parkinson Disease.

BACKGROUND AND PURPOSE: Skill acquisition (ie, performance changes during practice) occurs in a nonlinear fashion. Despite this, motor learning is typically measured by comparing discrete timepoints. Thus, typical measures of motor learning do not detect skill acquisition characteristics that may be clinically meaningful. Reliable prediction of motor skill learning in people with Parkinson disease (PD) would allow therapists to more effectively individualize practice doses to fit specific patients' needs. The purposes of this study were to (a) characterize postural skill acquisition in people with PD, and identify factors (such as acquisition rate and practice dose to plateau) that predict learning, and (b) investigate whether levodopa medication (L-dopa) status during practice impacted learning. METHODS: Twenty-seven adults with PD practiced a postural motor task over 3 days, followed by 2 retention tests. Participants were randomized to practice either ON or OFF L-dopa. Data for repeating and random sequences were each analyzed using nonlinear curve-fitting and mixed-effects regressions. Learning was defined as pretest minus retention test performance. RESULTS: Participants with less physical impairment demonstrated less learning on the repeating and random sequence tasks compared with participants with more impairment. Participants who improved faster during practice demonstrated less learning on the repeating sequence task compared with participants who improved more slowly. Reaching plateau during practice was not related to learning. L-dopa did not impair learning. DISCUSSION AND CONCLUSIONS: Participants' skill acquisition characteristics were related to learning a postural motor task. Patient-specific factors, such as the rate of skill acquisition, level of physical function, and medication status, may influence how postural motor practice is delivered during balance rehabilitation.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A250).

Dopamine Replacement Medication Does Not Influence Implicit Learning of a Stepping Task in People With Parkinson's Disease.

INTRODUCTION: Treatment of Parkinson's disease (PD) with exogenous dopamine (ie, levodopa) may positively affect motor symptoms, but may negatively affect other functions such as the learning of motor skills necessary for rehabilitation. This study aimed to determine whether levodopa medication affects general and sequence-specific learning of a stepping task and the transfer of movement skill to untrained balance tasks in people with PD. METHODS: Participants with PD were randomized to practice "on" (n = 14) or "off" (n = 13) levodopa medication. Participants practiced 6 blocks of 6 trials of 24 steps of a stepping task over an acquisition period of 3 consecutive days, followed by single retention blocks of 6 trials 2 and 9 days later. Participants were also assessed on untrained balance (ie, transfer) tasks "on" levodopa before practice and following late retention. RESULTS: There were no between-group differences in general learning, sequence-specific learning, or transfer of skill to untrained balance tasks ( P > .05). Both groups demonstrated general and sequence-specific learning ( P < .001) and trends for improvement in untrained tasks ( P < .001 to P = .26) following practice. Detailed analysis of early acquisition revealed no difference between medication groups. CONCLUSION: People with PD improved performance on the stepping task with practice. The between-group effect sizes were small, suggesting that levodopa medication status ("on" versus "off") during practice did not significantly affect general or sequence-specific learning of the task or components of early acquisition. The practice dose required to optimally result in functional improvements in untrained balance tasks, including reductions in falls, remains to be determined.