Infusing motor learning research into neurorehabilitation practice: a historical perspective with case exemplar from the accelerated skill acquisition program.

UNLABELLED: : This special interest article provides a historical framework with a contemporary case example that traces the infusion of the science of motor learning into neurorehabilitation practice. The revolution in neuroscience provided the first evidence for learning-dependent neuroplasticity and presaged the role of motor learning as critical for restorative therapies after stroke. The scientific underpinnings of motor learning have continued to evolve from a dominance of cognitive or information processing perspectives to a blend with neural science and contemporary social-cognitive psychological science. Furthermore, advances in the science of behavior change have contributed insights into influences on sustainable and generalizable gains in motor skills and associated behaviors, including physical activity and other recovery-promoting habits. For neurorehabilitation, these insights have tremendous relevance for the therapist-patient interactions and relationships. We describe a principle-based intervention for neurorehabilitation termed the Accelerated Skill Acquisition Program that we developed. This approach emphasizes integration from a broad set of scientific lines of inquiry including the contemporary fields of motor learning, neuroscience, and the psychological science of behavior change. Three overlapping essential elements-skill acquisition, impairment mitigation, and motivational enhancements-are integrated. VIDEO ABSTRACT AVAILABLE: (See Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A71) for more insights from the authors.

Self-management interventions for chronic disease: a systematic scoping review.

OBJECTIVE: To investigate the contributions of physiotherapy and occupational therapy to self-management interventions and the theoretical models used to support these interventions in chronic disease. DATA SOURCES: We conducted two literature searches to identify studies that evaluated self-management interventions involving physiotherapists and occupational therapists in MEDLINE, the Cochrane Library, CINAHL, EMBASE, AMED (Allied and Complementary Medicine), SPORTdiscus, and REHABDATA databases. STUDY SELECTION: Four investigator pairs screened article title and abstract, then full text with inclusion criteria. Selected articles (n = 57) included adults who received a chronic disease self-management intervention, developed or delivered by a physiotherapist and/or an occupational therapist compared with a control group. DATA EXTRACTION: Four pairs of investigators performed independent reviews of each article and data extraction included: (a) participant characteristics, (b) the self-management intervention, (c) the comparison intervention, (d) outcome measures, construct measured and results. DATA SYNTHESIS: A total of 47 articles reported the involvement of physiotherapy in self-management compared with 10 occupational therapy articles. The type of chronic condition produced different yields: arthritis n = 21 articles; chronic obstructive pulmonary disease and chronic pain n = 9 articles each. The theoretical frameworks most frequently cited were social cognitive theory and self-efficacy theory. Physical activity was the predominant focus of the self-management interventions. Physiotherapy programmes included disease-specific education, fatigue, posture, and pain management, while occupational therapists concentrated on joint protection, fatigue, and stress management. CONCLUSIONS: Physiotherapists and occupational therapists make moderate contributions to self-management interventions. Most of these interventions are disease-specific and are most frequently based on the principles of behaviour change theories.

The motor learning strategy instrument: interrater reliability within usual and virtual reality physical therapy interventions.

PURPOSE: To evaluate and compare the interrater reliability of the Motor Learning Strategy Rating Instrument (MLSRI) within usual and virtual reality (VR) interventions for children with acquired brain injury. METHODS: Two intervention sessions for each of 11 children (total, 22) were videotaped; sessions were provided by 4 physical therapists. Videotapes were divided into usual and VR components and rated by 2 observers using the MLSRI. A generalizability theory approach was used to determine interrater reliability for each intervention. RESULTS: Interrater reliability for usual interventions was high for the MLSRI total score (g-coefficient, 0.81), whereas it was low for the VR total score (g-coefficient, 0.28); MLSRI category g-coefficients varied from 0.35 to 0.65 for usual and from 0.17 to 0.72 for VR interventions. CONCLUSION: Adequate reliability was achieved within ratings of usual interventions; however, challenges related to MLSRI use to rate VR-based interventions require further evaluation.

Varied overground walking-task practice versus body-weight-supported treadmill training in ambulatory adults within one year of stroke: a randomized controlled trial protocol.

BACKGROUND: Although task-oriented training has been shown to improve walking outcomes after stroke, it is not yet clear whether one task-oriented approach is superior to another. The purpose of this study is to compare the effectiveness of the Motor Learning Walking Program (MLWP), a varied overground walking task program consistent with key motor learning principles, to body-weight-supported treadmill training (BWSTT) in community-dwelling, ambulatory, adults within 1 year of stroke. METHODS/DESIGN: A parallel, randomized controlled trial with stratification by baseline gait speed will be conducted. Allocation will be controlled by a central randomization service and participants will be allocated to the two active intervention groups (1:1) using a permuted block randomization process. Seventy participants will be assigned to one of two 15-session training programs. In MLWP, one physiotherapist will supervise practice of various overground walking tasks. Instructions, feedback, and guidance will be provided in a manner that facilitates self-evaluation and problem solving. In BWSTT, training will emphasize repetition of the normal gait cycle while supported over a treadmill, assisted by up to three physiotherapists. Outcomes will be assessed by a blinded assessor at baseline, post-intervention and at 2-month follow-up. The primary outcome will be post-intervention comfortable gait speed. Secondary outcomes include fast gait speed, walking endurance, balance self-efficacy, participation in community mobility, health-related quality of life, and goal attainment. Groups will be compared using analysis of covariance with baseline gait speed strata as the single covariate. Intention-to-treat analysis will be used. DISCUSSION: In order to direct clinicians, patients, and other health decision-makers, there is a need for a head-to-head comparison of different approaches to active, task-related walking training after stroke. We hypothesize that outcomes will be optimized through the application of a task-related training program that is consistent with key motor learning principles related to practice, guidance and feedback. TRIAL REGISTRATION: ClinicalTrials.gov # NCT00561405.

The physical environment as a fall risk factor in older adults: Systematic review and meta-analysis of cross-sectional and cohort studies.

BACKGROUND/AIM: Evidence that the physical environment is a fall risk factor in older adults is inconsistent. The study evaluated and summarised evidence of the physical environment as a fall risk factor. METHODS: Eight databases (1985-2006) were searched. Investigators evaluated quality of two categories (cross-sectional and cohort) of studies, extracted and analysed data. RESULTS: Cross-sectional: falls occur in a variety of environments; gait aids were present in approximately 30% of falls. COHORT: Home hazards increased fall risk (odds ratio (OR) = 1.15; 95% confidence interval (CI): 0.97-1.36) although not significantly. When only the high quality studies were included, the OR = 1.38 (95% CI: 1.03-1.87), which was statistically significant. Use of mobility aids significantly increased fall risk in community (OR = 2.07; 95% CI: 1.59-2.71) and institutional (OR = 1.77; 95% CI: 1.66-1.89) settings. CONCLUSIONS: Home hazards appear to be a significant risk factor in older community-dwelling adults, although they may present the greatest risk for persons who fall repeatedly. Future research should examine relationships between mobility impairments, use of mobility aids and falls.

Promoting Independent Mobility-related Physical ACTivity (IMPACT) in an inpatient stroke rehabilitation unit: a proof-of-concept evaluation of self-management intervention.

Purpose: To establish proof-of-concept of a novel rehabilitation self-management program that aims to optimize walking recovery after stroke through engaging patients in independent walking-related practice outside of supervised physiotherapy sessions.Materials and Methods: The Independent Mobility-related Physical ACTivity (IMPACT) Program is a coach-supported intervention that uses self-management strategies to empower patients to engage in additional autonomous walking-related activities after stroke during and after inpatient rehabilitation. The aim of this study was to assess whether implementation of this intervention would be associated with targeted patient behaviors; goal setting, negotiation and completion of a walking-related practice plan outside of formal therapy sessions. Using a pre-intervention/post-intervention design, the Independent Mobility-related Physical Activity program was implemented with a convenience sample of 10 adults (mean age 62.3; SD 11.7 years) within an inpatient stroke rehabilitation unit (mean stroke onset 25.3 [SD 10.5] days).Results: All participants were able to set a personal goal, negotiate an autonomous walking-related activity practice plan, and partially or completely adhere to that plan. Patients completed an average of 36 min/day of practice outside of supervised physiotherapy, practicing on weekdays and weekend days. All patients indicated that the Independent Mobility-related Physical Activity program helped them increase their activity, and indicated they would continue to practice walking-related activities beyond the coaching period.Implications for rehabilitationThe IMPACT program is a feasible self-management strategy to facilitate walking-related practice outside of supervised therapy time during inpatient stroke rehabilitation.Patients were able to engage in goal-setting and practice plan development with support of a therapist-coach.Patients who are able to stand and walk with minimal assist were able to practice walking-related activities outside of formal therapy sessions.Therapists may benefit from specific training and support to adopt self-management strategies into practice.

The application of motor learning strategies within functionally based interventions for children with neuromotor conditions.

PURPOSE: To identify and describe the application of 3 motor learning strategies (verbal instructions, practice, and verbal feedback) within 4 intervention approaches (cognitive orientation to daily occupational performance, neuromotor task training, family-centered functional therapy, and activity-focused motor interventions). METHODS: A scoping review of the literature was conducted. Two themes characterizing the application of motor learning strategies within the approaches are identified and described. RESULTS: Application of a motor learning strategy can be a defining component of the intervention or a means of enhancing generalization and transfer of learning beyond the intervention. Often, insufficient information limits full understanding of strategy application within the approach. CONCLUSIONS: A greater understanding of the application, and perceived nonapplication, of motor learning strategies within intervention approaches has important clinical and research implications.

Understanding teachers' perceptions of the motor difficulties of children with developmental coordination disorder (DCD).

BACKGROUND: Children with developmental coordination disorder (DCD) are often identified by classroom teachers and the identification process relies heavily on teachers' perceptions. The literature would suggest that teachers' perceptions may be influenced by a child's gender, behaviour and the type of motor problem they demonstrate. To date, the influence of these factors on teachers' perceptions of children with DCD has not been empirically tested. AIM: This study investigated whether child gender, behaviour and type of motor problem influenced teachers' ratings of concern and importance of intervening for children with motor difficulties. SAMPLE: One hundred and forty-seven teachers of children from 6 to 9 years of age participated in this study. METHOD: Hypothetical case scenarios were developed that experimentally manipulated the factors of child gender (male/female), behaviour (disruptive/non-disruptive) and type of motor problem (fine motor/gross motor). Teachers were given two case scenarios of the same gender (that varied by behaviour) and rated: (a) their degree of concern about children's motor problems and (b) how important they thought it was for the child to receive intervention for that problem. RESULTS: The effect of child gender on teachers' perceptions depends upon the type of motor problem. While child behaviour had a marginal influence on teachers' perceptions, interestingly, teachers appeared to recognize motor problems only in the absence of disruptive behaviour. The type of motor problem demonstrated also influenced teachers' perceptions. CONCLUSION: This study provides preliminary insight into factors that influence teachers' perceptions of children with DCD with clear implications for the classroom identification of children with DCD.

Varied overground walking training versus body-weight-supported treadmill training in adults within 1 year of stroke: a randomized controlled trial.

BACKGROUND: Although task-related walking training has been recommended after stroke, the theoretical basis, content, and impact of interventions vary across the literature. There is a need for a comparison of different approaches to task-related walking training after stroke. OBJECTIVE: To compare the impact of a motor-learning-science-based overground walking training program with body-weight-supported treadmill training (BWSTT) in ambulatory, community-dwelling adults within 1 year of stroke onset. METHODS: In this rater-blinded, 1:1 parallel, randomized controlled trial, participants were stratified by baseline gait speed. Participants assigned to the Motor Learning Walking Program (MLWP) practiced various overground walking tasks under the supervision of 1 physiotherapist. Cognitive effort was encouraged through random practice and limited provision of feedback and guidance. The BWSTT program emphasized repetition of the normal gait cycle while supported on a treadmill and assisted by 1 to 3 therapy staff. The primary outcome was comfortable gait speed at postintervention assessment (T2). RESULTS: In total, 71 individuals (mean age = 67.3; standard deviation = 11.6 years) with stroke (mean onset = 20.9 [14.1] weeks) were randomized (MLWP, n = 35; BWSTT, n = 36). There was no significant between-group difference in gait speed at T2 (0.002 m/s; 95% confidence interval [CI] = -0.11, 0.12; P > .05). The MLWP group improved by 0.14 m/s (95% CI = 0.09, 0.19), and the BWSTT group improved by 0.14 m/s (95% CI = 0.08, 0.20). CONCLUSIONS: In this sample of community-dwelling adults within 1 year of stroke, a 15-session program of varied overground walking-focused training was not superior to a BWSTT program of equal frequency, duration, and in-session step activity.

Development and Evaluation of Self-Management and Task-Oriented Approach to Rehabilitation Training (START) in the Home: Case Report.

BACKGROUND: The incidence of stroke and subsequent level of disability will increase, as age is the greatest risk factor for stroke and the world's population is aging. Hospital admissions are too brief for patients to regain necessary function. Research to examine therapy delivered within the home environment has the potential to expedite relearning of function and reduce health care expenditures. PURPOSE: This case report describes the use of the knowledge-to-action cycle (KTA) to develop and evaluate an evidence-based approach for rehabilitation in the home that incorporates self-management and task-oriented functional training (TOFT) for people with stroke. CASE DESCRIPTION: The KTA cycle was used to guide adaptation of evidence from self-management and TOFT into an approach titled START (Self-Management and Task-Oriented Approach to Rehabilitation Training). Three stakeholder symposiums identified barriers and supports to implementation. Clinical practice leaders were engaged as partners in the development of the intervention. An online learning management system housed the resources to support therapist training. Therapist focus groups were conducted and stroke outcomes were used to assess patient response. OUTCOMES: Eight therapists completed 4 workshops and applied the home intervention in 12 people with stroke. A mentoring process for therapists included feedback from peers and experts after viewing treatment videos. Therapist response was determined from the focus groups; patient response was measured by standardized assessments. The therapists noted that the intervention was easier to implement with patients who were motivated and had minimal cognitive impairment. DISCUSSION: The KTA cycle provided a structure for the development of this evidence-based rehabilitation intervention, which was feasible to implement in the home. Further evaluation needs to be undertaken to assess the effectiveness of START.

Disruptive influences of a cued voluntary shift on coordinated movement in Parkinson's disease.

A temporary and/or involuntary stoppage of movement is identifiable in the execution phase of writing, walking, and turning movements in individuals with Parkinson's disease (PD) and may be referred to as freezing. However, the unpredictability of such akinetic impairments has made it difficult to study experimentally. The present study compared PD and age-matched control groups in their ability to coordinate continuous and simultaneous upper limb movements in trials involving two parts. In the first part of each trial, participants performed either in-phase movements (symmetric, simultaneous movement toward and away from the midline of the body), or anti-phase movements (isodirectional). At the midpoint of the trial, they were signaled by an auditory metronome to execute an intentional and voluntarily switch from the coordination currently being performed to the opposite coordination pattern. In the second half of the trial participants were required to maintain performance in the other coordination mode. All trials were paced by an auditory metronome at one of three different speeds (0.75, 1.25, 1.75 Hz). Measures of temporal coordination (relative phase) indicated that overall, participants with PD required significantly longer periods of time to achieve a switch between coordination patterns compared to healthy controls, and experienced greater difficulty changing from the in-phase to anti-phase mode of coordination. As well, movement stoppage was observed in 53.9% of the in-phase to anti-phase switch trials, but in only 15.5% of the anti-phase to in-phase trials. We conclude that interruptions to movement execution are most common when switching to coordinated movements that impose greater motor demands in individuals with PD.

Perceptual and motor contributions to bimanual coordination.

Following earlier work by Mechsner et al. (Nature 414 (2001) 69), the purpose of this experiment was to determine the perceptual and motoric contributions to bimanual coordination. Twenty right-handed, healthy, young adults performed continuous, horizontal, linear movements of both upper limbs at frequencies of 1.5 and 2.0 Hz. The goal was to control the spatial-temporal displacement of two flags by coordinating upper limb movements in two perceptual conditions. In a congruent condition, the movement of the flags matched the movement of the upper limbs. In an incongruent condition, the movement of the flags was opposite to the movement of the upper limbs. Measures of error in coordination provided support primarily for a motor view of bimanual coordination, and failed to replicate the earlier findings of Mechsner et al.

Age-related differences and the role of augmented visual feedback in learning a bimanual coordination pattern.

The purpose of this study was to investigate the effects of aging and the role of augmented visual information in the acquisition of a new bimanual coordination pattern, namely a 90 degrees relative phase pattern. In a pilot study, younger and older adults received augmented visual feedback in the form of a real-time orthogonal display of both limb movements after every fifth trial. Younger adults acquired this task over three days of practice and retained the task well over periods of one week and one month of no practice while the older adults showed no improvement at all on the task. It was hypothesized that the amount of augmented information was not sufficient for the older adults to overcome the strong tendency to perform natural, intrinsically stable coordination patterns, which consequently prevented them from learning the task. The present study evaluated the age-related role of augmented visual feedback for learning the new pattern. Participants were randomly assigned within age groups to receive either concurrent or terminal visual feedback after every trial in acquisition. In contrast to the pilot study, all of the older adults learned the pattern, although not to the same level as the younger adults. Both younger and older adults benefitted from concurrent visual feedback, but the older adults gained more from the concurrent feedback than the younger adults, relative to terminal feedback conditions. The results suggest that when learning bimanual coordination patterns, older adults are more sensitive to the structure of the practice conditions, particularly the availability of concurrent visual information. This greater sensitivity to the learning environment may reflect a diminished capacity for inhibitory control and a decreased ability to focus attention on the salient aspects of learning the task.

The evaluation of change in pain intensity: a comparison of the P4 and single-item numeric pain rating scales.

STUDY DESIGN: Prospective observation study. OBJECTIVES: To compare the test-retest reliability and longitudinal validity (sensitivity to change) of 2 single-item numeric pain rating scales (NPRSs) with a 4-item pain intensity measure (P4). BACKGROUND: Pain is a frequent outcome measure for patients seen in physical therapy; however, the error associated with efficient pain measures, such as the single-item NPRS, is greater than for self-report measures of functional status. Initial evaluation of the P4 suggests that it is more reliable and sensitive to change than the NPRS. METHODS AND MEASURES: Two single-item NPRSs and the P4 were administered on 3 occasions--initial visit (n = 220), within 72 hours of baseline (n = 213), and 12 days following baseline assessment (n = 183)--to patients with musculoskeletal problems receiving physical therapy. Reliability was assessed using a type 2,1 intraclass correlation coefficient. Longitudinal validity was assessed by correlating the measures' change scores with a retrospective rating of change that included patients' and clinicians' perspectives. RESULTS: The test-retest reliability and longitudinal validity of the P4 were significantly greater (P1<.05) than both single-item NPRSs. Minimal detectable change of the P4 at the 90% confidence level was estimated to be a change of 22% of the scale range (9 points) compared to 27.3% (3 points) and 31.8% (3.5 points) for the 2-day NPRS and 24-hour NPRS, respectively. CONCLUSIONS: The findings of this study suggest the P4 is more adept at assessing change in pain intensity than popular versions of single-item NPRSs.

The effectiveness of community-based occupational therapy education and functional training programs for older adults: a critical literature review.

BACKGROUND: This paper examines the results of a critical literature review describing the provision of education and functional training programs by occupational therapists with older adults to maximize their occupational performance. PURPOSE: The critical review addressed the following question: What is the effectiveness of education and functional training programs in improving occupational performance and quality of life for older adults? Review methods are described and the outcomes of the critical review discussed. RESULTS: The results indicate that there is evidence that programs are effective in three areas: prevention of functional decline and falls, stroke and rheumatoid arthritis. Methodological limitations exist in some studies. There are several randomized controlled studies in this area, though the description of specific occupational therapy interventions is often vague and the programs could not be easily duplicated by occupational therapists. PRACTICE IMPLICATIONS: Occupational therapists are provided with information through this critical review to facilitate evidence-based practice when working with older adults.

Systematic reviews identify important methodological flaws in stroke rehabilitation therapy primary studies: review of reviews.

OBJECTIVE: A "review of reviews" was undertaken to assess methodological issues in studies evaluating nondrug rehabilitation interventions in stroke patients. STUDY DESIGN AND SETTING: MEDLINE, CINAHL, PsycINFO, and the Cochrane Database of Systematic Reviews were searched from January 2000 to January 2008 within the stroke rehabilitation setting. Electronic searches were supplemented by reviews of reference lists and citations identified by experts. Eligible studies were systematic reviews; excluded citations were narrative reviews or reviews of reviews. Review characteristics and criteria for assessing methodological quality of primary studies within them were extracted. RESULTS: The search yielded 949 English-language citations. We included a final set of 38 systematic reviews. Cochrane reviews, which have a standardized methodology, were generally of higher methodological quality than non-Cochrane reviews. Most systematic reviews used standardized quality assessment criteria for primary studies, but not all were comprehensive. Reviews showed that primary studies had problems with randomization, allocation concealment, and blinding. Baseline comparability, adverse events, and co-intervention or contamination were not consistently assessed. Blinding of patients and providers was often not feasible and was not evaluated as a source of bias. CONCLUSIONS: The eligible systematic reviews identified important methodological flaws in the evaluated primary studies, suggesting the need for improvement of research methods and reporting.

Studies of stroke rehabilitation therapies should report blinding and rationalize use of outcome measurement instruments.

OBJECTIVE: To review the reporting of key design features in studies of stroke rehabilitation therapies. STUDY DESIGN AND SETTING: We used purposive sampling to examine English-language, human-subject, comparative studies focusing on stroke rehabilitation therapy provided the effect of therapy was evaluated in at least one of the following six outcome domains: ambulation, cognition, quality of life, daily activities, dysphagia, or communication. We searched MEDLINE®, CINAHL®, PsycINFO®, and the Cochrane Database of Systematic Reviews (date range: January 2000 through late-January 2008) and extracted data from included studies using standardized forms. We depicted the extracted data in tables and summarized the findings qualitatively in the text. RESULTS: We retrieved 1,674 citations in the literature search and extracted data from 99 studies. Authors' reporting of key design features in stroke rehabilitation studies was lacking in four areas, that is, the background of persons delivering therapy, timing of therapy, subjects' receipt of prior or concomitant treatment, and psychometric properties of outcome measurement instruments. CONCLUSIONS: Except for four areas, reporting of key design features in studies of stroke rehabilitation therapies was quite comprehensive. Researchers should pay particular attention to reporting blinding, and they should rationalize the number of outcome measurement instruments used in their studies.

Documenting the content of physical therapy for children with acquired brain injury: development and validation of the motor learning strategy rating instrument.

BACKGROUND: A goal of physical therapy interventions for children and youth with acquired brain injury (ABI) is the learning and relearning of motor skills. Therapists can apply theoretically derived and evidence-based motor learning strategies (MLSs) to structure the presentation of a task and organize the environment in ways that may promote effective, transfer-oriented practice. However, little is known about how MLSs are used in physical therapy interventions for children with ABI. OBJECTIVE: The purpose of this study was to develop and validate an observer-rated Motor Learning Strategy Rating Instrument (MLSRI) quantifying the application of MLSs in physical therapy interventions for children with ABI. DESIGN: A multi-stage, iterative, item generation and reduction approach was used. METHODS: An initial list of MLS items was generated through literature review. Seven experts participated in face validation to confirm item comprehensiveness. In a content validation process, 12 physical therapists with pediatric ABI experience responded to a questionnaire evaluating feasibility and importance of items. Six physical therapy sessions with clients with ABI were videotaped at a children's rehabilitation center. The 12 physical therapists participated in a session where they: (1) rated session videos to test the MLSRI and (2) provided verbal feedback. RESULTS: Revisions were made sequentially to the MLSRI based on these processes. LIMITATIONS: The MLSRI was scored during videotape observation rather than being given a live rating, which may be onerous in certain settings and may influence therapist or child behavior. CONCLUSIONS: Further reliability investigations will determine whether the 33-item MLSRI is of help in documenting strategy use during intervention, as an evaluation tool in research, and as a knowledge transfer resource in clinical practice.

The role of theory in increasing adherence to prescribed practice.

PURPOSE: The purpose of this article is to apply theoretical frameworks to adherence behaviour and to guide the development of an intervention to increase adherence to prescribed home programmes. SUMMARY OF KEY POINTS: Delivering an effective intervention requires establishing one that is evidence based and of adequate dosage. Two-thirds of patients who receive home exercise prescriptions do not adhere to their home programme, which may contribute to their physiotherapy's being ineffective. The mediating concepts of self-efficacy (SE) and outcome expectations (OE) are common to the five relevant theories used to explain adherence to exercise: the health belief model, protection motivation theory, theory of reasoned action, theory of planned behaviour, and social cognitive theory. CONCLUSION/RECOMMENDATIONS: Few intervention studies with any theoretical underpinning have examined adherence to exercise. Even fewer have been designed to affect and measure change in the theoretical mediators of SE and OE in patient populations. Physiotherapists must consider increasing adherence as a component of effective physiotherapy. Ongoing research is needed to increase our understanding of adherence to prescribed home programmes and to design interventions to affect theoretical mediators for increasing adherence.

Intra-individual variability in recovery from paediatric acquired brain injury: relationship to outcomes at 1 year.

OBJECTIVE: To determine the relationship between the amount of intra-individual variability in measures of abilities and participation throughout the first 8 months of recovery from ABI and outcome scores at 1 year. Greater amounts of intra-individual variability throughout recovery are hypothesized to predict better outcome scores at 1 year. RESEARCH DESIGN: This is a secondary data analysis of a longitudinal cohort study. METHODS: Eighty-seven children and youths were assessed with self and proxy report measures of child functioning, family functioning and environmental factors at regular intervals after ABI. Mixed-effects modelling was used to determine individual linear recovery trajectories. Intra-individual variability was defined as the intra-individual standard deviation of the residuals around the recovery line. RESULTS: Less intra-individual variability in recovery predicts better outcomes of physical health (Child Health Questionnaire), behavioural functioning (Strengths and Difficulties Questionnaire), family coping (Impact on Family Scale) and impact of environmental barriers (Craig Hospital Inventory of Environmental Factors). As amount of intra-individual variability increases, outcomes become poorer. CONCLUSIONS: Findings support the existence of intra-individual variability in instrument scores over time in this sample and the impact of this variability on several outcomes at 1 year. Potential clinical and research implications are discussed.