A Reflection on Motor Learning Theory in Pediatric Occupational Therapy Practice

A reflection on motor learning theory in pediatric occupational therapy practice

Jill G. Zwicker I Susan R. Harris

Key words

I Motor learning I Theory, Pediatric practice I Occupational therapy Mots clés

I Apprentissage moteur I Théorie I Pratique pédiatrique I Ergothérapie

Abstract Background . Theory provides a guide to clinical practice. To date, the most prevalent theories in pediatric occupational therapy practice are sensory integration and neurodevelopmental treatment. Purpose . The purpose of this paper is to present a brief overview and reflection on motor learning theories as well as a summary of motor learning principles that can be used in pediatric practice. Key Issues . Over the past two decades, motor learning theory has been applied in adult occupational therapy practice, but it has been slow to gain popularity in pediatrics. Implications . Although therapists may be tacitly applying motor learning principles in practice, conscious and deliberate application of these principles to a variety of pediatric populations is required to determine if motor learning theory provides a viable and effective contribution to evidence-based, occupational therapy pediatric practice. Further research comparing motor learning interventions to other dominant interventions in pediatric occupational therapy is warranted.

Résumé Description . La théorie est un guide pour la pratique clinique. À ce jour, les théories les plus répandues concernant la pratique de l’ergothérapie en pédiatrie sont celles de l’intégration sensorielle et de l’approche du développement neurologique. But . Cet article présente un bref aperçu des théories de l’apprentissage moteur et propose une réflexion sur ces théories, tout en résumant les principes pouvant être appliqués en pratique pédiatrique. Questions clés . Depuis les vingt dernières années, les principes de la théorie de l’apprentissage moteur sont appliqués dans la pratique de l’ergothérapie auprès des adultes, alors que ces mêmes principes tardent à se répandre en pédiatrie. Conséquences . Bien qu’en pratique les ergothérapeutes appliquent tacitement les principes de l’apprentissage moteur, il serait nécessaire d’appliquer consciemment et délibérément ces principes auprès de différentes clientèles en pédiatrie, afin de déterminer si la théorie de l’apprentissage moteur contribue fondamentalement et efficacement à la pratique de l’ergothérapie en pédiatrie fondée sur les faits scientifiques. Il serait justifié de pousser plus loin les recherches en comparant des méthodes d’intervention basées sur les principes d’apprentissage moteur à d’autres méthodes fréquemment utilisées en ergothérapie dans le domaine de la pédiatrie.

heory is the driving force behind occupational therapy multi-system rather than hierarchical (Shepard, 1991). This practice. Using the Canadian Practice Process shift in thinking about the CNS led to the development of TFramework (Townsend & Polatajko, 2007), therapists contemporary theories of motor learning. While motor select frames of reference to guide their practice. In pediatric learning theory has been widely used in adult occupational occupational therapy practice, the dominant theoretical therapy practice, it has been slow to gain popularity in approaches used in the United States, Canada, Australia, and pediatrics. the United Kingdom are sensory integration (SI) theory and The purpose of this paper is to review the key principles neurodevelopmental treatment (NDT) (Brown, Rodger, of motor learning theories and their application to pediatric Brown, & Roever, 2005; Howard, 2002; Storch & Eskow, occupational therapy practice. Chinn and Kramer’s (1995) 1996). These theoretical approaches were developed in the framework will be used to reflect on the clarity, simplicity, 1960s and 1940s respectively and are based on a hierarchical generality, accessibility, and importance of motor learning model of the central nervous system (CNS). Since the late theories as a foundation for pediatric practice. We will then 1980s, the CNS has been conceptualized as multilevel and provide an example of how motor learning theories can be

applied to pediatric practice and will conclude with future and influence motor performance of new tasks. A recall directions for research and practice. schema initiates the GMP that closely resembles the desired Motor learning theories movement, and the recognition schema evaluates the occurring movement. The recall schema is then modified by Motor learning is defined as “a set of processes associated the movement experience. A major limitation of schema with practice or experience leading to relatively permanent theory is that it does not explain how GMP are initially changes in the capability for movement” (Schmidt & Lee, formed. Schmidt’s theory has evolved over time (Schmidt, 2005, p. 302). Motor learning has been a key concept in the 2003) and has provided important motor learning concepts fields of physical education and sport since the 1970s. Motor of knowledge of results and variability of practice , discussed learning theory entered the field of neurological rehabili - below. tation during the 1980s and has been applied primarily to adults with stroke (Carr & Shepherd, 1989; Gilmore & Dynamic systems theory Spaulding, 2001; Krakauer, 2006; Sabari, 1991). In recent Dynamic systems theory is considered a contemporary theory years, motor learning has formed the foundation for treating of motor learning despite its appearance prior to the previous children with developmental coordination disorder two motor learning theories (Bernstein, 1967). Bernstein’s (DCD)(Missiuna, Mandich, Polatajko, & Malloy-Miller, work resurfaced in the 1980s with the rejection of the hierar - 2001; Niemeijer, Smits-Engelman, & Schoemaker, 2007; chical view of the CNS. Dynamic systems theory places less Sugden & Henderson, 2007). No one theory of motor emphasis on the nervous system by viewing movement as learning has been able to explain motor skill acquisition in its emerging from the interaction of three general systems: the entirety, but each theory has offered an important contri - person, the task, and the environment (Kamm, Thelen, & bution to our understanding of how motor skills are learned. Jensen, 1990; Mathiowetz & Haughen, 1995; Newell, 1986). Three motor learning theories that have dominated the Each general system has several subsystems that interact with literature will be highlighted, and then the key principles of one another to either support or constrain movement. motor learning that have evolved from these theories will be Subsystems that have the potential to change are referred to summarized. as control parameters and may be the target of therapeutic intervention to improve motor learning. Practice and Closed-loop theory experience alter the formation of movement patterns through Adams (1971) was the first researcher to describe a theory of interaction with the environment and the demands of the motor learning. The primary aspect of his theory was the task. Attractor states are efficient patterns of movement that concept of a closed-loop process of acquiring skills. Briefly, develop with practice and experience for common tasks Adams posited that sensory feedback is required for learning (Kugler & Turvey, 1987; Mathiowetz & Haughen). motor skills. He proposed that movement was selected and Motor learning principles initiated by a memory trace , which was modified by a perceptual trace with repeated practice. This perceptual trace Several principles of motor learning have evolved from the is the internal reference within which to compare movement above theories and have been applied in normal and clinical and detect error. Adams’ theory assumes that motor learning populations. These principles include stages of learning, is enhanced by repeated practice of the same movement, with types of tasks, practice, and feedback. guidance if necessary, to minimize error. Adams’ (1971) theory has been refuted with two main Stages of learning lines of research. First, studies with animals (Fentress, 1973; Fitts and Posner (1967) described three stages of motor Taub, 1976) and humans (Rothwell et al., 1982) have learning: cognitive, associative, and autonomous. During the demonstrated that motor learning is possible without sensory cognitive stage , an individual may have a general idea of the feedback. Secondly, Adams’ contention that practice needs to movement required for a task but might not be sure how to be errorless has not been borne out by research; studies have execute that movement. Performance during this stage is indicated that variability in practice may be superior in likely to be highly variable with a large number of errors. promoting motor learning (Shea & Kohl, 1990, 1991). Improved performance is contingent upon the individual’s conscious effort to attend to the task requirements. Often this Schema theory is achieved through verbalization of movement strategies, To address the weakness inherent in Adams’ (1971) theory, which Adams (1971) referred to as the verbal motor stage in Schmidt (1975) proposed an open-loop process for motor his closed-loop theory of motor learning. learning known as schema theory. Briefly, Schmidt suggested The second, intermediate stage, of motor learning is the that generalized motor programs (GMP) are created from past associative stage . Skills become more refined with practice, movement patterns; these GMP are recalled from memory resulting in greater consistency of performance and fewer

30 FÉVRIER 2009 I REVUE CANADIENNE D’ERGOTH ÉRAPIE I NUM ÉRO 1 I VOLUME 76 © CAOT PUBLICATIONS ACE ZWICKER & H ARRIS errors. The therapist provides less guidance during this stage random practice , which involves varying the task demands and allows the individual to make errors so that he or she can over practice trials (Lee, Swanson, & Hall, 1991). The effects learn to adjust subsequent movements independently (Poole, of blocked versus random practice for children is less clear; 1991). Learning from errors is thought to promote general - some studies have found no difference between these practice ization to similar motor tasks. schedules for children (Pollock & Lee, 1997; Wegman, 1999), Automaticity of motor learning occurs in the third stage, whereas others have found similar results as in adults, with the autonomous stage . At this stage, the motor skill has been random practice facilitating greater motor learning (Granda learned and little cognitive effort is required to execute it. Vera & Montilla, 2003; Ste-Marie, Clark, Findlay, & Latimer, Automaticity is evident when a motor skill can be performed 2004). Evidence suggests that the different results may be while engaging in another task, such as walking and talking related to the complexity of the task and the age of the child or playing the piano and singing. Evidence from (Jarus & Goverover, 1999; Jarus & Gutman, 2001). neuroscience indicates that less brain activation is required A final aspect of practice is whether to practice tasks as when automaticity of movement has been achieved (Poldrack whole tasks or in parts . While learning parts of a task may be et al., 2005; Wu, Kansaku, & Hallett, 2004), suggesting that helpful during early stages of learning, this approach does not fewer attentional demands are required. facilitate learning the skill in the context in which it will be used (Peck & Detweiler, 2000). Research has shown that part Types of tasks versus whole training results in different kinematic profiles, Motor learning is contingent upon the type of task to be with better movement quality obtained in whole-task learned. Schmidt and Lee (2005) classified several types of practice conditions (Ma & Trombly, 2001). tasks that can affect how the skill is learned. Discrete tasks have a recognizable beginning and end (e.g., throwing a ball). Feedback Continuous tasks, on the other hand, do not have an inherent Intrinsic feedback is information provided by the sensory start and finish as part of the task (e.g., walking); continuous systems as a result of movement (Shumway-Cook & tasks have an arbitrary beginning and end, depending upon Woollacott, 2001) and is consistent with Gentile’s (1998) the individual. Serial tasks are a collection of discrete tasks notion of implicit learning. Implicit learning is not under that are strung together (e.g., dressing). Tasks can also be conscious control, but the therapist can facilitate it by classified as open versus closed , depending upon predictability structuring the task and environment to support effective in the environment. Open tasks are in an environment that is movement patterns (Gentile). Extrinsic feedback supplements constantly changing. The individual cannot plan an entire intrinsic feedback and forms the basis for explicit learning movement in advance but must rapidly adapt the plan in (Gentile; Shumway-Cook & Woollacott. 2001), which is response to a changing environment (e.g., playing hockey). learning that results from clearly stated directions or Closed tasks are in a stable environment, which offers instructions (Taber’s Online, 2000-2008). Verbal feedback predictability to the movement pattern (e.g., bowling). and demonstration are examples of how a therapist can promote explicit learning. Feedback can be given during the Practice movement ( concurrent ), right after the movement One of the most significant tenets of motor learning is (immediate ), at the completion of movement ( terminal ), or practice. Practice schedules, such as massed versus after a delay (Schmidt & Lee, 2005). Feedback can also be distributed practice and blocked versus random practice, given consistently (i.e., after every trial) or sporadically (i.e., have been studied extensively in motor learning literature. after some but not all trials). Contrary to what one might Massed practice involves continuously practicing a task with expect, sporadic feedback after a delay is superior for motor little or no rest; distributed practice entails practicing a task learning to consistent feedback given immediately after the alternating with periods of rest. The latter is generally movement (Schmidt, 1991; Winstein & Schmidt, 1990). The superior to massed practice in contributing to motor learning delay in feedback given over some trials allows the individual (Donovan & Radosevich, 1999). One notable exception was a to determine what factors are influencing performance and small study of children with autism in which no significant prevents reliance on external feedback to learn the skill. differences were found between massed and distributed While sporadic feedback is superior for adult motor learning, practice schedules on motor performance and learning (Wek recent evidence suggests that children respond differently; & Husak, 1989). children with 100% feedback during motor skill acquisition Blocked practice involves repetitive practice on the same performed significantly better on delayed retention than task. While this type of practice results in improved motor children on a reduced feedback schedule (Sullivan, Kantak, & performance in a short period of time, it does not necessarily Burtner, 2008). promote relatively permanent motor learning (Magill & Hall, Two other points related to feedback in motor learning 1990). Greater retention and transfer are accomplished with are knowledge of results (Salmoni, Schmidt, & Walter, 1984)

and knowledge of performance (Gentile, 1972). Knowledge of applied in the field of adult rehabilitation for the last two results is terminal feedback given verbally about the outcome decades (Jarus & Ratzon, 2005, Sietsema, Nelson, Mulder, of movement in terms of the goal. In contrast, knowledge of Mervau-Scheidel, & White, 1993; Stanton et al., 1983) but performance is feedback on the specific components of the only in recent years with children. Most motor learning movement pattern, not on the achievement of the goal. research with children has focused on DCD, including the Reflection on motor learning theories Cognitive Orientation to daily Occupational Performance (CO-OP) approach (Missiuna et al., 2001), Neuromotor Task Thus far, a brief overview of the major motor learning Training (Niemeijer, Schoemaker, & Smits-Engelman, 2006; theories and the main principles of motor learning have been Niemeijer, Smits-Engelman, Reynders, & Schoemaker, 2003; presented. We will now apply a framework proposed by Niemeijer et al., 2007), task-specific intervention (Revie & Chinn and Kramer (1995) for critically evaluating motor Larkin, 1993), and ecological intervention (Sugden & learning theories in order to reflect on how they might be Henderson, 2007). Children with cerebral palsy have also applicable in pediatric occupational therapy practice. Motor benefited from therapy based on motor learning (Eliasson, learning theory will be evaluated on five criteria: clarity, 2005; Ketelaar, Vermeer, Haart, van Petegem-van Beek, & simplicity, generality, accessibility, and importance. Helders, 2001; Thorpe & Valvano, 2002). Principles of motor learning have applicability to a much broader range of Clarity children with disabilities, but this is largely undiscovered. Clarity refers to “how well a theory can be understood and how consistently the ideas are conceptualized” (Chinn & Accessibility Kramer, 1995, p. 127). From the perspective of a clinician, Given the voluminous literature on motor learning, empirical “motor learning theory” is not particularly clear; this review accessibility is a strength of motor learning theories. Concepts highlights three motor learning theories that are contra - and relationships have been tested for several decades by dictory in many respects. Motor learning is not one theory different disciplines, resulting in refinements to motor but rather several interpretations and concepts related to how learning theory or development of new theories. The bulk of motor skills are acquired. In rehabilitation literature, the term research has focused on schema theory, but dynamic systems “motor learning” appears to refer to a theoretical approach, theory is gaining popularity (see Shumway-Cook & with little reference to a specified theory. The use of this Woollacott, 2007; Schmidt & Lee, 2005 for overviews). Yet, catch-all term adds to the confusion about what motor despite the application of motor learning theories for decades, learning theory is and how it can be applied in practice. At a limited number of studies has been conducted in pediatric best, we seem to apply motor learning principles with little rehabilitation (Eliasson, 2005; Missiuna et al., 2001; Niemeijer regard for the theory from which they evolved. Without a et al., 2003; Niemeijer et al., 2006; Niemeijer et al., 2007; clear understanding of the theoretical basis of motor Thorpe & Valvano, 2002). Deliberate application of the theory learning, we cannot adequately apply the theory, test it is another form of accessibility, which also has been lacking in empirically, or determine its usefulness in clinical practice. pediatric occupational therapy practice. We may be tacitly using motor learning principles in our practice, but we are not Simplicity necessarily documenting our theoretical framework or Each of the motor learning theories presented are naturally reflecting motor learning in our clinical reasoning. complex because they aim to explain and predict how complex motor skills are learned. Application of motor Importance learning principles is seemingly straightforward, but there Motor learning theories are highly compatible with models of are many factors to consider in designing an intervention occupational therapy practice (Townsend & Polatajko, 2007; program: practice schedule, amount of practice, type of task, Strong et al., 1999). In pediatric practice in particular, a stage of the learner, amount and type of feedback, environ - child’s acquisition of motor skills is important to his or her mental influences, and the like. The multiple factors that functioning in self-care activities, participating in school, and need to be taken into account may hinder therapists in engaging in play. Motor learning has great clinical signif - consistently applying motor learning theory to practice. icance to pediatric occupational therapists, yet it is underutilized. In a survey of Canadian and Australian Generality pediatric occupational therapists, only 30.5% and 33.0% Motor learning concepts have broad applicability across respectively used motor learning theory in their treatment of the lifespan in both typical (Brydges, Carnahan, Backstein, & children with neurological conditions (Brown et al., 2005). In Durowski, 2007; Ma, Trombly, & Robinson-Podolski, 1999) Australia, 20.4% of surveyed occupational therapists used and clinical populations (Jarus, 1994; Poole, 1991; Sabari, motor learning theory for children with learning disabilities, 1991; Valvano, 2004). Motor learning theories have been but Canadian occupational therapists did not even identify

32 FÉVRIER 2009 I REVUE CANADIENNE D’ERGOTH ÉRAPIE I NUM ÉRO 1 I VOLUME 76 © CAOT PUBLICATIONS ACE ZWICKER & H ARRIS using motor learning theory for this population. therapist. Alan had left-sided spastic hemiplegia as a result of The importance of motor learning theory in pediatric his ABI but was fortunately right-handed; he required the use practice cannot be underestimated. Treatments based on of a powered wheelchair for community-based activities. motor learning theory have shown more promising results Both Alan and his parents were concerned that he seldom compared to SI for children with DCD (Polatajko & Cantin, played with classmates or friends due, in part, to his limited 2005) and NDT for children with cerebral palsy (Butler & motor skills. Together with the school occupational therapist, Darrah, 2001). they identified the functional goal of increasing Alan’s In summary, reflection on motor learning theory using playtime with age-mates in his neighborhood. Selection of a Chinn and Kramer’s (1995) framework has demonstrated meaningful goal represents the first component of goal- that motor learning theory has generality and importance but directed training (Mastos et al., 2007). may be lacking in clarity and simplicity for application to Alan’s specific goal was to learn how to bowl so that he pediatric occupational therapy. Accessibility may be improved could go bowling with a group of neighborhood friends. The by deliberately applying motor learning theory to practice second component of goal-directed training is to assess and reflecting use of motor learning principles in our clinical baseline performance (Mastos et al., 2007). To assess baseline reasoning. To that end, we will now share an example of how performance, the school occupational therapist analyzed motor learning could be applied to a child with a disorder Alan’s functional abilities with his right upper extremity other than DCD or cerebral palsy. (person), while sitting in his wheelchair in the bowling alley Application of motor (environment), and performing the desired occupation (bowling). Because Alan had no difficulty grasping the learning theory to pediatric bowling ball by inserting his fingers into the three holes but occupational therapy practice did have trouble releasing it, as part of the baseline Because dynamic systems theory is the most recent iteration assessment the therapist performed a task analysis (Mastos et of motor learning, we will develop an example of its al.) of the motor skills required to release the ball. The application to pediatric occupational therapy practice. We therapist also determined that there were no specific environ - will also illustrate the three-stage model of motor learning as mental constraints caused by Alan’s wheelchair or with described by Fitts and Posner (1967). A recent set of case accessibility to the bowling alleys and lanes so she decided to reports involving two adults with acquired brain injury (ABI) develop a motor-learning-based intervention program to (Mastos, Miller, Eliasson, & Imms, 2007), in which dynamic assist Alan with developing the ability to release the bowling systems theory was used as the basis for goal-directed ball in order to propel it down the lane. To accomplish this, training, will be highlighted to develop an analogous example Alan’s therapist developed the following initial therapy for a child with ABI. In attempting to clarify and concep - objective for Alan based on his therapy goal: “While sitting in tualize (i.e., bring clarity to) dynamic systems theory, Mastos his wheelchair in a specified ‘practice lane’ at the local and colleagues stated that the underlying principles of the bowling alley, Alan will release the bowling ball onto the lane goal-directed training approach stem from dynamic systems independently four out of five times within an eight-minute theory, “which suggest[s] that movement patterns emerge as period with physical assistance and verbal cueing from his a result of the interaction between the person’s abilities, the occupational therapist.” environment and the goal” (p. 47). They defined goal- The intervention (third component of goal-directed directed training simply as “an activity-based approach to training) was based on Fitts and Posner’s (1967) three stages intervention” (p. 47). In an attempt to simplify the dynamic of motor learning. In the first, or cognitive stage, the therapist systems theory, the authors (occupational therapists and first asked Alan to try to problem solve, or think through the physical therapists) used principles of motor learning to skills needed to release the bowling ball. She then provided guide their intervention approach, that is, they used goal- both physical cueing and verbal instructions to facilitate directed training. Because of similarities in the sequelae from Alan’s release of the ball (Mastos et al., 2007). In the second, ABI in adults and children, we will generalize Mastos et al.’s or associative stage, Alan practiced releasing the ball on the goal-directed training approach to an example of a child with bowling alley without the added physical assistance from the ABI, thus translating dynamic systems theory into pediatric therapist but with continued verbal cueing. He was allowed to practice and making this theory more accessible and more make errors and to learn from those errors as he repeatedly important to pediatric clinicians. (practice) attempted to release the ball onto the alley. During In our case example, Alan is a 10-year-old boy who had the third stage of learning, the autonomous stage, Alan was an acquired (traumatic) brain injury from a motor vehicle able to consistently release the ball onto the alley without the accident 4 years previously. He had a medical diagnosis of need for verbal cueing from the therapist. moderate ABI, was living at home, and received school-based The fourth and final component of goal-directed consultation from an occupational therapist and a physical training is to evaluate the outcome of the therapy goal. The

outcome of the initial specific therapy objective can be phase and report on the child’s knowledge of results. During evaluated independently by the therapist (Randall & the associative stage, we could highlight variability of practice McEwen, 2000) or could be broadened into five discrete steps with a random practice schedule to facilitate motor learning. representing different levels of success using goal attainment We could also indicate that greater emphasis is placed on scaling (Ottenbacher & Cusick, 1993), as described by Mastos implicit feedback at this stage so the child can attend to errors and colleagues (2007). and make adjustments for subsequent movement (and rely Discussion less on explicit feedback ). We could collect outcome data through our clinical records and publish our findings as case Implications for practice reports. These are critical first steps in determining the The purpose of this paper was to provide a brief overview of viability and effectiveness of motor learning principles in the motor learning theories and highlight motor learning various clinical populations of children with whom we work. principles that might be applied to pediatric practice. Based on this review, it was suggested that motor learning theory is Directions for future research neither clear nor simple, but it has great potential for The amount of practice required to learn motor skills is pediatric occupational therapy practice. Motor learning is largely unknown. Preliminary evidence from the CO-OP widely applicable to the populations served by pediatric approach suggests that 10 sessions may be sufficient to learn therapists, but empirical studies have not yet determined for motor skills in the context of a task-specific intervention whom it is beneficial. Preliminary evidence suggests that based on the child’s goals. Greater practice time is likely children with cerebral palsy and those with DCD have made required for children with neuropathology, such as cerebral functional gains with interventions based on motor learning. palsy or developmental delay. More research is needed to Given the propensity for neuroplastic change in the nervous determine effective practice schedules for different types of system, children with other neurological disorders, develop - tasks in a variety of pediatric populations. mental delay, autism, and learning disabilities may also Using the four-step, goal-directed training process benefit from this approach to improve motor skills and developed by Mastos and colleagues (2007), pediatric functional performance. occupational therapists could replicate the adult case study Many authors have previously advocated for the use of examples by applying motor learning principles to children motor learning theory in occupational therapy practice with ABI in their own practices. Similarly, there are published (Baker, 1999; Goodgold-Edwards, 1984; Jarus, 1994; examples from the pediatric physical therapy literature in Lesensky & Kaplan, 2000; Poole, 1991), yet it is still not which motor learning principles have been applied in widespread in pediatrics. This may be due, in part, to the lack interventions for children with cerebral palsy (Ketelaar et al., of a practice model that translates these theoretical principles 2001; Thorpe & Valvano, 2002) that could serve as useful into a usable frame of reference for practice. The CO-OP models for occupational therapy intervention research. approach is close to achieving this goal as it has taken many Finally, clinical trials comparing motor learning of the principles and incorporated them into a treatment intervention to interventions based on current, dominant approach for children with DCD (Polatajko et al., 2001). pediatric occupational therapy theory (e.g., sensory Sugden and Henderson (2007) have also outlined guidelines integration) would determine if a shift in pediatric practice is for using motor learning principles in interventions for warranted. children with motor impairment. Conclusion Although a formal model for motor learning practice has yet to be developed for children with developmental Motor learning theories have a rich research history and disabilities, we are probably applying many motor learning broad applicability to normal and clinical populations. To principles tacitly in our practice. As clinicians, we need to be date, they have been underutilized in pediatric occupational more conscious of and deliberate in our application of these therapy practice, probably because of the current dominance principles to determine if they are effective and to further of SI and NDT theories in practice and the lack of a cohesive extend our understanding of motor learning theory. As a practice model based on motor learning principles. With a starting point, we can reflect the use of the theory in our concerted effort, principles from motor learning theory can clinical reasoning and documentation. For example, our be deliberately applied in practice to determine if motor documentation could describe our intervention in terms of learning theory offers a contribution to evidence-based blocked practice during the cognitive stage of learning so the pediatric occupational therapy practice. child can understand the task. We might start practicing Acknowledgements parts of the tasks at this early stage, but then move to practicing the whole skill in context . We might also describe Jill Zwicker has been awarded a Quality of Life Strategic the type of explicit feedback provided during the cognitive Training Fellowship in Rehabilitation Research from the

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