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Critically Appraised Topics Department of Occupational Therapy

2021

Critically Appraised Topic Paper: What is Motor Learning Theory? Critically Appraised Topic Paper: What is Motor Learning Theory?

How Can It Be Implemented into Occupational Therapy How Can It Be Implemented into Occupational Therapy

Interventions for Individuals with Cerebrovascular Accidents? Interventions for Individuals with Cerebrovascular Accidents?

Allyson Bourque

Alison O'Sadnick

Bourque, Allyson; O'Sadnick, Alison; Skogen, Alexis; and Vold, Callie, "Critically Appraised Topic Paper:

What is Motor Learning Theory? How Can It Be Implemented into Occupational Therapy Interventions for

Individuals with Cerebrovascular Accidents?" (2021).

Critically Appraised Topics

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Bourque, O’Sadnick, Skogen & Vold, 2021

occupational therapy rehabilitation for individuals with cerebrovascular accidents (CVA)? If so,

how might occupational therapists incorporate motor learning theory into intervention design

with maximum efficacy?

Purpose Statement

learning theory guides interventions that are considered to be best practice for individuals with

CVAs. We want to determine what is best practice for this population to provide practitioners

with synthesized research allowing practitioners to implement the most effective, client-centered,

evidence-based interventions possible.

contextual lens interacts with the person’s skills and abilities to enable them to perform certain

tasks; this interaction results in an individual’s performance range (Dunn et al., 1994). The

relationship between the person and their context presents an understanding of the extent to

which the person can perform specific tasks (Dunn et al., 1994). According to the motor learning

theory, occupational therapists develop therapeutic interventions by considering which task

requirements are most appropriate and which conditions of their environment may need to be

adapted to elicit optimal performance (Sabari, 1990). A person’s context is viewed as

and EHP (Dunn et al., 1994; Sabari,1990). If an occupational therapist evaluates an individual’s

performance without considering the context of the performance, there is a great risk the

performance will be interpreted incorrectly (Dunn et al., 1994). The lack of consideration for the

Prevention (2021) reported that every year more than 795,000 people in the United States have a

CVA, and about 610,000 of these are first or new CVAs. CVA is the leading cause of adult

disability in the United States, resulting in challenges such as weakness on one side of the body,

a decline in cognitive and emotional functioning, social disability, inability to walk, inability to

care for themselves, and a decrease in community participation (Nilsen et al., 2015). According

to the American Stroke Association (2018), women are at a higher risk of CVA compared to men

due to pregnancy, preeclampsia, birth control, hormone replacement, migraines, and atrial

fibrillation. The African American population has a higher chance of a CVA leading to death

compared to Caucasians due to higher blood pressure, diabetes, and obesity (The American

Stroke Association, 2018). People that are affected by CVAs experience deficits in muscle

Bourque, O’Sadnick, Skogen & Vold, 2021

their performance. There are multiple allied health disciplines that provide interventions

addressing functional outcomes for individuals with CVAs (Zahl et al., 2017). The rehabilitation

team may include, but is not limited to physical therapy, occupational therapy, recreational

therapy, and speech-language pathology (Zahl et al., 2017).

CVA rehabilitation in occupational therapy. Motor learning refers to internal processes that are

associated with practice or experience and lead to relatively permanent changes in motor

behavior (Schmidt et al., 1988; as cited in Jarus, 1994). Motor learning theory approaches to

CVA therapy consist of addressing motor impairments post-CVA, high repetition of a

cumulative of 10,000 repetitions for optimal motor recovery (Kleim et al., 1998; Nudo et al.,

disparities for what is considered best practice for individuals with CVAs. New research has

started to show that a task-oriented approach may be better than motor learning theory-oriented

approach when providing occupational therapy interventions to individuals with CVAs

(Almhdawi et al., 2016). Almhdawi et al. (2016) defined task-oriented training as a “highly

individualized, client-centered, occupational therapy, functional-based intervention compatible

with motor learning and motor control principles such as intensive motor training, variable

practice and intermittent feedback” (p. 445). Scobbie et al. (2013) identified goal setting as best

occurred in the last 20 years in the development and testing of interventions for CVA

rehabilitation, but there are many gaps in the evidence to inform clinical practice (Langhorne et

commonly referred to as a stroke, cell death resulting from lack of oxygen and blood flow to the

brain (Shiel, 2017). Intervention: treatment for a specific diagnosis.

Summary of Search

practice, current practice, motor learning theory, and frames of reference used in occupational

therapy for individuals with CVAs. Upon refining our focus question, we found that not all of

our initial articles were relevant to our topic resulting in 30 articles that met our criteria. Many of

our foundational articles were published decades ago, however, are still valid and relevant to our

Bourque, O’Sadnick, Skogen & Vold, 2021

databases were chosen given their plethora of evidence-based, occupational therapy literature.

Search terms used were: cerebrovascular accident, CVA, motor learning theory, stroke,

they did not closely fit the population, did not provide good information pertaining to specific

interventions used in practice and their efficacy, did not include information related to gaps in

practice, or did not contain current evidence.

Included in this critical analysis portion of this project was one qualitative study (Jaber et

cognition, memory, temperament, personality, energy, sleep, attention, psychomotor and

perceptual skills, mobility and stability of joints, muscle power, tone, reflexes, and endurance

(Langhorne et al., 2011). Affected body structures that contribute to these impairments include

the brain, cardiovascular system, legs, arms, and shoulders (Langhorne et al., 2011).

individual’s performance in different instrumental activities of daily living (IADL) and activities

of daily living (ADL) (Waddell et al., 2015). In IADLs specifically, individuals had difficulties

(Waddell et al., 2015; Jaber et al., 2018). The top reported ADL that is impacted by CVAs was

dressing and the top reported IADL was communication (Waddell et al., 2015). Waddell et al.,

(2015) also reported that some of the challenges noticed with their individuals were in the leisure

(Langhorne et al., 2011). Motor learning theory, task-specific training, and goal setting are

deemed as “best practices” in the evidence base (Almhdawi et al., 2016; Jarus, 1994; Sabari,

1990; Scobbie et al., 2013). The following paragraphs will compare motor learning theory, task-

specific training, and goal setting as interventions for individuals with CVAs.

Motor learning theory is affected by three major factors such as environmental

conditions, cognitive processes, and movement organization (Sabari, 1990). Environmental

demands determine how people organize purposeful movement and influence a person’s choice

of motor strategies (Sabari, 1990). Ultimately a person’s environment impacts the mental and

motor processes required to complete the task at hand. A person’s environment influences their

motor learning, therefore the therapist must consider the nature of the environment because

Bourque, O’Sadnick, Skogen & Vold, 2021

There are many strategies supported by the literature to increase retention and transference of

learned skills. Strategies such as increasing the difficulty of the learning context during practice,

using an open environment, and having limited knowledge of the task response facilitate

cognitive-motor functioning during the acquisition stage which enhances the retention and

transference of learned skills (Jarus, 1994). Selecting activities that include these strategies

further facilitates retention and transference because clients are forced to draw on prior

knowledge and develop a new movement plan for each practice trial (Jarus, 1994). Therapists

should utilize these strategies when designing interventions based on motor learning theory for

individuals with CVAs.

but also incorporating meaningful activity and progressive challenges to the client’s abilities

(Lang & Birkenmeier, 2014 as cited in Rowe & Neville, 2018). Therapeutic activities often focus

on sensorimotor control domains such as strength, endurance, active range of motion, degrees of

freedom, and postural control (Almhdawi et al., 2016). Therapeutic activities consist of open and

closed tasks. Open tasks involve unstable contextual factors during task performance and maybe

unpredictable during therapeutic practice (Gentile 1972, 1987 as cited in Sabari, 1990). Open

tasks require appropriate timing, sequencing, and spatial anticipation, such as being able to

task training in a contextually variant environment to produce motor schemata that are versatile

enough to adapt to the conditions clients will encounter in their daily lives (Higgins & Spaeth,

1972; Sabari, 1990). Closed tasks are contextually stable and do not vary over time (Sabari,

(Scobbie et al., 2013). Goal setting provides the opportunity for client-centered care which

increases the client’s adherence to their therapy program and optimizes their goal-related

behaviors (Scobbie et al., 2013). Scobbie et al. (2013) designed a goal-action planning

framework to guide health professionals through a systematic goal-setting process, which

consists of four main stages: goal negotiation, goal setting, action planning and coping planning,

and appraisal and feedback. The primary goal of this framework is to optimize client goal-

attainment and client involvement (Scobbie et al., 2013). Research has shown that clients that are

more involved in the goal-setting process set goals with a stronger personal relevance and are

more satisfied with their therapy experience (Scobbie et al., 2013). Recommendations for

Bourque, O’Sadnick, Skogen & Vold, 2021

and ensure that the set goals include the five recommended criteria.

Conclusion

There are multiple claims of what is considered best practice intervention for individuals

with CVAs. In this literature synthesis, we explored the evidence in the literature claiming motor

learning theory, task-oriented training, and goal setting as best practice interventions. While

there is large support for motor learning theory in the literature, there is not a claim that this is

the gold standard of practice for this population. Our synthesis of motor learning literature

suggests a shift from neurofacilitation techniques towards motor learning theory approaches, as

clients achieve greater improvement when therapy is guided by the principles of motor learning

theory, it is only supported by a handful of case studies (Flinn, 1995; Gillen, 2000, 2002). Goal

setting is claimed to be best-practice in stroke rehabilitation, but according to the literature, there

is no consensus regarding how to optimally deliver the goal-setting intervention in practice or

what the key components of goal-setting interventions consist of (Scobbie et al., 2013). Our

literature synthesis provided the strongest support for motor learning theory as best practice

intervention for individuals with CVAs.

Are motor learning theory-based interventions considered to be part of best practice in

occupational therapy rehabilitation for individuals with CVAs? If so, how might occupational

therapists incorporate motor learning theory into intervention design with maximum efficacy?

theory, which states that a person’s environmental demands determine how they are able to

organize purposeful movement and influences their choice of motor strategies (Dunn et al., 1994;

Sabari, 1990). Context is a fundamental component to both EHP and motor learning theory and

should be considered when designing interventions for individuals with CVAs. When a client

receives occupational therapy due to a CVA, it is often because of a need to learn or relearn

motor skills and a desire to be able to perform them in many contexts (Jarus, 1994). Individuals

with CVAs experience daily challenges completing occupations such as driving, self-care, home

management, community mobility and leisure activities due to adverse changes in vision,

cognition, memory, temperament, personality, energy, sleep, attention, psychomotor and

perceptual skills, mobility and stability of joints, muscle power, tone, reflexes and endurance

Bourque, O’Sadnick, Skogen & Vold, 2021

Occupational therapy places a large emphasis on purposeful activity. The use of purposeful

activity provides the therapist with an opportunity to incorporate motor learning theory concepts

into goals that are occupation-based and client-centered (Sabari, 1990). The occupational

therapist should consider the client's cognitive processes and desired motor skills when designing

intervention to ensure the tasks or activities are challenging yet attainable (Sabari, 1990).

Research also supports the administration of motor training in the client’s natural context to most

closely align with common, everyday occurrences (Jarus, 1994; Langhorne et al., 2011).

Occupational therapists understand that motor skills also need to be applicable and transferable

to contexts outside of the client’s most common or contrived contexts. In order to produce the

greatest retention and transference of learned motor skills across a variety of contexts, the

focuses primarily on the rehabilitation aspect of how the skill contributes to the client’s

independence and is less concerned with how the skill is learned (Gliner, 1985). In opposition,

motor learning theory is primarily focused on how the skill is learned, controlled, and retained

(Gliner, 1985). By implementing motor learning theory into occupational therapy intervention,

learning processes supported by research designed to increase transference and retention are

utilized, which overall increases the client’s independence in daily activities, catering to the

primary focus of occupational therapy. Clients who receive care in a stroke unit were most likely

health disciplines such as physical therapy, recreational therapy and speech language pathology

may also use motor learning theory to address functional implications of CVAs (Zahl et al.,

2017). Barriers to the implementation of these interventions in a clinical setting need to be better

practice. Some barriers present in the literature include lack of evidence-based practice experts

amongst staff, increased cost associated with selecting evidence-based practice, time constraints,

logistical challenges, inadequate equipment, limited ability to trial and observe evidence-based

practice in entry-level education and practice (See Table 1) (Bayley et al., 2012; Levac et al.,

2016; McCluskey et al., 2013; Petzold et al., 2014; Scobbie et al., 2013; Scott et al.,

2020). Through our literature search, it was discovered that there is not a document that clearly

defines best practice interventions for individuals with CVAs. The presence of a document with

clear guidelines for best practice in the literature would make best practice guidelines more

accessible for practitioners to follow and implement. Other opportunities that would be

beneficial to reducing barriers of evidence-based practice implementation include experiential

Bourque, O’Sadnick, Skogen & Vold, 2021

practitioner, schedules are often filled, and interventions are often habitual. It is important to

continue researching evidence-based practice after leaving an educational program. This can be

achieved through independent research, attending conferences, panels, or workshops, or by

enrolling in a program with mastery in the field of interest.

Table 1