Principles into practice: an observational study of physiotherapists use of motor learning principles in stroke rehabilitation

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 UnitsParticipants: 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