A reflection on motor learning theory in pédiatrie occupational

therapy practice
Jill G. Zwicker • Susan R. Harris

Key words
• Motor learning • Theory, Pédiatrie practice • Occupational therapy

Mots clés
• Apprentissage moteur • Théorie • Pratique pédiatrique • Ergothérapie

Abstract
Background. Theory provides a guide to clinical practice. To date, the most prevalent theories in pédiatrie 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
pédiatrie 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 pédiatrie populations is
required to determine if motor learning theory provides a viable and effective contribution to evidence-based, occupational
therapy pédiatrie practice. Further research comparing motor learning interventions to other dominant interventions in pédiatrie
oeeupational therapy is warranted.

Résumé
Description. La théorie est un guide pour la pratique elinique. A eejour, les théories les plus répandues eoneernant la pratique de
l'ergothérapie en pédiatrie sont eelles de l'intégration sensorielle et de l'approehe du développement neurologique. But Cet
artiele présente un bref aperçu des théories de l'apprentissage moteur et propose une réflexion sur ees théories, tout en résumant
les prineipes pouvant être appliqués en pratique pédiatrique. Questions clés. Depuis les vingt dernières années, les prineipes de
la théorie de l'apprentissage moteur sont appliqués dans la pratique de l'ergothérapie auprès des adultes, alors que ees mêmes
prineipes tardent à se répandre en pédiatrie. Conséquences. Bien qu'en pratique les ergothérapeutes appliquent taeitement les
prineipes de l'apprentissage moteur, il serait néeessaire d'appliquer eonseiemment et délibérément ees prineipes auprès de
différentes elientèles en pédiatrie, afin de déterminer si la théorie de l'apprentissage moteur eontribue fondamentalement et
effieaeement à la pratique de l'ergothérapie en pédiatrie fondée sur les faits seientifiques. Il serait justifié de pousser plus loin les
reeherehes 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.

T
heory is the driving force behind occupational therapy
practice. Using the Canadian Practice Process
Framework (Townsend & Polatajko, 2007), therapists
select frames of reference to guide their practice. In pédiatrie
occupational therapy practice, the dominant theoretical
approaches used in the United States, Canada, Australia, and
the United Kingdom are sensory integration (SI) theory and
neurodevelopmental treatment (NDT) (Brown, Rodger,
Brown, & Roever, 2005; Howard, 2002; Storch & Eskow,
1996). These theoretical approaches were developed in the
1960s and 1940s respectively and are based on a hierarchical
model of the central nervous system (CNS). Since the late
1980s, the CNS has been conceptualized as multilevel and
multi-system rather than hierarchical (Shepard, 1991). This
shift in thinking about the CNS led to the development of
contemporary theories of motor learning. While motor
learning theory has been widely used in adult occupational
therapy practice, it has been slow to gain popularity in
pediatrics.
The purpose of this paper is to review the key principles
of motor learning theories and their application to pédiatrie
occupational therapy practice. Chinn and Kramer's (1995)
framework will be used to reflect on the clarity, simplicity,
generality, accessibility, and importance of motor learning
theories as a foundation for pédiatrie practice. We will then
provide an example of how motor learning theories can be

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 ZWICKER & HARRIS
applied to pédiatrie practice and will conclude with future
directions for research and practice.
Motor learning theories
Motor learning is defined as "a set of processes associated
with practice or experience leading to relatively permanent
changes in the capability for movement" (Schmidt & Lee,
2005, p. 302). Motor learning has been a key concept in the
fields of physical education and sport since the 1970s. Motor
learning theory entered the field of neurological rehabili-
tation during the 1980s and has been applied primarily to
adults with stroke (Carr & Shepherd, 1989; Gilmore &
Spaulding, 2001; Krakauer, 2006; Sabari, 1991). In recent
years, motor learning has formed the foundation for treating
children with developmental coordination disorder
(DCD)(Missiuna, Mandich, Polatajko, & Malloy-Miller,
2001; Niemeijer, Smits-Engelman, & Schoemaker, 2007;
Sugden & Henderson, 2007). No one theory of motor
learning has been able to explain motor skill acquisition in its
entirety, but each theory has offered an important contri-
bution to our understanding of how motor skills are learned.
Three motor learning theories that have dominated the
literature will be highlighted, and then the key principles of
motor learning that have evolved from these theories will be
summarized.
Closed-loop theory
Adams (1971) was the first researcher to describe a theory of
motor learning. The primary aspect of his theory was the
concept of a closed-loop process of acquiring skills. Briefly,
Adams posited that sensory feedback is required for learning
motor skills. He proposed that movement was selected and
initiated by a memory trace, which was modified by a
perceptual trace with repeated practice. This perceptual trace
is the internal reference within which to compare movement
and detect error. Adams' theory assumes that motor learning
is enhanced by repeated practice of the same movement, with
guidance if necessary, to minimize error.
Adams' (1971) theory has been refuted with two main
lines of research. First, studies with animals (Fentress, 1973;
Taub, 1976) and humans (Rothwell et al., 1982) have
demonstrated that motor learning is possible without sensory
feedback. Secondly, Adams' contention that practice needs to
be errorless has not been borne out by research; studies have
indicated that variability in practice may be superior in
promoting motor learning (Shea & Kohl, 1990,1991).
Schema theory
To address the weakness inherent in Adams' (1971) theory,
Schmidt (1975) proposed an open-loop process for motor
learning known as schema theory. Briefly, Schmidt suggested
that generalized motor programs (GMP) are created from past
movement patterns; these GMP are recalled from memory
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and influence motor performance of new tasks. A recall
schema initiates the GMP that closely resembles the desired
movement, and the recognition schema evaluates the
occurring movement. The recall schema is then modified by
the movement experience. A major limitation of schema
theory is that it does not explain how GMP are initially
formed. Schmidt's theory has evolved over time (Schmidt,
2003) and has provided important motor learning concepts
of knowledge of results and variability of practice, discussed
below.
Dynamic systems theory
Dynamic systems theory is considered a contemporary theory
of motor learning despite its appearance prior to the previous
two motor learning theories (Bernstein, 1967). Bernstein's
work resurfaced in the 1980s with the rejection of the hierar-
chical view of the CNS. Dynamic systems theory places less
emphasis on the nervous system by viewing movement as
emerging from the interaction of three general systems: the
person, the task, and the environment (Kamm, Thelen, &
Jensen, 1990; Mathiowetz & Haughen, 1995; Newell, 1986).
Each general system has several subsystems that interact with
one another to either support or constrain movement.
Subsystems that have the potential to change are referred to
as control parameters and may be the target of therapeutic
intervention to improve motor learning. Practice and
experience alter the formation of movement patterns through
interaction with the environment and the demands of the
task. Attractor states are efficient patterns of movement that
develop with practice and experience for common tasks
(Kugler & Turvey, 1987; Mathiowetz & Haughen).
Motor learning principles
Several principles of motor learning have evolved from the
above theories and have been applied in normal and clinical
populations. These principles include stages of learning,
types of tasks, practice, and feedback.
Stages of learning
Fitts and Posner (1967) described three stages of motor
learning: cognitive, associative, and autonomous. During the
cognitive stage, an individual may have a general idea of the
movement required for a task but might not be sure how to
execute that movement. Performance during this stage is
likely to be highly variable with a large number of errors.
Improved performance is contingent upon the individual's
conscious effort to attend to the task requirements. Often this
is achieved through verbalization of movement strategies,
which Adams (1971) referred to as the verbal motor stage in
his closed-loop theory of motor learning.
The second, intermediate stage, of motor learning is the
associative stage. Skills become more refined with practice,
resulting in greater consistency of performance and fewer
• VOLUME 7 6

errors. The therapist provides less guidance during this stage
and allows the individual to make errors so that he or she can
learn to adjust subsequent movements independently (Poole,
1991). Learning from errors is thought to promote general-
ization to similar motor tasks.
Automaticity of motor learning occurs in the third stage,
the autonomous stage. At this stage, the motor skill has been
learned and little cognitive effort is required to execute it.
Automaticity is evident when a motor skill can be performed
while engaging in another task, such as walking and talking
or playing the piano and singing. Evidence from
neuroscience indicates that less brain activation is required
when automaticity of movement has been achieved (Poldrack
et al, 2005; Wu, Kansaku, & Hallett, 2004), suggesting that
fewer attentional demands are required.
Types of tasks
Motor learning is contingent upon the type of task to be
learned. Schmidt and Lee (2005) classified several types of
tasks that can affect how the skill is learned. Discrete tasks
have a recognizable beginning and end (e.g., throwing a ball).
Continuous tasks, on the other hand, do not have an inherent
start and finish as part of the task (e.g., walking); continuous
tasks have an arbitrary beginning and end, depending upon
the individual Serial tasks are a collection of discrete tasks
that are strung together (e.g., dressing). Tasks can also be
classified as open versus closed, depending upon predictability
in the environment. Open tasks are in an environment that is
constantly changing. The individual cannot plan an entire
movement in advance but must rapidly adapt the plan in
response to a changing environment (e.g., playing hockey).
Closed tasks are in a stable environment, which offers
predictability to the movement pattern (e.g., bowling).
Practice
One of the most significant tenets of motor learning is
practice. Practice schedules, such as massed versus
distributed practice and blocked versus random practice,
have been studied extensively in motor learning literature.
Massed practice involves continuously practicing a task with
little or no rest; distributed practice entails practicing a task
alternating with periods of rest. The latter is generally
superior to massed practice in contributing to motor learning
(Donovan & Radosevich, 1999). One notable exception was a
small study of children with autism in which no significant
differences were found between massed and distributed
practice schedules on motor performance and learning (Wek
& Husak, 1989).
Blocked practice involves repetitive practice on the same
task. While this type of practice results in improved motor
performance in a short period of time, it does not necessarily
promote relatively permanent motor learning (Magill & Hall,
1990). Greater retention and transfer are accomplished with
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ZWICKER & HARRIS
random practice, which involves varying the task demands
over practice trials (Lee, Swanson, & Hall, 1991). The effects
of blocked versus random practice for children is less clear;
some studies have found no difference between these practice
schedules for children (Pollock & Lee, 1997; Wegman, 1999),
whereas others have found similar results as in adults, with
random practice facilitating greater motor learning (Granda
Vera & Montilla, 2003; Ste-Marie, Clark, Findlay, & Latimer,
2004). Evidence suggests that the different results may be
related to the complexity of the task and the age of the child
(Jarus & Goverover, 1999; Jarus & Gutman, 2001).
A final aspect of practice is whether to practice tasks as
whole tasks or in parts. While learning parts of a task may be
helpful during early stages of learning, this approach does not
facilitate learning the skill in the context in which it will be
used (Peck & Detweiler, 2000). Research has shown that part
versus whole training results in different kinematic profiles,
with better movement quality obtained in whole-task
practice conditions (Ma & Trombly, 2001).
Feedback
Intrinsic feedback is information provided by the sensory
systems as a result of movement (Shumway-Cook &
Woollacott, 2001) and is consistent with Gentile's (1998)
notion of implicit learning. Implicit learning is not under
conscious control, but the therapist can facilitate it by
structuring the task and environment to support effective
movement patterns (Gentile). Extrinsic feedback supplements
intrinsic feedback and forms the basis for explicit learning
(Gentile; Shumway-Cook & Woollacott. 2001), which is
learning that results from clearly stated directions or
instructions (Tabers Online, 2000-2008). Verbal feedback
and demonstration are examples of how a therapist can
promote explicit learning. Feedback can be given during the
movement (concurrent), right after the movement
(immediate), at the completion of movement (terminal), or
after a delay (Schmidt & Lee, 2005). Feedback can also be
given consistently (i.e., after every trial) or sporadically (i.e.,
after some but not all trials). Contrary to what one might
expect, sporadic feedback after a delay is superior for motor
learning to consistent feedback given immediately after the
movement (Schmidt, 1991; Winstein & Schmidt, 1990). The
delay in feedback given over some trials allows the individual
to determine what factors are inñuencing performance and
prevents reliance on external feedback to learn the skill.
While sporadic feedback is superior for adult motor learning,
recent evidence suggests that children respond differently;
children with 100% feedback during motor skill acquisition
performed significantly better on delayed retention than
children on a reduced feedback schedule (Sullivan, Kantak, &
Burtner, 2008).
Two other points related to feedback in motor learning
are knowledge of results (Salmoni, Schmidt, & Walter, 1984)
• CANADIAN JOURNAL OF OCCUPATIONAL THERAPY • FEBRUARY 2 0 0 9 31
 ZWICKER & HARRIS
and knowledge of performance (Gentile, 1972), Knowledge of
results is terminal feedback given verbally about the outcome
of movement in terms of the goal. In contrast, knowledge of
performance is feedback on the specific components of the
movement pattern, not on the achievement of the goal.
Reflection on motor learning theories
Thus far, a brief overview of the major motor learning
theories and the main principles of motor learning have been
presented. We will now apply a framework proposed by
Chinn and Kramer (1995) for critically evaluating motor
learning theories in order to reflect on how they might be
applicable in pédiatrie occupational therapy practice. Motor
learning theory will be evaluated on five criteria: clarity,
simplicity, generality, accessibility, and importance.
Clarity
Clarity refers to "how well a theory can be understood and
how consistently the ideas are conceptualized" (Chinn &
Kramer, 1995, p, 127), From the perspective of a clinician,
"motor learning theory" is not particularly clear; this review
highlights three motor learning theories that are contra-
dictory in many respects. Motor learning is not one theory
but rather several interpretations and concepts related to how
motor skills are acquired. In rehabilitation literature, the term
"motor learning" appears to refer to a theoretical approach,
with little reference to a specified theory. The use of this
catch-all term adds to the confusion about what motor
learning theory is and how it can be applied in practice. At
best, we seem to apply motor learning principles with little
regard for the theory from which they evolved. Without a
clear understanding of the theoretical basis of motor
learning, we cannot adequately apply the theory, test it
empirically, or determine its usefulness in clinical practice.
Simplicity
Each of the motor learning theories presented are naturally
complex because they aim to explain and predict how
complex motor skills are learned. Application of motor
learning principles is seemingly straightforward, but there
are many factors to consider in designing an intervention
program: practice schedule, amount of practice, type of task,
stage of the learner, amount and type of feedback, environ-
mental influences, and the like. The multiple factors that
need to be taken into account may hinder therapists in
consistently applying motor learning theory to practice.
Generality
Motor learning concepts have broad applicability across
the lifespan in both typical (Brydges, Carnahan, Backstein, &
Durowski, 2007; Ma, Trombly, & Robinson-Podolski, 1999)
and chnical populations (Jarus, 1994; Poole, 1991; Sabari,
1991; Valvano, 2004), Motor learning theories have been
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applied in the field of adult rehabilitation for the last two
decades (Jarus & Ratzon, 2005, Sietsema, Nelson, Mulder,
Mervau-Scheidel, & White, 1993; Stanton et al,, 1983) but
only in recent years with children. Most motor learning
research with children has focused on DCD, including the
Cognitive Orientation to daily Occupational Performance
(CO-OP) approach (Missiuna et al„ 2001), Neuromotor Task
Training (Niemeijer, Schoemaker, & Smits-Engelman, 2006;
Niemeijer, Smits-Engelman, Reynders, & Schoemaker, 2003;
Niemeijer et al,, 2007), task-specific intervention (Revie &
Larkin, 1993), and ecological intervention (Sugden &
Henderson, 2007), Children with cerebral palsy have also
benefited from therapy based on motor learning (Eliasson,
2005; Ketelaar, Vermeer, Haart, van Petegem-van Beek, &
Helders, 2001; Thorpe & Valvano, 2002), Principles of motor
learning have applicability to a much broader range of
children with disabilities, but this is largely undiscovered.
Accessibility
Given the voluminous literature on motor learning, empirical
accessibility is a strength of motor learning theories. Concepts
and relationships have been tested for several decades by
different disciplines, resulting in refinements to motor
learning theory or development of new theories. The bulk of
research has focused on schema theory, but dynamic systems
theory is gaining popularity (see Shumway-Cook &
Woollacott, 2007; Schmidt & Lee, 2005 for overviews). Yet,
despite the application of motor learning theories for decades,
a limited number of studies has been conducted in pédiatrie
rehabilitation (Eliasson, 2005; Missiuna et al,, 2001; Niemeijer
et al,, 2003; Niemeijer et al,, 2006; Niemeijer et al,, 2007;
Thorpe & Valvano, 2002), Deliberate application of the theory
is another form of accessibility, which also has been lacking in
pédiatrie occupational therapy practice. We may be tacitly
using motor learning principles in our practice, but we are not
necessarily documenting our theoretical framework or
reflecting motor learning in our clinical reasoning.
Importance
Motor learning theories are highly compatible with models of
occupational therapy practice (Townsend & Polatajko, 2007;
Strong et al„ 1999), In pédiatrie practice in particular, a
childs acquisition of motor skills is important to his or her
functioning in self-care activities, participating in school, and
engaging in play. Motor learning has great clinical signif-
icance to pédiatrie occupational therapists, yet it is
underutilized. In a survey of Canadian and Australian
pédiatrie occupational therapists, only 30,5% and 33,0%
respectively used motor learning theory in their treatment of
children with neurological conditions (Brown et al„ 2005), In
Australia, 20,4% of surveyed occupational therapists used
motor learning theory for children with learning disabilities,
but Canadian occupational therapists did not even identify
• VOLUME 76

using motor learning theory for this population.
The importance of motor learning theory in pédiatrie
practice cannot be underestimated. Treatments based on
motor learning theory have show^n more promising results
compared to SI for children with DCD (Polatajko & Cantin,
2005) and NDT for children with cerebral palsy (Butler &
Darrah, 2001).
In summary, reflection on motor learning theory using
Chinn and Kramers (1995) framework has demonstrated
that motor learning theory has generality and importance but
may be lacking in clarity and simplicity for application to
pédiatrie occupational therapy. Accessibility may be improved
by deliberately applying motor learning theory to practice
and reflecting use of motor learning principles in our clinical
reasoning. To that end, we will now share an example of how
motor learning could be applied to a child with a disorder
other than DCD or cerebral palsy.
Application of motor
learning theory to pédiatrie
occupational therapy practice
Because dynamic systems theory is the most recent iteration
of motor learning, we will develop an example of its
application to pédiatrie occupational therapy practice. We
will also illustrate the three-stage model of motor learning as
described by Fitts and Posner (1967). A recent set of case
reports involving two adults with acquired brain injury (ABI)
(Mastos, Miller, Eliasson, & Imms, 2007), in which dynamic
systems theory was used as the basis for goal-directed
training, will be highlighted to develop an analogous example
for a child with ABI. In attempting to clarify and concep-
tualize (i.e., bring clarity to) dynamic systems theory, Mastos
and colleagues stated that the underlying principles of the
goal-directed training approach stem from dynamic systems
theory, "which suggest[s] that movement patterns emerge as
a result of the interaction between the persons abilities, the
environment and the goal" (p. 47). They defined goal-
directed training simply as "an activity-based approach to
intervention" (p. 47). In an attempt to simplify the dynamic
systems theory, the authors (occupational therapists and
physical therapists) used principles of motor learning to
guide their intervention approach, that is, they used goal-
directed training. Because of similarities in the sequelae from
ABI in adults and children, we will generalize Mastos et al.'s
goal-directed training approach to an example of a child with
ABI, thus translating dynamic systems theory into pédiatrie
practice and making this theory more accessible and more
important to pédiatrie clinicians.
In our case example, Alan is a 10-year-old boy who had
an acquired (traumatic) brain injury from a motor vehicle
accident 4 years previously. He had a medical diagnosis of
moderate ABI, was living at home, and received school-based
consultation from an occupational therapist and a physical
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ZWICKER & HARRIS
therapist. Alan had left-sided spastic hemiplegia as a result of
his ABI but was fortunately right-handed; he required the use
of a powered wheelchair for community-based activities.
Both Alan and his parents were concerned that he seldom
played with classmates or friends due, in part, to his limited
motor skills. Together with the school occupational therapist,
they identified the functional goal of increasing Alan's
playtime with age-mates in his neighborhood. Selection of a
meaningful goal represents the first component of goal-
directed training (Mastos et al., 2007).
Alan's specific goal was to learn how to bowl so that he
could go bowling with a group of neighborhood friends. The
second component of goal-directed training is to assess
baseline performance (Mastos et al, 2007). To assess baseline
performance, the school occupational therapist analyzed
Alan's functional abilities with his right upper extremity
(person), while sitting in his wheelchair in the bowling alley
(environment), and performing the desired occupation
(bowling). Because Alan had no difficulty grasping the
bowling ball by inserting his fingers into the three holes but
did have trouble releasing it, as part of the baseline
assessment the therapist performed a task analysis (Mastos et
al.) of the motor skills required to release the ball. The
therapist also determined that there were no specific environ-
mental constraints caused by Alan's wheelchair or with
accessibility to the bowling alleys and lanes so she decided to
develop a motor-learning-based intervention program to
assist Alan with developing the ability to release the bowling
ball in order to propel it down the lane. To accomplish this,
Alan's therapist developed the following initial therapy
objective for Alan based on his therapy goal: "While sitting in
his wheelchair in a specified 'practice lane' at the local
bowling alley, Alan will release the bowling ball onto the lane
independently four out of five times within an eight-minute
period with physical assistance and verbal cueing from his
occupational therapist."
The intervention (third component of goal-directed
training) was based on Fitts and Posner's (1967) three stages
of motor learning. In the first, or cognitive stage, the therapist
first asked Alan to try to problem solve, or think through the
skills needed to release the bowling ball. She then provided
both physical cueing and verbal instructions to facilitate
Alan's release of the ball (Mastos et al., 2007). In the second,
or associative stage, Alan practiced releasing the ball on the
bowling alley without the added physical assistance from the
therapist but with continued verbal cueing. He was allowed to
make errors and to learn from those errors as he repeatedly
(practice) attempted to release the ball onto the alley. During
the third stage of learning, the autonomous stage, Alan was
able to consistently release the ball onto the alley without the
need for verbal cueing from the therapist.
The fourth and final component of goal-directed
training is to evaluate the outcome of the therapy goal. The
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 ZWICKER & HARRIS
outcome of the initial specific therapy objective can be
evaluated independently by the therapist (Randall &
McEwen, 2000) or could be broadened into five discrete steps
representing different levels of success using goal attainment
scaling (Ottenbacher & Cusick, 1993), as described by Mastos
and colleagues (2007).
Discussion
Implications for practice
The purpose of this paper was to provide a brief overview of
motor learning theories and highhght motor learning
principles that might be applied to pédiatrie practice. Based
on this review, it was suggested that motor learning theory is
neither clear nor simple, but it has great potential for
pédiatrie occupational therapy practice. Motor learning is
widely applicable to the populations served by pédiatrie
therapists, but empirical studies have not yet determined for
whom it is beneficial. Preliminary evidence suggests that
children with cerebral palsy and those with DCD have made
functional gains with interventions based on motor learning.
Given the propensity for neuroplastic change in the nervous
system, children with other neurological disorders, develop-
mental delay, autism, and learning disabilities may also
benefit from this approach to improve motor skills and
functional performance.
Many authors have previously advocated for the use of
motor learning theory in occupational therapy practice
(Baker, 1999; Goodgold-Edwards, 1984; Jarus, 1994;
Lesensky & Kaplan, 2000; Poole, 1991), yet it is still not
widespread in pediatrics. This may be due, in part, to the lack
of a practice model that translates these theoretical principles
into a usable frame of reference for practice. The CO-OP
approach is close to achieving this goal as it has taken many
of the principles and incorporated them into a treatment
approach for children with DCD (Polatajko et al., 2001).
Sugden and Henderson (2007) have also outlined guidelines
for using motor learning principles in interventions for
children with motor impairment.
Although a formal model for motor learning practice has
yet to be developed for children with developmental
disabilities, we are probably applying many motor learning
principles tacitly in our practice. As clinicians, we need to be
more conscious of and deliberate in our application of these
principles to determine if they are effective and to further
extend our understanding of motor learning theory. As a
starting point, we can reflect the use of the theory in our
clinical reasoning and documentation. For example, our
documentation could describe our intervention in terms of
blocked practice during the cognitive stage of learning so the
child can understand the task. We might start practicing
parts of the tasks at this early stage, but then move to
practicing the whole skill in context. We might also describe
the type of explicit feedback provided during the cognitive
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phase and report on the child's knowledge of results. During
the associative stage, we could highlight variability ofpractice
with a random practice schedule to facilitate motor learning.
We could also indicate that greater emphasis is placed on
implicit feedback at this stage so the child can attend to errors
and make adjustments for subsequent movement (and rely
less on explicit feedback). We could collect outcome data
through our clinical records and publish our findings as case
reports. These are critical first steps in determining the
viability and effectiveness of motor learning principles in the
various clinical populations of children with whom we work.
Directions for future research
The amount of practice required to learn motor skills is
largely unknown. Preliminary evidence from the CO-OP
approach suggests that 10 sessions may be sufficient to learn
motor skills in the context of a task-specific intervention
based on the child's goals. Greater practice time is likely
required for children with neuropathology, such as cerebral
palsy or developmental delay. More research is needed to
determine effective practice schedules for different types of
tasks in a variety of pédiatrie populations.
Using the four-step, goal-directed training process
developed by Mastos and colleagues (2007), pédiatrie
oeeupational therapists eould replicate the adult case study
examples by applying motor learning principles to children
with ABI in their own practices. Similarly, there are published
examples from the pédiatrie physieal therapy literature in
which motor learning principles have been applied in
interventions for children with cerebral palsy (Ketelaar et al.,
2001; Thorpe & Valvano, 2002) that could serve as useful
models for occupational therapy intervention research.
Finally, chnical trials comparing motor learning
intervention to interventions based on current, dominant
pédiatrie oeeupational therapy theory (e.g., sensory
integration) would determine if a shift in pédiatrie praetiee is
warranted.
Conclusion
Motor learning theories have a rieh research history and
broad applicability to normal and clinical populations. To
date, they have been underutilized in pédiatrie oeeupational
therapy praetiee, probably beeause of the eurrent dominance
of SI and NDT theories in practice and the lack of a cohesive
practice model based on motor learning principles. With a
concerted effort, principles from motor learning theory can
be deliberately applied in practice to determine if motor
learning theory offers a contribution to evidence-based
pédiatrie oeeupational therapy practice.
Acknowledgements
Jill Zwicker has been awarded a Ouality of Life Strategic
Training Fellowship in Rehabilitation Research from the
• VOLUME 7 6

Canadian Institutes of Health Research Musculoskeletal and
Arthritis Institute and a Senior Graduate Training
Scholarship from the Michael Smith Foundation for Health
Research. The authors wish to thank Dr. Lyn Jongbloed for
reviews of an earlier draft of this paper.
Key messages
Currently, the most prevalent theories in pédiatrie
occupational therapy practice are sensory integration
and neurodevelopmental treatment.
Research from adult populations and from children
wilh developmental coordination disorder suggest
thai motor learning theory may have greater applica-
bility to pédiatrie occupational therapy practice than
the current state-of-affairs.
Pédiatrie occupational therapists may be tacitly
applying motor learning principles in their practice,
but the use of motor learning theory needs to be more
explicit in their clinical reasoning and documentation.
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Book Marks • Livres à la page
Occupational and Physical Therapy for
Children with Rheumatic Diseases:
A Clinical Handbook (2008)
Gay Kuchta & Iris Davidson, (Eds.)
Radcliffe Publishing
30 Amberwood Parkway
Ashland, Ohio
US, 44805
344 pages, $89,00 US
ISBN: 9781846192333
Occupational therapist Cay Kuchta and physiotherapist Iris
Davidson have compiled decades of practice expertise into this
resource manual to guide practice with children who have arthritis
and related conditions.
The book is organized into 6 sections. The first three sections,
intended to be a quick reference for therapists, list considerations
for assessment and treatment of inflammatory joint disease,
connective tissue diseases, and idiopathic pain. Section 4 outlines
rehabilitation interventions in greater detail, while section 5 is
comprised of contributions from the pédiatrie rheumatology team:
rheumatologists, nurses, and social worker address medical
management, pain, physical activity, transition to adulthood, and
collaboration among team members to support children and
families. The flnal section, a collection of handouts that can be
VOLUME 7 6 • NUMBER 1
ZWICKER & HARRIS
acquisition and retention of fundamental motor skills.
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effects on motor performance and learning of autistic children.
Perceptual and Motor Skills, 68, 107-113,
Winstein, C, J,, & Schmidt, R, A, (1990), Reduced frequency of
knowledge of results enhances motor skill learning. Journal of
Experimental Psychology: Learning, Memory, and Cognition, 16,
677-691,
Wu, T, Kansaku, K,, & Hallett, M, (2004), How self-initiated
memorized movements become automatic: A functional fMRI
study. Journal of Neurophysiology, 91, 1690-1698,
Authors
Jill G. Zwicker, MA, OT (C) is PhD candidate. Rehabilitation
Sciences, Faculty of Medicine, University of British Columbia,
T325-2211 Wesbrook Mall, Vancouver, BC, Canada, V6T 2B5,
Telephone: (604) 827-3369, E-maü: jzwicker@interchange,ubc,ca
Susan R. Harris, PhD, PT, FCAHS, is Professor Emérita,
Department of Physical Therapy, Faculty of Medicine,
University of British Columbia, T212-2211 Wesbrook Mall,
Vancouver, BC, Canada, V6T 1Z3, Telephone: (604) 822-7944,
E-mail: shar(g'interchange,ubc,ca
copied (or downloaded from the publisher's website), inform
children, parents, and teachers how to manage symptoms like pain
and fatigue, use backpacks, choose shoes, plan travel, apply
ergonomics at school, adapt sports and physical education, make
decisions about alternative therapy and much more, A list of web
sites and suppliers of therapy equipment rounds out the resource
section.
There is limited prose to read. Instead, information is
organized into charts and tables to trigger problem-solving.
Excellent, full-colour photographs and line drawings illustrate
therapeutic procedures. Tables are full of practical tips for
assessment and intervention used across the continuum of acute,
out-patient, and community-based care, with a strong focus on
self-management. Tips remind practitioners to be sensitive to
differing cultural expectations and child preferences, and ways to
build trust, especially applicable to working with teens who may
engage in behaviours they don't wish to disclose to parents but
have an impact on their health care, such as using alcohol or sexual
relationships.
As occupational therapy and physiotherapy educators in
rheumatology, we highly recommend this handbook for students
and all rehabilitation practitioners who work with children who
have rheumatic diseases,
Catherine Backman and Linda Li
• CANADIAN JOURNAL OF OCCUPATIONAL THERAPY • FEBRUARY 2 0 0 9 37