Principles into Practice: An Observational Study of Physiotherapists use of Motor Learning Principles in Stroke Rehabilitation

Abstract

Objective(s): To describe a) how motor learning principles are applied during post stroke physiotherapy, with a focus on lower limb rehabilitation; and b) the context in which these principles are used, in relation to patient and/or task characteristics.

Design: Direct non-participation observation of routine physiotherapy sessions, with data collected via video recording. A structured analysis matrix and pre-agreed definitions were used to identify, count and record: type of activity; repetitions; instructional and feedback statements (frequency and type); strategies such as observational learning and augmented feedback. Data was visualised using scatter plots, and analysed descriptively.

Setting: 6 UK Stroke Units PARTICIPANTS: 89 therapy sessions were observed, involving 55 clinicians and 57 patients.

Results: Proportion of time spent active within each session ranged from 26% to 98% (mean 85, SD 19). The frequency of task repetition varied widely, with a median of 3.7 repetitions per minute (IQR 2.1-8.6). Coaching statements were common (mean 6.46 per minute), with 52% categorised as instructions, 14% as feedback, and 34% as verbal cues/motivational statements. 13% of instructions and 6% of feedback statements were externally focussed. Examining the use of different coaching behaviours in relation to patient characteristics found no associations. Overall, practice varied widely across the dataset.

Conclusions: To optimise the potential for motor skill learning, therapists must manipulate features of their coaching language (what they say, how much and when) and practice design (type, number, difficulty and variability of task). There is an opportunity to implement motor learning principles more consistently, to benefit motor skill recovery following stroke.

Trial registration number: Clinicaltrials.gov (NCT03792126). CONTRIBUTION OF THE PAPER.

Keywords: Coaching; Intensity; Motor Learning; Motor Performance; Rehabilitation; Stroke.

Fig. 1

Frequency of coaching statements and patient characteristics. The relationship between the frequency of coaching statement’s (statements per minute) and a) time since stroke, b) stroke severity. A line of best fit is given to aid visualisation.

Fig. 2

Use of an external focus of attention and patient characteristics. The relationship between the proportion of externally focussed coaching statements (%) and a) physical independence (mRMI Score), b) cognitive impairment (MoCA score). A line of best fit is given to aid visualisation.

Fig. 3

Focus of attention categories for instructional statements, for each individual treatment session.

Fig. 4

Focus of attention categories for feedback statements, for each individual treatment session.