Ten guiding principles for movement training in neurorehabilitation

Article accepted

This article has been accepted for publication. Peer reviews and author responses are available at the end of the article.

Abstract

Clinicians and researchers in neurorehabilitation continue to have difficulties with reporting and describing the many active components used within physical therapy interventions. People with neurological conditions can present with cognitive, perceptual, behavioural and physical impairments that require individual consideration within their training program. Current knowledge from the areas from motor control theories, neuroscience and clinical evidence from neurological and musculoskeletal rehabilitation all inform the design of movement training programs. Such a diverse field of theoretical, scientific and clinical knowledge makes it difficult to agree upon a consistent way to label the many components relevant to training. This article proposes the use of ten guiding principles of movement training that can provide terminology for use in neurorehabilitation clinical practice that could be used by both professionals and individuals with neurological conditions. The ten Movement Training Principles could potentially improve interdisciplinary collaboration, enhance teaching of the clinical reasoning process and drive innovation for future therapies.

Reviews

Author: Geert Verheyden
Review date: 9th November 2020
DOI: to be allocated
Permalink: Review - Ten guiding principles for movement training in neurorehabilitation

This article presents a comprehensive set of guiding principles for motor therapy, at first for the domain of neurorehabilitation. The article is a narrative review and although there is value in this type of summaries, it is for me insufficiently clear what the origin is of the ten principles. With other words, what was the basis of the author for deriving these elements as the guiding principles. For instance, Lennon et al. (Lennon, S., Ramdharry, G., & Verheyden, G. (2018). Physical Management for Neurological Conditions E-Book. Elsevier Health Sciences) also present 10 key principles of physical management in neurorehabilitation. I understand the difference in scope (movement training versus physical management), but some framework for the pathway to the ten principles presented here should be proposed to the reader.

The introduction lacks a coherent flow. Paragraph 1 is clear and demonstrates the advantage of a common language (but is this the aim of this article?). The link between the next four paragraphs (neuroplasticity, theories, technology and patient) and the guiding principles is unclear to me. They seem to provide some examples of knowledge linked to the domain but their fit within the story is lacking. The last paragraph should explicitly state the aim.

I would be in favour of a sort of methods section (1) how the principles were determined and (2) how the information for each of the principles was collected.

My suggestion would be to rethink the build-up of figure 1. It seems now presented as a continuum which is actually not the case.

The presentation of each of the principles is in my opinion too exemplary. I like table 1 with definitions and examples and would therefore suggest that each of the principles would consist of:

  • Definition; what is the agreed explanation and meaning of principle (and what is it perhaps not). This definition should be referenced. I’m afraid not one principle in table 1 has a reference now. Sometimes, under definition, there is actually no definition given (e.g. 7. biomechanics in table 1).
  • Evidence-based practice results: this is now lacking. As a reader, we need to have confidence that what is suggested is actually of benefit. A reader now would not become convinced about such an advantage. Examples should also be specific. Now, many of the literature findings presented are vague I’m afraid.
  • Examples of the principle applied in clinical practice. Again, one needs to be specific here. For instance in table 1, line 1, “Sensory priming as a warm-up exercise.” What is meant by this? This is actually the case for nearly all principles in table 1.

The discussion should start with the aim and critically reflect upon the product (the principles) and process (how the principles were derived), and what the next steps would be. A limitations section is always useful for a reader.

Author: Ken Chance-Larsen
Review date: 24th June 2020
DOI: to be allocated
Permalink: Review - Ten guiding principles for movement training in neurorehabilitation

Thank you for the opportunity to review this interesting article.

I’d like to commend James McLoughlin for developing this article, it is well written and addresses important issues with high clinical relevance.

I have offered some opinions below that I hope can be useful in developing the article and numbered these for ease of reference.

Introduction

  1. You provide a comprehensive list labels for ‘treatments’ or ‘movement training interventions’ and make the point that there is potential for inconsistencies when describing these interventions, making ‘information dissemination incredibly challenging’. I wonder if you would consider developing this to clarify that any inconsistent labelling might also be due to journal publication guidelines and restrictions. Is this to do with a lack of treatment fidelity or is it a reporting issue? Or could it be a bit of both?
    A minor point: the word ‘incredibly’ is perhaps better replaced by a less emotive adverb?

Actual and Predicted Bodily State.

  1. I suggest avoiding the use of exclamation marks to make a point (‘…why we cannot tickle ourselves!’).
  2. This sentence needs rewriting to make more sense: ‘Whiplash and concussion patients show deficits in cervical joint position error of the head in space’.

Cognitive Selection and Planning

  1. The second sentence (‘These motor chunks…’) needs supporting with a citation.

Practice and Variability

  1. The Birkenmeier et al (2010) study included 15 patients (humans) and I am therefore not certain how your statement regarding dose of practice having shown promise in animal studies can be supported by this source. Please clarify.
  2. Regarding this sentence: ‘For some movements, very high movement repetition numbers will be needed to drive neuroplasticity and functional change, however the benefits of high repetitions for stroke upper limb rehabilitation still reach a plateau in terms of functional effectiveness (Lang et al., 2016).’
    These authors interpreted their findings in a way that does not seem to quite support the sentiment of your sentence. They found overall small treatment effects with no evidence of a a dose-response effect. They did see plateau effect but only for one of the four groups. I suggest reviewing this section to reflect the apparent paucity of research supporting any correlation between high movement repetition number and positive change.

Biomechanics.

  1. The last sentence in this section includes the word ‘enormous’ and I suggest using less emotive language to reduce any perceptions – rightly or wrongly – of bias.

Physical Capacity.

  1. Regarding this sentence: ‘Tendinopathy, osteoporosis and osteoarthritis exercises all need individualized management of load, in addition to those recovering from ligament sprains, stress fractures and muscle strains (Drew & Finch, 2016).’
    When I look at this review I can’t see any mention of any of the conditions listed. Please clarify (and apologies if I’ve missed something obvious).

Beliefs and Self-efficacy.

  1. Regarding this sentence: ‘Fear of movement in pain states and beliefs around certain ‘safe’ or ‘correct’ postures result in kinesiophobia (Vaegter et al., 2018).’
    Firstly, this was a relatively small study and it would therefore be problematic to use this study to support this absolute causative claim. Further, the authors do not seem to present empirical data to support this link. I have only looked at the abstract of the study so realise that I might have missed relevant information.

Other.

  1. There are some apparent inconsistencies in citation style, some author first names and/or initials are included whilst most citations do not include these.

Thank you for the opportunity to review this interesting paper. I agree with James McLoughlin that MTPs have relevance across many domains and I congratulate the author on his achievement.

Amendments made to this article following review

Introduction
First sentence has been updated to focus on the origins of knowledge used in movement training in neurorehabilitation
“Movement training within neurorehabilitation utilises knowledge from the fields of theoretical motor control and learning, exercise science and rehabilitation.”
A second paragraph has been included to give an example of useful guiding principles.
“The use of guiding principles can be an effective way of categorizing relevant themes in neurorehabilitation. Important principles for neurological rehabilitation have been previously summarised that include patient centred care, the ICF, team work, prediction, neural plasticity, motor control, functional movement reeducation, skill acquisition, self-management and health promotion (Lennon et al., 2018) . These principles can help guide evidence based clinical practice by providing a broad conceptual framework. While some of these principles address movement, there is still scope to provide further detail and guidance with respect to movement training.”
A new Paragraph 4 explains the origins for more specific guiding principles on movement training.
With respect to movement training, there is an opportunity to provide even further guidance to the way we describe and prescribe training principles in clinical practice. Movement training components taught in neurorehabilitation education are often sourced from theoretical areas that include motor control theories and motor learning, exercise science and self-management.
Paragraph 6 has added comments on the importance of motor learning
“Motor learning has a long history within neurorehabilitation and refers to the process of skill acquisition and problem solving that can be promoted through various types of practice (Kleynen et al., 2020; Krakauer & Thomas Carmichael, 2017; Maier et al., 2019). Motor learning includes several types of sensorimotor learning, cognitive strategies and other variables that we should consider to intensify our interventions to optimise the learning process (Guadagnoli & Lee, 2004).”
Paragraph 7 has added comment on the importance of exercise science.
“Exercise science integrates knowledge from biomechanics, functional training, strength and conditioning, pain and injury management. These themes have important implications for movement training that include information about exercise type, frequency, intensity and time (American College of Sports Medicine, 2017) injury and load management (Drew & Finch, 2016).”
A new opening sentence for paragraph 7 supports the importance of self-management.
“Self-management has become an integral part of neurorehabilitation (Jones & Riazi, 2011).”
Paragraph 8 has been re-written to give a more clear aim, summarizes the the areas for which the MTPs have been derived and their potential to be used as a common language.
“The importance of a common language to describe the movement system within physical therapy has been recognized as a priority (Association & Others, 2015). The aim of this paper is to briefly summarise the relevance of ten ‘Movement Training Principles’ (MTPs) in the context of movement training in neurological populations and discuss their potential in facilitating a common language to support education, research and valuable collaborations for neurorehabilitation (Figure 1).These principles originate from the areas motor control/learning, exercise science and self-management, and can be used across all health disciplines involved in movement training, including Physiotherapists, Exercise Physiologists, Occupational Therapists and Personal Trainers. These principles are likely to be relevant for movement training for many clinical populations, however this paper will focus on neurorehabilitation.”
The opening paragraph of the discussion has been rewritten to review the aim of the paper, the benefit of combining knowledge from the areas of motor control and motor learning, exercise science and self-management and then begins a discussion on the potential benefit of the MTPs in assisting in a common language.
“The aim of this paper is to summarise the relevance of ten ‘Movement Training Principles’ (MTPs) in the context of movement training in neurological populations and discuss their potential in facilitating a common language to support education, research and valuable collaborations for neurorehabilitation. The MTPs categorise ten interrelated factors that impact physical therapy that can be targeted in training programs using various possible strategies (Table 1). The MTPs bring together relevant principles from the areas of motor control and motor learning, exercise science and self-management are intended to assist neurorehabilitation practice and research by;”
A paragraph (second to last) on limitations has been added.
“There are several limitations to the ten MTPs. The principles are derived from a variety of theoretical origins, many of which have yet to be proven scientifically. This makes it difficult to provide certainty about their importance in specific clinical scenarios. Evidence regarding MTPs in specific neurological populations will take time, however a common language could potentially support this process through improved research methodology and critical analysis of clinical research. The MTPs could also be misinterpreted, particularly in terms of the level of importance of each principle and the fact that each of the principles are interrelated in many ways. As guiding principles, support will need to be provided, with further work underway to determine the usability and helpfulness for students, health professionals, patients, and researchers. Finally, the MTPs do not currently include adjunct interventions that may play an important role in the future of movement training in neurorehabilitation, such as brain stimulation techniques (Rothwell, 2016), vagus nerve stimulation (Engineer et al., 2019) and pharmacological treatments such as fampridine (Valet et al., 2019). The effect of these interventions on MTPs will need to be considered as more evidence becomes available.”
Table 1
Each of the 10 definitions have been updated as required and supporting references have been included.
1.Awareness of intrinsic body positions and the surrounding space. Multiple incoming sensations during movement become predictable and reliable, with a sense of ownership and agency (D. M. Wolpert & Flanagan, 2001)
2.Knowledge of Performance is information about movement pattern via verbal feedback and non-verbal sensory cues from tactile, proprioceptive, auditory and vision (Shumway-Cook & Woollacott, 2006)

Knowledge of Results provides explicit information from external verbal, non-verbal, visual coaching about the outcomes of the movement, or goal achievement (Shumway-Cook & Woollacott, 2006)
3. Implicit information comparing predicted versus actual movement sensations produce sensory prediction errors during practice. These errors reduce as skill acquisition improves (D. M. Wolpert et al., 2011).
4. A form of achievement or reward as a result of the movement (Xiuli Chen et al., 2018).
5. The process of consciously thinking, planning and choosing from a variety of movement options in order to complete the required outcome. This may involve problem solving, selection, sequencing or guided discovery of movements (Diedrichsen & Kornysheva, 2015; McEwen et al., 2014).
6. Practice can be determined using a select number of repetitions of a movement or time spent actively practicing (Lang et al., 2015).
Variations can include subtle changes in speed, timing and direction in movement performance and rest intervals between repetitions or sessions (Dhawale et al., 2017)
7. The physical science of stationary and moving body parts (LeVeau, 1984).
8. The actual or potential ability to perform movements or physical activity (Kasper et al., 2017).
9. Internal focus on the body parts, sensations and actual technique of movement performance (Wulf, 2013).
External focus on the result of the movement or other related factors. Cues to help the initiation, sequence or timing of a movement. (Wulf, 2013)
10. Perceived self‐efficacy is concerned with people's beliefs in their ability to influence events that affect their lives (Bandura, 2010).
All references have been updated.

Conflict of interest statement

The author reports no conflict of interest.

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