Introduction and Overview
Thank you for participating in this course on motor skill acquisition for optimal occupational performance. Today, I'm going to be presenting this topic from a pediatric perspective. However, for those of you who work with adults, this information is still applicable across the lifespan.
Hypothesis
I want to start with the idea of a working hypothesis. Many people tend to equate a hypothesis with research. However, we can use hypotheses when working with our clients. During the assessment process, we typically begin by thinking about what is going on with each client. As we continue to work with a client and reflect on their performance, we refine our process and make adjustments as needed. Another way to use a hypothesis is to think about some of the collective themes and trends that you're seeing with your clients. How do those trends have an impact on client results and performance?
In my experience, OTs are generally not involved in the transition process (e.g., transitioning a child with autism into adulthood, or into a work environment). Similarly, with some of the individuals we treat in the clinic with more physical-based disabilities, we see success in the clinic, but those skills are not being generalized into other environments (e.g., school, home, work, community).
Why is this generalization not occurring? My hypothesis is that if an individual stays on the cognitive level with a task, that individual will be unable to achieve strong occupational performance within that task or occupation. This has negative consequences with respect to participation, transitioning, and social engagement.
Research: Benefits of Motor Skill Acquisition
The following research studies support the benefits of motor skill acquisition:
- Piernaar and colleagues through their research found that motor control is directly linked to success in school (Piernaar et al., 2014). The school environment is a rich and demanding context, requiring one to have strong motor control.
- In 2012, Ericsson and Karlsson found that having a consistent school physical education program resulted in improved motor skills, which then also translated into increased success in school subjects, such as math and reading, as well as other school successes.
- In 2016, Razza, Martin, and Grooks-Gunn found a relationship between motor control and effortful control, which is part of self-regulation and allows for executive functions.
- Katcheson, Hauck, and Ulrich analyzed the importance of motor programs for individuals with autism (Katcheson et al., 2016).
- In 2017, Cacola, Miller, and Williamson looked at the distinct differences between autism spectrum disorder (ASD) and developmental coordination disorder (DCD), also known as dyspraxia (difficulty with motor learning). Although these disorders are different, they both respond to motor learning protocols. With DCD, we tend to emphasize motor learning protocols; we don't always do that with autism.
Motor Control vs. Motor Learning
What is motor control? Motor control is the output of motor ability or having controlled coordinated movements. In this context, coordination is the speed, efficiency, and ease with which someone can perform a motor task.
What is motor learning? Motor learning is learning how to do motor skills so that you can eventually have the motor control. For example, if you're thinking about math, you learn how to add the numbers together. The control part would be that you could do a math problem at the moment, perhaps in your head. That's what we're thinking about: learning it and then having motor control. Motor control is also the analysis of how someone is able to have this motor outcome.
Dynamic Action/Systems Theory
One concept that I want to discuss today is that of dynamic systems theory (also known as dynamic action theory). In Figure 1, you can see three overlapping circles with the words task, environment, and individual. In order to reach optimal motor performance, all three of these things need to work together. Where they all meet in the center -- that is when optimal performance can be achieved.
Figure 1. Dynamic action/systems theory.
Why is this important? Dynamic theory suggests that a new movement emerges due to a critical change in one of those three systems (individual, task, and environment). A control parameter is a variable that regulates change in the behavior of the entire system. For example, velocity could be a variable that regulates change. If a person is walking, and they increase their velocity, they can change their gait to a trot or a gallop. That's one aspect of the movement that creates change.
Movement is an emergent process. Dyscontrol can be treated. It's hierarchical and systems-based, involving the three systems of the individual, the task, and the environment. In occupational therapy, this is a task-oriented and evidence-based approach. If we're being true occupational therapists, we view occupation not only as the end result but also the means to achieve our end result (Shumway-Cook & Woollacott, 2016).
When thinking about implementing the dynamic action theory with our clients, there are some positive outcomes that can result. We have the ability to:
- Understand how to train or retrain motor skills
- Decrease frustration during motor tasks
- Optimize occupational performance rather than just task-practice
- Generalize skills
Evidence for Task-Oriented Approaches
There is a wide body of evidence to support task-oriented approaches. In 2009, Smallfield and Karges conducted a study and found that "occupational therapists use pre-functional activities that aim to improve performance skills and body structures more often than occupation-based activities that incorporate meaningful activities into therapy sessions." In other words, OTs were not doing an effective job of using occupation as a means to an end; they were doing more pre-functional activities with their clients. As a result, clients were not achieving high enough performance levels in therapy, and consequently, the skills were not being generalized outside of the clinic.
In the evidence, motor control has been identified as a significant concern for many of the populations that we treat. In pediatrics, as well as adults, there are all sorts of motor issues that we see with our clients. There are motor issues related to ADHD (Kaiser et al., 2015), ASD (Ewen et al., 2016), dyspraxia or DCD (Adams et al., 2014), and TBI (Risen et al., 2015), among others.
In 2009, Zwicker and Harris conducted research showing that motor learning was being applied in adult occupational therapy, but it was slow to gain popularity with pediatric populations. This is an interesting finding because, in pediatrics, we tend to have a longer time to work with children, so we really don't have an excuse not to get children to these higher levels of control.
To reiterate, the following three components lead to motor learning and motor control: the task/occupation, the individual, and the environment. Not one component is more important than the other. As OTs, we have a tendency to get caught up with the individual, and we forget about the occupation or the environment, which are equally as important.
Let's break down those three components one step further. When looking at the task, we need to assess whether it is a mobility task, a stability task, a manipulation task, or a combination thereof. In addition, when working with an individual, we need to think about their cognition, their sensory perceptions, and also their actions. With regard to the environment, we need to take into consideration whether it is a regulatory or non-regulatory environment. We will go into greater detail about these sub-components coming up shortly.
Case Example: Xavier
Meet Xavier. He loves YouTube videos, swimming, and playing with his dog. He’s a math “whiz”. He also has dyspraxia and has a difficult time with motor planning with poor body awareness, difficulty with sensory processing, and impulsivity. Xavier becomes frustrated easily and tends to avoid any motor challenges. He seeks movement to avoid stationary balance challenges, often pretending to fall or purposely be silly instead. He would like to learn how to do jumping jacks so he can do calisthenics with his karate class. He also wants to be able to dribble a basketball for P.E. games. Xavier is in 4th grade and is 9 years old.
Xavier's characteristics are typical of what we might see in a pediatric client who has sensory issues, dyspraxia, stationary balance issues, and stationary postural control issues.
The Task
The motor tasks that Xavier deems as important to achieve are dribbling a basketball for gym class and doing jumping jacks for calisthenics in his karate class. When we think about performing tasks, they can be described on a continuum of less challenging to more challenging.
The less challenging tasks have the following characteristics:
- They are more discrete. They have a very specific beginning and end. An easier task may be described as a serial task, which means it is a bunch of discrete tasks put together. A discrete task has a beginning and an end. For example, if I were to spin a top, it spins, and then it stops. If I spin the top multiple times, then I've done it in a serial way.
- They have stability. In other words, the task doesn't have moving parts, making it less challenging.
- They involve less manipulation of objects.
- They require a lower level of attention.
- Closed practice. Easier tasks are more predictable. For example, if we bounce one type of ball, it's always going to bounce the same way. But if you get a variety of types of balls, they will bounce differently, increasing the unpredictability level as well as the difficulty level.
In contrast, more challenging tasks:
- Are continuous. They have no clear beginning or end; it just keeps going. Whereas a cartwheel might be more discrete, running is more continuous. Swimming can be quite continuous unless you're swimming just one lap and then it has a beginning and end.
- Involve more mobility, as opposed to stability. Harder tasks have moving parts. The entire activity may involve more movement.
- Require more manipulation of objects.
- Require a higher attention level. Because it's mobile, and it has manipulation, a higher level of attention is needed for the task.
- Are more open, more unpredictable and less controlled.
One of Xavier's goals is to do jumping jacks. Jumping jacks require a lot of mobility. They're going to be a little bit more challenging because you're moving your arms and your legs at the same time. The attention level is going to be higher. The object that you're moving is your body, so it requires more gross motor manipulation than fine motor. The other thing you have to think about is whether or not it's closed or open. Is it predictable? With Xavier, this task is probably a little bit more on the unpredictable or less controlled side, because you've got two halves moving together. You also have to think about whether it is discrete, with a beginning and an end. This one has a beginning and an end; each jumping jack counts as one rep, so it would be considered a serial task. Since it's less challenging in some aspects and more challenging in others, this task would probably fall in the middle range of the continuum.
If we wanted to make it more simple, to start with the less challenging aspect, we could move the stability piece and instead of jumping, we could have Xavier step out one foot and focus more on the arm movements. Or, you could have him lean against the wall, or have him lie down on the floor.
The Environment
There are aspects related to the environment that can be considered either regulatory or non-regulatory. Regulatory involves all of the aspects of the environment that are necessary for successful performance of the task involved. An example would be putting on a shirt while sitting on the edge of the bed. The aspects that would be regulatory are the texture of the shirt, the size of the openings for the head and the arms, the buttonholes, the size of the buttons, and what types of buttons they are. Other aspects would include the firmness of the bed, the height of the bed, and the type of floor. All of these things are necessary to consider for successful performance.
Non-regulatory aspects of the environment are not integral for the performance of the task; however, they can be distracting. In our previous example, the color of the shirt doesn't matter, but if the child doesn't like the color of the shirt, that could distract him or her from performing. The smell of breakfast coming from the kitchen might be distracting or bothersome. Noise in the hallway could be distracting. These are things to consider when you're thinking about environmental aspects.
Motor Learning
With motor learning, now we're starting to think about how the person is going to learn this. There are several layers or categories within motor learning. We have non-associative learning and associative learning, as well as procedural and declarative learning (Shumway-Cook & Woollacott, 2016).
Non-associative learning. Non-associative learning has two aspects: habituation and sensitization.
- Habituation is when you do something repeatedly and the response diminishes when the stimulus is repeated. If you keep doing it over and over again, eventually you habituate to it. One example of habituation is if you are wearing a Band-Aid. Eventually, you don't even notice that it's there.
- Sensitization is a progressive amplification of a response with repeated administrations of a stimulus. In other words, you start to notice the stimulus more with repeated progressions, whereas with habituation you notice it less. An example of this might be a tag sewn into the back of your shirt. If it feels bothersome to you, it is going to become more annoying the longer you wear the shirt.
Associative learning. Associative learning is learning an association between two stimuli. There are two aspects to associative learning: operant conditioning and classical conditioning.
- Operant conditioning is a reinforcement given after a behavior changes the frequency or form of that behavior. This comes into play when we think about feedback that we give the children or the adults that we're working with. With operant conditioning, the behavior happens, you reward it, and that changes either how much they do the behavior or the form of the behavior. You might choose not to reward it; you might give a negative reinforcer, which stops the behavior.
- Classical conditioning is trial and error learning. With classical conditioning, the behaviors that are rewarded tend to be repeated over other behaviors. Essentially, with classical conditioning, you use trial and error and you stick with what works.
Procedural learning. Procedural learning is when you are learning tasks that can be performed without attention or conscious thought. These are things that are habitual to us and don't require a lot of attention.
Declarative learning. Declarative learning is a little different, because that knowledge can be consciously recalled, which requires awareness, attention, and a reflective process. Declarative learning is much more advanced than procedural learning.
Procedural memory is a lesser involved skill, usually developing by 10 years of age, whereas declarative memory continues to mature into young adulthood. The more rapid the maturation of procedural relative to declarative memory may promote learning in children (Finn et al., 2016). When tasks become more habitual for children, that's when they have more success in the school environment, because they can now learn and focus on what they're doing.
Levels of Analysis of Movement
As the therapist, when you analyze movement, you want to think about three aspects:
- Analysis at the action level: What are the steps required?
- Analysis at the movement level: What aspects of kinesiology are involved?
- Analysis at the neuromotor level: What are the systems and processes needed?
