Dụng Cụ Chỉnh Hình Và Chân Tay Giả Trong Phục Hồi Chức Năng (Ấn Bản Thứ 3)

42
Section I  Building Baseline Knowledge
unsteady gait patterns as they return to their vehicles, but for
very different reasons. The quality of the sensory data that
the individual with diabetic neuropathy can collect may not
be sufficient for accurate perception of environmental con­
ditions, and, complicated by distal weakness, her patterns
of movement may not meet the challenges presented by the
sloped and slightly movable ground surface. The individual
who is tipsy has normal data collection ability; however, the
temporary impairment in cognitive function (judgment and
perception) and less efficient “error control” associated with
alcohol consumption lead to motor behaviors that are not
matched to environmental demands. Both baseball fans may
stumble, walk with a wide base of support, or reach for the
support of solid objects as they make their way toward their
cars, but the underlying individual contributors to this motor
outcome are quite different.
Nature of the Task
The task is the second essential component to the overall out­
come or motor behavior performed. A functional task may
require an individual to organize goal-directed movement
to address one or more of the following motor control goals
(Figure 3-4):
• Maintaining or adjusting antigravity posture (static, antic­
ipatory, or reactionary postural control)94–96
• Transitioning from one stable position to another (quasimo­
bility; e.g., moving from sitting to standing)97–99
• Moving a limb or the whole body through space (e.g.,
reaching, lifting, carrying, walking, stair climbing, walking
on inclines, avoiding obstacles, hopping, running)100–102
• Using or manipulating tools appropriate to the task (e.g.,
assistive devices, objects needed for ADLs)103,104
Any task can be described along a number of different
dimensions or continua: it can have discrete beginning and
endpoints (e.g., transferring from bed to chair) or be continu­
ous (e.g., walking or running over large distances). They can
involve stability or require mobility, occur at various speeds,
require different levels of accuracy or precision, and demand
different levels of attention or focus (Box 3-1). Repetitive and
overlearned tasks performed in predictable (closed or fixed)
environments are often executed on a nearly automatic level,
requiring little attention; this allows the individual to focus
attentional resources on other prioriteis.105 Tasks occurring
in a changing (dynamic or open) environment must be flex­
ible or adaptable to be successful and require a higher degree
of attention during performance.106,107 Finally, the complexity
of the task and the attentional requirements for effective task
performance must be considered.108
One way to understand the nature of a task (either bro­
ken into components or as a whole) is to examine or clas­
sify the task using Gentile's Taxonomy of Movement Tasks
(Figure 3-5).40 The first component considered in the taxon­
omy is the movement task's outcome goals: does the task pri­
marily focus on stability of the body, transition between stable
positions, or on transport (movement) of the body through
space? As an example of a body stability task, consider the
ability of an individual learning to use a transfemoral pros­
thesis to control hip and pelvic position while in single-limb
stance on the prosthetic side, while slowly lifting the “intact”
limb to place it on a stool or step placed in front of him or her.
STABILITY
Postural control:
Static
Anticipatory
Reactive
MOBILITY
Use of body segments
Whole-body transport
TRANSITION
Quasi-mobility:
Discrete movement
between positions
MANIPULATION
Use of tools
Interaction with objects
GOAL-DIRECTED
MOVEMENT
FIGURE 3-4  The components or nature of the task being attempted also influence the movement
that emerges: The task can include or combine goals of stability, transitions, mobility, and manipula­
tion of tools or objects.

Chapter 3  Motor Control, Motor Learning, and Neural Plasticity in Orthotic and Prosthetic Rehabilitation
43
A transitional (quasimobile) task for this person might be
practicing moving between sitting and standing position from
various seating surfaces or heights.4 A body mobility task
for the same individual might be to learn to use a cadence-
responsive prosthetic knee unit by altering gait speed, chang­
ing direction, or navigating through a crowded public space.
The next consideration is whether the task involves use of,
or interaction with, a tool or object (i.e., is object manipu­
lation part of the task?). In working with persons with spi­
nal cord injuries to develop postural control in sitting, for
example, therapists often use catching and throwing activities
with balloons and balls of various weights, thrown at differ­
ent speeds and in varying directions, to provide opportunity
to master this body stability skill.109–111 Managing assistive
devices (e.g., cane, crutches) during transfers or operating
orthotic knee locks or prosthetic knee units during trans­
fers are examples of object manipulation during transitional
motor tasks. Learning to use an ambulatory assistive device
(e.g., crutch walking in a four-point reciprocal pattern; man­
aging crutches when ascending or descending stairs) is a
prime example of a body mobility task that requires object
manipulation.112,113
Characteristics of the Environment
The final component of the Shumway-Cook and Woollacott's
model of motor control is the setting, environmental con­
text, or conditions in which the goal-directed movement
takes place (Figure 3-6). The physical therapist must examine
(and, during intervention, purposefully manipulate) the envi­
ronmental context in which functional movement occurs. Is
the physical environment comfortable to be in while taking
part in exercise and other rehabilitation interventions? Is it
­visually interesting and stimulating but not too distracting or
challenging? Is the motor task occurring in an environment
that is predictable (i.e., in a closed environment), or is there
a degree of variability and possibility of change external to
the individual (i.e., an open environment) that will require
the individual to monitor and respond more carefully while
performing the task?114–116 Therapists must also consider the
social-emotional context of the environment that is rooted
in the interpersonal interaction: will the individual feel sup­
ported and encouraged as he takes risks and makes errors
as part of the development of skill in salient activities? Or
does the emotional environment contribute to anxiety about
receiving negative criticism or a fear of failure?117,118
For the therapeutic application of environmental vari­
ables, therapists can consider both macroenvironmental
influences (e.g., actual physical conditions that influence
task demand, the therapeutic setting, or the involvement of
family members), as well as microenvironmental influences
(e.g., the level of visual and auditory “noise” present in the
therapy room or variations in surfaces over which a client
may be sitting or walking). Mastery of a motor task within
a single, simple environment does not directly translate into
safe performance of the same task under more complex and
demanding environmental conditions. Navigating up and
down a set of training steps in the physical therapy gym
does not mean that the individual with stroke or paraplegic-
level spinal cord injury will be functional and safe on a wet,
leaf-covered, uneven brick staircase (with no railings) when
entering or leaving his best friend's house or favorite neigh­
borhood hangout.119,120
When working with persons with acquired brain injury
functioning at the Rancho Los Amigos cognitive ­continuum
• Discrete: The beginning or end point of movement, or
both, as determined by the task itself (e.g., stepping onto
a curb, donning a prosthesis, catching a ball).
• Serial: An ordered sequence of discrete movements,
defined by the task itself (e.g., climbing a flight of stairs).
• Continuous: The beginning and end points of the task
are determined and controlled by the individual (e.g.,
riding a bicycle, deciding when to start or stop).
• Stability: The primary task goal is to maintain position
of body segments (often against gravity or in response to
perturbation) or to keep the body's center of mass within
the available base of support during functional activity
(e.g., to provide a secure base in sitting or standing for
subsequent skilled use of extremities).
• Transitional (quasimobility): The primary task goal is to
move the body from a starting position of stability to a
different ending position of stability (e.g., moving from
sitting to standing, rolling from supine to prone, getting
up from the floor).
• Mobility: The primary task goal is to move a body part,
or the entire body, through physical space (e.g., rolling
over in bed, walking or running, reaching for an object
on a shelf or on the floor).
• Manipulation continuum: The degree to which a task
requires the individual to use (manipulate) or inter­
act with one or more external objects in order to com­
plete the activity successfully (e.g., fastening buttons or
handling clothes during dressing, donning/doffing a
prosthesis or orthosis, opening doors during mobility,
locking the brakes on a wheelchair).
• Automaticity: The degree to which the task is well under­
stood and can be carried out automatically or requires
attention because of high task demand (level of precise­
ness, consequence of error) or the changing nature of the
task or environmental conditions (e.g., threading a sew­
ing needle, walking down an icy sloping walkway, catch­
ing a thrown object).
• Variability in performance: The degree to which an indi­
vidual is able to adapt the performance of a learned task
in response to differences in environmental conditions
or changes in task constraints; the flexibility to apply
what has been learned to similar or novel situations.
BOX 3-1  Descriptors of Movements Based on the Attributes/Nature of a Task

44
Section I  Building Baseline Knowledge
BODY STABILITY
TRANSITION
(Quasi-mobility)
BODY TRANSPORT
No object
manipulation
Object
Manipulation
No object
manipulation
Object
Manipulation
No object
manipulation
Object
Manipulation
CLOSED ENVIRONMENT
No
variability
Stand in prosthesis
unsupported in the
parallel bars in a
quiet PT gym
Stand in prosthesis
unsupported while
putting on jacket in a
quiet PT gym
Practice the sit-to-
stand transition from
a single chair with
armrests in a quiet PT
gym
Practice the sit to
stand transition from
the same chair while
managing axillary
crutches
Walk the length of
the parallel bars at
comfortable speed,
turn around, repeat
Walk forward with
crutches using a 2-
point gait pattern in
an empty hallway
Trial
variability
Stand in prosthesis in
parallel bars with
diagonal weight shifts
on command
Stand in prosthesis in
parallel bars catching
ball from different
directions and speeds
Transfer to and from
wheelchair, toilet,
and shower seat,
moving to left and
right in random order
Transfer between
seating surfaces of
different heights
while holding a full
glass of water in a
quiet PT gym
Practice stepping in
different directions
and distances in the
parallel bars
Walk up to a closed
door, opening it, and
walking through
while using a cane
OPEN ENVIRONMENT
No
variability
Remain standing
upright as people
walk by at regular
intervals from similar
directions
Retrieve an object
repeatedly from the
same spot on the
floor in a corner of a
busy PT gym
Practice moving from
standing to sitting
using arms in a pre-
positioned chair in
the cafeteria of the
rehabilitation hospital
Move from standing
to sitting and vice
versa from a rocking
chair while managing
crutches
Practice ascending
and descending a set
of training stairs in
the corner of a busy
PT gym
Approach and ascend
a full flight of stairs in
a quiet hallway, using
bilateral canes
Trial
variability
Remain upright while
standing in line in a
busy public area
Retrieve various
randomly dropped
objects throughout
an active PT gym
Rise repeatedly from
a seat in the movie
theater so that other
people (of various
height and weight)
can move past into
the row
Scoot sideways while
sitting, managing the
blankets on a soft
mattress so that
grandchildren can
climb into bed to
hear a story
Ascend and descend
stairs using the railing
in a busy public space
Walk from car to
supermarket door,
pushing the grocery
cart across the busy
parking lot
FIGURE 3-5  Examples of therapeutic activities for an individual learning to use bilateral transtibial
prosthesis, based on a modified version of Gentile's Taxonomy of Movement Tasks.

Chapter 3  Motor Control, Motor Learning, and Neural Plasticity in Orthotic and Prosthetic Rehabilitation
45
of 4 (confused and agitated), 5 (confused inappropriate), or
6  (confused appropriate), therapists must provide a struc­
tured and predictable environment for functional and rehabil­
itative activities, so that the demands of the environment do
not exceed the individual's ability to monitor and respond to
the challenges that the environment presents.121–123 A complex
environment can be overwhelming to the individual recover­
ing from brain injury; the structured environment provides
opportunity to complete key tasks with minimal frustration
and behavioral complications. However, the complexity of the
environment must be gradually increased as the individual
prepares for discharge. Being able to cross the street safely at a
crosswalk with real traffic is a more complex task than manag­
ing curbs and walking over a distance in the rehabilitation gym.
Gentile's taxonomy provides an organizational strat­
egy for intervention planning by rehabilitation professions
­working with individuals with musculoskeletal or neuro­
muscular impairments and limitations in performing func­
tional activities. The primary goal of a man who has had a
recent stroke may be to climb stairs so that he can return to
his home, where the bedroom and bathroom are upstairs.
In the early stages of rehabilitation, it may be necessary to
first concentrate on static postural control and controlled
weight shifting in sitting and standing on a firm support
surface (body stability, no object manipulation, predict­
able environment). As the quality and control of these
motor tasks become more consistent, intervention expands
to include ambulation in the parallel bars (body mobility,
no object manipulation, unvarying environment), then
with an assistive device in a quiet hallway (body mobility,
object manipulation, predictable environment), and finally
in a busy rehabilitation gym in which the individual must
PHYSICAL
CHARACTERISTICS
Lighting and acoustics
Spacing of equipment
Flooring characteristics
Room temperature
Background noise
Visual surround
CHALLENGES
(Closed vs. open)
Predictability
Distractions
Variability
Complexity
SOCIAL-EMOTIONAL
CONTEXT
Stress, anxiety, fear
Safety, and support
GOAL-DIRECTED
MOVEMENT
FIGURE 3-6  In considering the role of the environment on motor performance, the therapist must
understand the challenges that it presents, the social-emotional context that might influence the
individual's ability to move, and the physical characteristics of the movement space that affect the
individual's safety and ability to move. Therapists often manipulate the social-emotional context by
providing physical support and encouragement to create a situation where it is safe for the individual
to attempt difficult movement and risk failure (error) as part of the motor learning process.

46
Section I  Building Baseline Knowledge
anticipate and react to others in the environment (body
mobility, object manipulation, changing ­environment). As
postural control becomes more efficient on level surfaces,
task demand is increased by increasing speed or attempting
more challenging surfaces such as stairs, inclines, and step­
ping over obstacles; this may initially occur in a relatively
predictable environment but must eventually occur in an
“open” situation in which the individual must dynamically
react to or navigate around other persons and objects.
Skill Acquisition Models
Movement has also been examined from the behavioral per­
spective, with a focus on quality of motor performance and
acquisition of skilled behavior. Researchers with this perspec­
tive are interested in the influence of cognitive-information
processing and cognitive psychology on motor behavior.
They concentrate on the acquisition of skill, the learning pro­
cesses associated with skills, and the refinement process of
skills across applications. Early on, studies of skill acquisition
focused on orientation to the task; as the field developed and
expanded, focus shifted toward understanding the process
of skill development. This led to formulation of the concepts
of motor memory and schema. Adams’ theory of feedback-
based learning was a catalyst for later research, which gave
rise to Schmidt's schema theory for motor learning.
Current motor control theory has become a blend of the
various bodies of study presented in this section, integrating
neurophysiological, dynamic systems/ecological, and behav­
ioral models. This shared interest gave rise to the study of
motor learning, which is concerned with the adaptation and
application of movement strategies to altered or novel func­
tional, behavioral, and environmental contexts.
THEORIES OF MOTOR LEARNING
Although models of motor control focus on how the bio­
logical system organizes and adapts movement as it occurs,
models of motor learning consider how the individual comes
to understand and consistently perform a particular behav­
ioral task. The outcome of effective motor learning is mas­
tery of skilled behaviors so that the individual can function
appropriately in his or her physical and social environment.
Most models of motor learning are founded on four distinct
notions about learning:
1. Motor learning is a dynamic process that leads to acquisi­
tion of ability for skilled actions.
2. In order for motor learning to occur, there must be an
opportunity to practice and build experience. Making
errors is a necessary part of the learning process; as learn­
ing occurs motor memories are established.
3. Motor learning itself cannot be observed directly; it is
inferred by observation of changes in motor behavior that
become consistent over time.
4. Learning produces relatively permanent changes in the
capability for skilled behavior, by building motor memory;
as a result, what has been learned can be applied or adapted
when altered task or environmental constraints occur.
In order to effectively master a novel motor task or recover
from disease-disrupted motor function, the individual must52,124:
• Develop sensory and perceptual strategies for collecting
information relevant to the task at hand and the environ­
ment in which is occurring
• Understand key features of the task, the performance
environment, and any tools required to complete the task
successfully
• Activate the components of the motor control system
(anticipatory, guiding, corrective, and reactive) necessary
for skillful performance of the task
• Apply (transfer) knowledge of the task, environment and
tools in order to adapt skilled motor performance to situ­
ations that are different from the one in which learning
took place
Rehabilitation professionals must be careful to distin­
guish between the concepts of motor learning and motor
performance. Motor performance is the observable action or
behavior that can be measured (rated) qualitatively or quan­
titatively by an observer.41 As health care professionals who
focus on function, therapists are quite skilled at examining
motor performance, and determining whether an individual
is moving normally or is coping with some form of move­
ment dysfunction. Physical therapists use both subjective rat­
ings (e.g., ratings of perceived exertion; using the terms “poor,
fair, good, normal/excellent” to describe static postural con­
trol, dynamic balance ability, or endurance), and objective
performance-based scales and measures (e.g., self-selected
and fast walking speeds, Timed Up and Go times, Functional
Reach distances, Dynamic Gait Index scores, 6-minute walk
test distance, Gross Motor Functional Measure scores, among
many others).125–131
In contrast, motor learning refers to the process that
leads to changes in the quality, consistency, and efficiency of
motor performance of a given individual. This process is not
easily measured except by considering consistency or how
other dimensions of performance of the task change over
time. Comparisons of baseline performance to postinter­
vention performance indicate changes in quality of perfor­
mance. Although motor performance tends to transiently
improve after a single practice session, we cannot be confi­
dent that learning has occurred until performance becomes
consistent after multiple sessions over a period of time.132,133
Improvement in motor performance to the level of con­
sistency infers that effective motor learning has occurred.
Motor learning has occurred when the task can be accom­
plished in various ways as situations demand.
Evolution of Models of Motor Learning
Initial models of motor learning were published in the early
1970s, the most prominent being Adams’ closed-loop theory
and Schmidt's schema theory.134,135 Both models assume that,
as a result of the motor learning process, the brain develops
generalized motor programs: rules for timing and sequenc­
ing of muscle activity for key tasks.132 The closed-loop theory
proposes that sensory information generated from move­
ments occurring during performance of functional tasks

Chapter 3  Motor Control, Motor Learning, and Neural Plasticity in Orthotic and Prosthetic Rehabilitation
47
­provides feedback necessary to build the memory and percep­
tual traces that guide and refine subsequent performance of
the task.134 In contrast, schema theory suggests that an open-
loop process occurs, in which a general set of rules for a par­
ticular movement is developed (motor recall and sensory
recognition schema) over time. Such schemas allow the indi­
vidual to continuously compare actual outcomes of move­
ment with anticipated (feedforward)/predicted outcomes via
error detection and correction mechanism.135,136 According to
schema models, variability of practice must occur to establish
and strengthen the movement schema over time.137,138
In the 1990s, Newell proposed an alternative ecological
model of motor learning (resonant with Bernstein's dynamic
systems model of motor control) that suggests individuals use
a problem-solving approach to discover the optimal strategy to
produce the task (performance) given both environmental and
task influences.139,140 By exploring the perceptual motor work­
space during practice, individuals begin to recognize salient
sensory/perceptual cues as they explore movement options
that might lead to successful task completion. In viewing a
demonstration, perceptual information helps the learner better
understand the nature of the task and task-related movements
that need to be mastered. Perception during (knowledge of
performance) and perception after (knowledge of results) task-
related movement provides intrinsic feedback that assists the
problem solving process in the development of optimal strat­
egies for the task at hand. Therapists can provide augmented
information (explicit cues and extrinsic feedback) to facilitate
an individual's search for optimal strategies. In this way, the
perception (salient cues about the task and the ­environmental)
and action (adaptive motor performance of the task.) are linked
so that task-relevant connection is established.145
Refer to Shumway-Cook and Woollacott132 and Schmidt
and Lee128 for a more detailed discussion of these theoretical
models.
Temporal Considerations
Motor learning has also been explained through a tempo­
ral perspective in which learning occurs in stages over time.
Various three- and two-stage models have been proposed to
describe the process for acquisition of a skill and for adapt­
ability or generalization/transfer of the skill (Table 3-1).
Three-stage models generally describe the earliest stage
as the discovery stage, in which an understanding of the
nature of a task is developed through trial and error, some­
times with guidance.54,128,137–144 In this initial stage of motor
learning, the need for attention is high, and there is signifi­
cant trial and error-related variability in task performance
early on, with an eventual understanding or selection of the
best plan for the task for that individual. Once a plan has
been settled on, the second stage of motor learning focuses
on refinement of the performance; error during performance
decreases while efficiency of performance increases, but
attention is still required and distraction is often problem­
atic, interfering with performance.145 In the third and final
stage of motor learning, the individual can generalize or
adapt the learned skill to changing environmental demands;
much less attention to task is required, and the task can be
performed effectively in various ways under multiple envi­
ronmental demands.
Building on the work of Lereijken and colleagues,
Shumway-Cook and Woollacott describe a system-oriented
three-stage model, integrating principles of dynamic sys­
tems motor control, human development, and the ecological
model of motor learning.132,144 Early in motor learning, indi­
viduals constrain (freeze) the degrees of freedom among limb
segments (joints) involved in the task as a means of reduc­
ing task difficulty; this freezing cocontraction around joints
results in relatively accurate movement, although the mov­
ment typcially has a high energy cost.146 As learning occurs,
there is a tendency to “unfreeze” joints sequentially such that
movement becomes more fluid and energy-efficient. With
mastery, the individual employs freedom of movement to
­fluidly perform the task and can adapt to changing character­
istics of the environment.147
Two-stage models of motor learning focus on (1) acqui­
sition of the skill and (2) adaptation or application of the
skilled motor behavior.148 The initial phase consolidates the
first two components of the three-stage models: Acquisition
and refinement of performance occur within the same stage.
Variability of performance occurs through internal demands
within the individual's attempts to find and select a preferred
action/strategy before refinement. In the second stage perfor­
mance is variable due to external demands of the environ­
ment: The person must adapt the task accordingly; this is
quite similar to the final component of each of the three-stage
models.149
Implicit and Explicit Aspects of Motor Learning
To understand the process of motor learning, it is impor­
tant to consider the principles underlying all learning pro­
cesses: how new information is translated into memory to
become useful. One can think about learning as the pro­
cess of acquiring new information and new skills; memory
then is the product or outcome of the learning process.150
Learning is one of the major drivers of plasticity within
the CNS, stimulating formation of new synapses as well as
refinement of existing neural connections throughout the
brain.151,152 This plasticity is evident as information is moved
from our short term (working) memory into initial long
term memory stores which become better established, and
more resistant to disruption, with practice and experience
(Figure 3-7).153
Learning theorists describe two major categories of learn­
ing: implicit (nondeclarative) and explicit (declarative) learn­
ing (Figure  3-8).154 Both categories lead to functional and
physiological changes in synapses of involved areas of the
spinal cord, brainstem, and forebrain.155 One aspect of motor
learning falls into the category of implicit procedural learn­
ing: it requires trial and error (discovery) in a relevant and
functional context.155 Consistently improved task perfor­
mance over time and situation provide evidence of effec­
tive procedural learning. Neural structures thought to be
necessary for implicit procedural learning include cortex

48
Section I  Building Baseline Knowledge
TABLE 3-1  Comparison of Concepts in the Major Models of Motor Learning
Models
Descriptive Stages/Movement Characteristics
THREE-STAGE MODELS
Fitts and Posner142
COGNITIVE
Early skill acquisition through trial and error;
performance highly variable to find most
effective strategy for task
ASSOCIATIVE
Refinement of skill; performance less
variable and more efficient
AUTONOMOUS
Low attention necessary for task; transfer
or adapting skill to other environments;
performance of skill during multiple task
demands
Vereijken, Whiting, and Beek54
NOVICE
Discovery of task constraints; restriction
of degrees of freedom to simplify task
ADVANCED
Release of some degrees of freedom to
coordinate movement; adapt tasks to
environmental demands
EXPERT
All degrees of freedom released; exploitation of
mechanical forces to complement environmental
forces
Larin144
(Refers to children)
DISCOVERY
Verbal-cognitive stage; physical and verbal
guidance necessary
INTERMEDIATE
Motor stage; independent performance,
greater consistency
AUTONOMOUS
Skilled performance; economy of effort; task
adaptable to environment
Shumway-Cook, Woollacott
Systems Model132
STAGE 1
Co-contraction to constrain degrees of freedom
to reduce the number of body segments or
joints to be controlled during movement
STAGE 2
Gradual release of degrees of freedom of
limb segments results in gradual increase
in control and flexibility of the body during
movement
STAGE 3
Mastery of the skilled movement with automaticity
and variability during performance, allowing
adaptation and transfer of skill in response to
changing conditions/demands
TWO-STAGE MODELS
Gentile148
EXPLICIT LEARNING
Attainment of action-goal; conscious mapping
of the movement's structure; rapid stabilization
of performance
IMPLICIT LEARNING
Dynamics of force generation; active and passive force components finely tuned unconsciously;
gradual change in performance
Manoel and Connolly147

ACQUISITION
Formulation of the action plan; understanding task
and how to accomplish it; stabilization of action
ADAPTATION
Task and environment interaction; task is fluid with range of options to cope with new situations;
breakdown of stable task and reorganization for new action plans

Chapter 3  Motor Control, Motor Learning, and Neural Plasticity in Orthotic and Prosthetic Rehabilitation
49
of the frontal and parietal lobes, nuclei of the basal ganglia,
and cerebellar cortex and nuclie.156–158 Recent work has also
identified that the hippocampus in involved in perceptual
components of procedural learning.159 Explicit (declarative)
learning is founded on attention and conscious thought and
can be described or demonstrated by the learner.160 Neural
structures involved with explicit learning include prefrontal
cortex, cingulate gyrus (limbic system), head of the caudate
nucleus, medial temporal lobes, and hippocampus.161 The
hippocampus plays a key role in motor learning because it
contains a cognitive-spatial map of the typical areas in which
humans function.166 Early motor learning is strengthened, as
evidenced by changes in output of the primary motor cortex,
when explicit learning of sequences is associated with implicit
learning.162–164
Once sequential aspects of the task are well understood,
the need to pay close attention during motor performance
diminishes, and the skill becomes less effortful as it transitions
toward automaticity.165 As automaticity increases, the ability
to attend to simultaneous tasks also increases.166,167 There is
growing evidence that the transition from early motor learn­
ing of complex, sequentially organized tasks to automatic­
ity requires more time and practice as a person ages.168–171
Encouragement and feedback that focus on building percep­
tions of capability (self-efficacy) with respect to better perfor­
mance than peers appears to enhance motor learning in both
young and older adults.172,173
Key motor learning concepts that physical therapists work­
ing with individuals new to prosthetic or orthotic use include
practice conditions and schedule; the role of variability, con­
textual interference, and feedback on skill acquisition; devel­
opment of automaticity of performance; as well as retention
and transfer of the newly learned motor skill (Box 3-2).128,132
Each is discussed in the following section.
THE IMPORTANCE OF PRACTICE
Common to all models of motor learning is the concept of
practice: Motor learning cannot occur unless the individ­
ual has an opportunity to gain experience through repeated
attempts (both successful and unsuccessful) at accomplish­
ing the desired movement task.174 Much of the research lit­
erature in the area of motor learning is devoted to exploration
LEARING & MEMORY
EXPLICIT
(DECLARATIVE)
EXPLICIT
(NON-DECLARATIVE)
Habituation
Sensitization
Associative
Conditioning
Priming
Procedural
Skills & Habits
Facts
Events
FIGURE 3-8  Learning is the process of acquiring information or skill while memory is the product
of the learning process. Traditionally, the learning process has been described as having two separate
domains: explicit or declarative learning, which is primarily involved in acquisition of knowledge
about facts and events, and implicit or nondeclarative learning. Much of motor learning falls into the
category of procedural implicit learning: the mastery of skills and habits. Recent research evidence
using functional magnetic resonance imaging suggests that there are interactions between explicit
and implicit processes (arrow) regardless of whether the focus is on fact or movement.
Parallel continuum of learning
Neural modifiability
Persisting
changes
Persisting
changes
Changes
in
synaptic
efficiency
Changes
in
synaptic
connections
Long-term
changes
Short-term
changes
FIGURE 3-7  The gradual shift from short term (acquisition) to long
term (retention) learning and memory is reflected in a move along
the continuum of neural modifiability. Short-term changes, associ­
ated with an increased synaptic efficiency, persist and gradually give
way to structural changes, the underpinnings of long-term learning.
(From Shumway-Cook A, Woollacott MH [eds]. Motor Control:
Translating Research into Clinical Practice, 4th ed. Philadelphia:
Wolters Kluwer Lippincott Williams & Wilkins, 2012. p. 84.)

50
Section I  Building Baseline Knowledge
of practice and the optimal conditions or configurations in
which it occurs. Conditions of practice can be classified or
designed in several different ways. The type of practice used
can influence the efficacy of motor learning that occurs, as
well as its carryover or generalizability to similar tasks or
environmental conditions.
Variability
In a complex and variable world, there are innumerable ways
to respond to challenges that are encountered. Over the life
span, typically developing individuals explore many move­
ment options to accomplish salient task goals, ­developing
a set of action plans that demonstrate both automaticity in
performance and adaptability to variations in task or envi­
ronmental constraints (i.e., the mastery of bipedal locomo­
tion, over different surfaces, at various speeds, in closed
versus open environments).175,176 Discovery learning and the
feedback/feedforward provided by error during repeated
practice across conditions with differing constraints allows
the individual to develop an understanding (perception) of
the common elements of the task wherever and whenever it
is performed.174,177,178 This perception provides the flexibil­
ity to select from a range of task-specific options and adapt
movement in response to variations encountered in daily
life; variability in skilled movement is an adaptive resource
responsive to variation in environmental demands.179
The movement patterns of individuals with neurological
or neuromuscular dysfunction, however, often demonstrate
hypervariability or hypovariability.176,180 Too much or too little
variability is problematic: Perception of the nature of the task
and of interaction between task and environment may be lim­
ited or altered, and acquisition of skill may be challenged by
the constraints associated with altered muscle performance
and motor control.181–183 Functionally, this contributes to a
reduced ability to adapt (vary) performance in response to
changing environmental conditions. The rigidity character­
istic of Parkinson disease, for example, creates “super stabil­
ity” of the trunk and extremities that interferes with mobility
(locomotion) and postural control when task conditions
change (i.e., the need to increase speed, walk through door­
ways, or to walk on inclines).181,184 In persons with stroke,
impaired ability to move the involved upper extremity was
accompanied by difficulty recognizing action of the corre­
sponding limb when observing others or a computer model.185
In persons with right hemisphere stroke, impairments of
attention and perception challenge the ability to develop the
set of task-specific movement options necessary for adap­
tive function in response to variations in environment and
context.186,187 While implicit motor learning can be success­
ful after a stroke, movement during acquisition stages is often
slower and more variable in both blocked and random prac­
tice conditions.188 Variability in movement is also altered in
children with hypertonic and dyskinetic cerebral palsy, and in
those with developmental coordination disorder.179,182,189
In rehabilitation, therapists set up opportunities for discov­
ery motor learning for patients that are designed to enhance
the likelihood of discovering, from among all possible move­
ment options, the set of movements most likely to result in
successful task performance.175,176 This is accomplished by
manipulating the environmental and task constraints in rel­
evant and meaningful ways to actively engage the individual
in iterations of the task, with the goal of promoting both per­
ceptual understanding and a usable set of action options for
completing the task.175,190,191
Practice Conditions: Blocked, Random, or Serial?
One way to describe practice is by whether it occurs in a
blocked or random sequence. Blocked practice (also known as
constant practice) is characterized by separate but subsequent
repeated trials of the same task.132,174 For blocked practice, the
task is repeated under consistent environmental conditions.
Modified blocked practice involves repeating the motor task
three or more times in one condition before altering condi­
tions or context in which practice of the same task is repeated.
During blocked practice, the individual concentrates on per­
formance of a single task; this focus reduces overall demand
on working memory. As a result, quality of performance tends
to improve substantially over successive bouts of blocked
practice. In healthy adults, acquisition of skill appears to be
effective (performance becomes more accurate over a single
practice session) with blocked practice, however retention of
the skill over time and transfer of the skill to differing con­
ditions is not as strong.192 Blocked practice appears to have
• Contextual interference: The work of keeping many
options available in working memory over time when
involved in discovering solutions to movement prob­
lems during the acquisition of skill in motor learning.
• Blocked: A single motor behavior (task) is repeated
multiple times in unchanging environmental condi­
tions. Performance improves within the practice ses­
sion, but less than optimal retention across sessions.
• Random (variable): Practice of the targeted motor task is
interspersed or embedded within trials of different motor
behaviors. Although performance in a single practice ses­
sion is less consistent, there is better retention of skills
across practice sessions and environmental conditions.
• Serial: A series of separate (related or unrelated) tasks
is performed in the same sequence for multiple trials.
• Massed: Time for active practice exceeds rest time
between trials.
• Distributed: Time for active practice is less than rest
time between trials.
• Part task training: Each component of a motor behav­
ior is practiced separately. Assists accuracy or effi­
ciency of performance of the single-task component.
• Whole task training: The entire motor behavior is prac­
ticed as a single task. Enhances the individual's ability to
problem solve and adapt task performance across prac­
tice sessions and differing environmental conditions.
BOX 3-2  Summary of the Dimensions or
Characteristics of Practice

Chapter 3  Motor Control, Motor Learning, and Neural Plasticity in Orthotic and Prosthetic Rehabilitation
51
a positive impact on retention of skill for children younger
than 10 years; this is thought to be a function of emergence of
information processing capability in late childhood and early
adolescence.193,194
For the individual with transfemoral amputation working
on stance control on the prosthetic limb, a blocked practice
session might include stepping up onto a stool with the intact
limb for 10 trials (repetitions), while standing in the parallel
bars. The level of difficulty of the activity could be advanced
by setting up an additional practice session, asking the indi­
vidual to perform a similar task while supporting himself or
herself with a straight cane to a practice curb or step outside
the parallel bars. Theoretically, practice in the parallel bars
would provide a model to use when performing a similar
activity outside the parallel bars.
Random practice (also described as variable practice) is
characterized as practicing a set of tasks in which order and
perhaps difficulty of tasks varies across bouts of ­practice.132,174
Because of the variation encountered during random prac­
tice, there is less improvement of performance in a given
practice session (compared with blocked practice); how­
ever, there is greater retention of what has been learned
over time. Theoretically, random practice creates contextual
interference (the work of keeping many options available in
working ­memory over time) that actually enhances learn­
ing and mastery over time despite poorer immediate perfor­
mance.174,192 While this may be counterintuitive, the efficacy
of contextual interference on mastery of complex movement
tasks is well supported.195–199 One of the proposed mecha­
nisms for enhanced retention in random practice is increased
attentional demand that results in better use of perceptual
understanding to prepare for movement.197,199 The degree of
similarity of tasks (distraction) undertaken during a practice
session can also be a source of contextual interference; greater
attention is required to discriminate between tasks with simi­
lar but distinct characteristics.198 The improvement of reten­
tion occurs even when the context or characteristics of the
task are somewhat altered; thus random variable practice may
enhance transfer of learning.174
To practice the primary task of stance phase stability
using a random practice order, the individual with a trans­
femoral prosthesis would be involved in an ongoing session
of gait training. As this person walked the length of the par­
allel bars (or across the gym), he or she might be asked to
step up onto a stool or over an obstacle at a different point
in the walk and to change direction or speed on randomly
delivered commands. The walk itself might be repeated
10 times (practice trials), with a step up onto or over the
stool and changing speed and direction at a different point
in each of the 10 trials of walking. These trials of stepping
up or over and altering speed and direction do not occur
sequentially but instead are interspersed throughout the
entire ambulation event.
A third practice condition called serial practice can be
thought of as a blending of the blocked and random prac­
tice order. Serial practice is a collection of different tasks
performed sequentially, from a designated starting point to
a defined ending point, always occurring in the same order,
and repeated as a whole set of movement tasks.132,174
In a serial practice session for an individual learning to use
a transfemoral prosthesis, the therapist may instruct him or
her to repeat a specific sequence of movements such as the
following:
1. Rise from a seated position and take three steps toward an
obstacle in your pathway.
2. Step over the stool (obstacle) with your intact (right) foot,
bringing your prosthetic limb around the object in a small
arc.
3. Complete three more gait cycles and turn around to the
right.
4. Walk back toward the obstacle, stepping over it with the
prosthesis first on the return.
5. Continue walking back to the chair, turn, and sit down.
6. Rise to standing once again, and repeat the entire sequence
until you have done it a total of × number of times.
The original task of stepping onto the stool with the right
foot has been embedded into a series of different (but some­
what related) tasks performed in the same order over multiple
trials.
Another way to classify practice is by the relative period of
time spent in active practice versus rest time between practice
sessions. In conditions of massed practice, there is more time
spent over a practice trial than there is rest time between tri­
als. Fatigue may be a factor in decreases in performance over
repeated practice sessions if rest periods are insufficient.
In  conditions of distributed practice, the amount of practice
time is less than or equal to the amount of rest time between
­trials.132,174 Given evidence of better retention and transfer of
skills with longer rest periods between practice trials (i.e., dis­
tributed practice), rest appears to be more than a period of
physical recovery; it may also enhance consolidation of per­
ceptual schemas and action rules associated with the skill that
has been practiced into memory.200 What is not yet understood
is how much practice time and how much rest is optimal for
tasks of different complexity or learners with various resources
or impairments.
Part vs. Whole Task Training
Many functional tasks have sequential, recognizable subcom­
ponents. The task of rising from a chair, for example, may
require moving forward toward the edge of the seat, changing
foot position, leaning forward to shift body weight from the
ischial tuberosities toward the feet, lifting off the seat, accel­
erating quickly upward into standing, and then establishing
postural control in the upright position.201 The task of walk­
ing can be divided into stages including weight acceptance in
early stance, stability during single limb stance, preparation
for swing at the end of stance, and initiation through comple­
tion of limb advancement during swing phase.202 When work­
ing with individuals who have neurological, neuromuscular,
or musculoskeletal related movement dysfunction, therapists
often use task analysis to determine what subcomponents of
the task are problematic. The therapist might opt to practice
the problematic components of the task to build skill before

52
Section I  Building Baseline Knowledge
attempting the entire task (part to whole training) or to prac­
tice the entire task repeatedly (whole task training). In partial
task training, the task is divided into separate parts, and each
part is explained or modeled as distinct components of the
task, while in whole task training the entire task is explained
verbally or modeled (demonstrated) in entirety from begin­
ning to end. The decision to structure training as part ver­
sus whole is influenced by level of difficulty of the task; the
degree that the individual has already mastered some of the
task components; the individual's ability to attend to the task,
his or her level of motivation and frustration; and safety con­
siderations as the task is attempted. Tasks that are serial in
nature lend themselves in part to whole training; spending
time practicing complex or difficult task components (ending
the session by putting all of the components together to per­
form the whole task) often leads to better retention and trans­
fer than the same amount of time spent practicing the entire
task.174,202,203 Tasks that are continuous, such as carrying a tray
while walking through the cafeteria, are not as easily sepa­
rated into components because of the degree of coordination
and interplay necessary among task components. When coor­
dination, timing, and interaction must be learned, whole task
training appears to be more efficacious.174,203,204
Relationships: Practice, Retention, and Transfer
The effectiveness of the various practice conditions on motor
learning has been the subject of many studies in psychology,
movement science, and rehabilitation. As we consider the
evidence that these studies present to us (to determine their
clinical relevance and possible application), it is ­important
to note the specific outcome of practice that is being inves­
tigated. Are  the researchers focused on change in quality
of performance during practice trials (i.e., skill acquisition
within a session) or in carryover of understanding of the task
from one practice session to another (i.e., postpractice perfor­
mance or retention over time)? This distinction is particularly
important for rehabilitation professionals to keep in mind.
How, then, do rehabilitation professionals determine
whether the interventions they have implemented have
resulted in effective motor learning and skill development?
Rather than focusing on improvement in a single session, we
look instead at the development of automaticity and the abil­
ity to adapt performance across sessions and circumstances.
Although performance over repeated trials within a practice
session is often observed, this is not a reliable indicator that
motor learning has occurred. Consistency in motor behavior
(as the product of the learning process) across sessions and
over time suggests that there has been retention (consolida­
tion), a relatively permanent change in motor behavior. The
ability to transfer what has been learned and apply the set of
movement options across situations appears to be related to
the opportunity to practice under a variety of environment
conditions and constraints.
Scientists who study motor learning hypothesize that
individuals who develop flexible learning strategies through
random practice and whole-task training are better able to
transfer learned skills to novel situations. This is critical for
the individuals we care for, who will ultimately need to per­
form skills beyond the rehabilitation practice environment
(rehabilitation settings) as they return to the real world
environment of their homes and community. Keeping this
in mind, rehabilitation professionals need to carefully con­
sider and choose the practice conditions that will lead to the
best possible functional outcomes for individuals for whom
they care.
INTRINSIC AND EXTRINSIC FEEDBACK
A second key concept in motor learning paradigms centers on
the provision of feedback during practice trials (Box 3-3).205
As movement occurs, it generates intrinsic (inherent) feedback
that the CNS (especially the cerebellum as a system inter­
ested in coordination and error control) compares with the
sensation that it “anticipates” (feedforward) will or should
result from the movement. Extrinsic (augmented) feedback
refers to information about the movement performance that
is ­provided by an external source before, during, or after the
movement. If rehabilitation professionals understand the
“what, when, why, and how” of extrinsic feedback (and com­
bine them with appropriately structured practice), they will
be much more effective in facilitating motor learning as well
as the individual's ability to problem solve or adapt a motor
skill. Rehabilitation professionals must determine what type
of information is most appropriate (knowledge of perfor­
mance or knowledge of results) for the individual they are
working with, as well as how and when the feedback would
best be provided (feedback mode and schedule).
To initiate a therapy session, the therapist may ask an indi­
vidual how he or she might approach a functional motor
problem, and what they expect will happen when performing
a task: for example, “We're going to practice moving from the
bed to the chair. How can you prepare to do this? What is the
first thing you need to do? Are you ready to do it?” This pro­
vides extrinsic augmented feedforward information aimed at
engaging the person in the exploration of probable solutions
for the initial steps of the transfer task. If the therapist asks the
person to assess what he or she felt or experienced during the
performance, they are providing concurrent extrinsic feed­
back. If the therapist asks or comments on performance after
the task is completed, they are providing terminal extrinsic
feedback. Therapists provide extrinsic feedback, sometimes
without careful thought, in each intervention encounter
when they say “Good job!” or “Did that work out the way
you expected?” or “What might you do differently next time
you try this?” In providing extrinsic information, the thera­
pist calls the person's attention to, and enhances the use of,
intrinsically generated feedback (or sometimes the substitu­
tion of an alternative source of information in the presence of
sensory impairment).
Knowledge of Performance and Knowledge of Results
Extrinsic information can provide the individual who is learn­
ing a new motor strategy or skill with either knowledge of
results (KR), information about the outcome of the movement

Chapter 3  Motor Control, Motor Learning, and Neural Plasticity in Orthotic and Prosthetic Rehabilitation
53
(i.e., whether it was successful), or knowledge of performance
(KP), information about the quality or execution of the move­
ment (accuracy of the performance).205 Much of the research
on feedback in motor learning has focused on KR (outcome);
however, in rehabilitation, we often use KP (quality; e.g.,
“Do you think that you were leaning far enough forward as
you began to stand up?”) to help individuals recognize and
respond to movement errors.
Evidence in the literature suggests that, although KR
does not necessarily lead to better performance dur­
ing practice conditions, this type of augmented feedback
information contributes to better task performance dur­
ing retention tests.133,205 The individual learning a new skill
may benefit most by considering whether he or she has
accomplished a movement goal (KR), especially in early
and mid stages of motor learning, rather than how accu­
rately or efficiently the goal was attained (KP). Early on,
details about quality of performance may interfere with
the individual's developing understanding of the nature
of the task and ability to sort through possible strategies
that might be used. In later stages of motor learning, when
focus shifts to refinement or improved precision of perfor­
mance, KP is probably a more appropriate and powerful
form of feedback information, as long as the task is consis­
tently accomplished.206
It appears that augmented and intrinsic KP feedback leads
to better quality and consistency of performance during prac­
tice, but perhaps to less accurate performance in retention
tests.165,205 Although KP may not enhance retention as much
as hoped, it has been found to be both effective and necessary
in the acquisition of complex motor tasks, as compared with
mastery of simple motor tasks.206,207
How and when Should Feedback be Used?
Another thread within the motor learning research literature
explores the efficacy of different frequencies and timing in
the provision of augmented information. Providing too much
anticipatory prompting before initiation of the task or exces­
sive feedback as the task proceeds and is completed can actually
be detrimental to the learning process. Frequent KR-focused
feedback, provided on almost each trial of the task, often
contributes to dependence on external guidance and ulti­
mately degrades performance on retention tests. Summarized
KR-focused feedback given at infrequent intervals (after mul­
tiple trials) appears to improve performance during practice,
as well as on retention testing.208–210 Delaying the timing of KR
appears to have a positive effect on performance during prac­
tice, as well as on retention tests. Providing feedback after trials
that are relatively successful appears to enhance motor learn­
ing more than when trials are full of error.211–213 Researchers
BASIC DEFINITIONS
• Intrinsic (inherent): Sensations generated by move­
ment of the body itself, monitored by sensory receptors
(exteroception, proprioception, vestibular, visual, audi­
tory), and transmitted to the brainstem and brain via
sensory pathways.
• Extrinsic (augmented): Information provided about the
movement task by sources external to the individual who
is moving. Extrinsic feedback can be provided by another
individual (e.g., the therapist or coach), or by an exter­
nal device (e.g., biofeedback, other types of signals) that
would not necessarily be present during usual perfor­
mance of the task. It can be provided before, during, or
after movement.
DIMENSIONS OF EXTRINSIC FEEDBACK
• Knowledge of performance (KP): Information about the
quality of the movement, provided during or following
performance.
• Knowledge of results (KR): Information about the out­
come (success) of the movement or task, provided after it
has been completed.
VARIATIONS OF EXTRINSIC FEEDBACK
• “Feedforward”: Prompts or clues provided prior to move­
ment to assist the learner's active engagement in problem
solving or preparation for the motor task.
• Concurrent: KP information about the movement pro­
vided as it occurs.
• Terminal: KP or KR information provided after the
movement task has been completed. This can be provided
either as soon as the movement is finished (immediate) or
after a period of time (delayed).
• Distinct: KP or KR information about one specific prac­
tice trial.
• Accumulated (summary): KP or KR information
that reflects multiple attempts to perform the task or
movement.
CHANNELS USED FOR EXTRINSIC FEEDBACK
• Verbal: Questions or statements made by the therapist or
coach about the movement.
• Nonverbal: Gestures and facial expressions made by the
therapist or coach; touch or guidance used to direct or
redirect attention or movement; lights, whistles, or other
sounds used to guide or influence the learning during or
following the movement.
TIMING FOR EXTRINSIC FEEDBACK
• Consistent (100%): KR or KP distinct information pro­
vided after every practice trial.
• Reduced (50%, 33%, 25%): KR or KP distinct or sum­
mary information provided after every other, every third,
or every fourth practice trial.
• For poor trials: Providing feedback for trials with large
errors during practice.
• For good trials: Providing feedback for trials with rela­
tively small or few errors during a practice trial.
BOX 3-3  Definitions for Feedback in Motor Learning

54
Section I  Building Baseline Knowledge
have noted that KR, like random practice and whole training
methods, better prepares individuals for adapting motor per­
formance to changing environmental demands, resulting in
better performance on retention tests. These findings are con­
sistent across individuals with no neurological impairment;
adults with stroke, head injury, and Parkinson's disease; chil­
dren with cerebral palsy and developmental delay; and per­
sons with mild cognitive impairment and early dementia.214–219
There is gathering evidence that allowing individuals to pace
or control feedback frequency also has a beneficial impact on
the retention (effectiveness) of what has been learned.220–222
What Modality for Feedback is Appropriate?
Extrinsic feedback (augmented information) can be pro­
vided in a number of ways, using the visual system (e.g.,
demonstration and modeling, targets and other visual cues);
the auditory system (e.g., informational verbal prompts or
questions, use of tone of voice); and somatosensory-tactile
systems (e.g., manual contacts, tapping/sweeping motions,
compression of limb segments to cue stability response, trac­
tion/elongation of limb segments to cue mobility, appropri­
ate resistance to guide movement).
Early in the motor learning process, therapists judiciously
use all three modalities, keeping in mind that early stages of
motor learning are periods of experimentation and trial/error
as the individual becomes familiar with the nature of the task
and problem solves strategies that lead to accomplishment of
the task. Although it is tempting to explicitly direct and “tell”
someone with movement dysfunction how to move more effi­
ciently, prompting by using questions often can more effectively
engage the individual in an active learning process. It appears
that certain tasks are more responsive to particular modalities
of feedback than others.223,224 In persons with stroke, for exam­
ple, visual feedback about weight distribution is useful for bal­
ance activities and auditory feedback about force production
positively impacts on learning the sit to stand transition; effi­
cacy of verbal and kinesthetic is not as well understood.225,226
Simple tasks appear to be learned more easily follow­
ing demonstration or physical practice, with or without
KP-focused feedback. The learning of more cognitively
and motorically complex tasks, on the other hand, bene­
fitted from a combination of demonstration and practice
with KP feedback.226 Many studies suggest that an external
focus of attention (success or quality of the movement) has
a more beneficial effect on motor learning than an internal
­(kinesthetic) focus of attention during practice.227–230
As individuals move into the later stages of motor learning,
therapists must be aware of the need to wean the amount and
frequency of augmented information as the individual moves
toward becoming adept at the task. In the final stages of motor
learning, augmented information becomes less and less essen­
tial or effective, as mastery of the motor task is achieved.
Using Normative Feedback
There is increasing evidence that providing information that
is normative (social-comparative) has a positive impact on
motor learning.227 Providing feedback that suggests that the
individual is doing as well or better than others in similar sit­
uations, when paired with KR information about outcomes
of the individual's actual practice, appears to improve trial-
to-trial performance as well as retention.231,232 Making a state­
ment at the start of a therapy session focused on a difficult
motor task indicating persons facing similar challenges typ­
ically do well and are able to master the task with practice
enhances the individual's expectations of their own ability
(self-efficacy) and reduces anxiety associated with risk of fail­
ure; this enhances motor learning as well.233
Mental Practice and Imagery
Another resource available to assist the process of motor
learning is the incorporation of mental practice and imagery
into therapeutic interventions. Mental practice is defined as
the imagined execution of a task-related movement without
actual movement or muscle activation.234 Mental practice of a
motor task is thought to activate the same areas and networks
of the CNS that actual movement does, especially if the task
has been previously practiced.234,235 Growing evidence in both
the human performance and rehabilitation literature indicates
that mental practice and the use of imagery enhance learning
effects of physical practice and improves motor performance
and retention.236–238 Mental practice and motor imagery that
focus on ease and quality of movement have been found to be
particularly helpful in acquisition of motor skills in persons
recovering from acute and chronic stroke.239,240
Imagery and mental practice appear to have a more pow­
erful influence on improving performance during skill
acquisition; their impact on retention of skills is not as well
understood. This has implications for application to practice
in therapeutic settings. Given high-volume patient case loads
and the realities of multiple patients per therapist during ses­
sions, mental imagery can be an effective tool for maintaining
involvement of the client in the activity even when the thera­
pist is attending to other patients.
Role of Sleep in Motor Learning
Newly acquired motor memory becomes more stable (more
resistant to disruption or interference) during sleep.241 The
procedural memory consolidation process appears to reduce
the need for neocortical (prefrontal lobe) input into the neu­
ronal representation of the movement, making it easier to
recall the movement and increasing efficacy of retention.242
While early research suggested that consolidation during sleep
actually improved learning (off-line learning) and enhanced
motor performance, more recent work proposes that it instead
provides protection against forgetting by counteracting both
physical and neuronal fatigue associated with practice.243,244
Whichever perspective will prove to be accurate, it appears
that sleep is a key component in the motor learning process.
The positive effect of sleep on retention of newly learned
skills appears to be true for motor skills that have been physi­
cally practiced as well as those reinforced by mental imagery,
in both persons who are healthy and in persons with CNS
­pathology.245,246 It is important that opportunity for uninter­
rupted overnight sleep for offline consolidation of motor

Chapter 3  Motor Control, Motor Learning, and Neural Plasticity in Orthotic and Prosthetic Rehabilitation
55
memory is a key component of the rehabilitation process for
persons with stroke.247,248 Individuals with prefrontal lobe
damage (e.g., after traumatic brain injury), who typically are
quite challenged by novel motor tasks presented during reha­
bilitation, appear to benefit significantly from the opportu­
nity for off-line learning and memory consolidation that
occurs during a night of sound sleep.248
Importance of Patient/Client-Centered Goals
Rehabilitation goals focus on improving an individual's abil­
ity to participate in meaningful activities. One aspect of the
motor learning process that is often taken for granted is the
salience of the task to the learner; therapists may assume
that the goals that they have developed for a given patient
(e.g., to walk 150 feet safely and efficiently using an assis­
tive device and a prosthesis or orthosis) are consistent
with the goals of the individual with whom they are work­
ing, when in fact there may be a mismatch.249,250 Emerging
evidence suggests that focusing on the tasks that are most
meaningful to the individual enhances motivation and atten­
tion, necessary components of the motor learning process
as well as facilitators of neural plasticity and recovery after
brain injury.251,252 A sense of empowerment and increasing
self-efficacy contributes to efficacy of learning when an indi­
vidual works toward a goal that is particularly meaningful to
that person.253–255
How does a rehabilitation professional assist an individ­
ual to identify salient personal goals and use these goals to
inform design of appropriate opportunity for motor learn­
ing (Figure 3-9)? Framing goals at the level of activity and
participation is the first step.256 The next is to ensure that
stated goals reflect consensus (as much as possible) of the
patient and the health professional.257 Such consensus is a
key influence on the relationship between the patient and
the health professional; being “on the same page” creates
a level of trust that provides a solid foundation for risking
failure in the rehabilitation learning environment.257 Goals
for motor learning are most effective if they reflect both
expertise of the therapist and expectations of the individ­
ual beginning rehabilitation; at times, reaching consensus
requires patient and family education as well as negotiation
about priorities.258–260 Effectively defined goals are (1) spe­
cifically related to the task to be accomplished or mastered;
(2) measurable (i.e., use quantifiable metrics of distance,
time, effort or difficulty, and frequency of performance), (3)
ambitious yet achievable within the forecasted episode of
care; (4) relevant, realistic, and congruent with the individ­
ual's potential and expectations; and (5) include a timeline
for achievement.261 Establishing clearly stated and measur­
able goals provides a framework for assessment of outcomes
of interventions, as well as revision or progression of activi­
ties that will further improve functional capacity and ability
to participate in meaningful activity. Such attention to early
establishment of functional goals has been found to posi­
tively affect on outcome of rehabilitation for children with
cerebral palsy and persons with spinal cord injury, stroke,
and traumatic brain injury.262–267
Neural Plasticity in Motor Control and
Motor Learning
Rehabilitation professionals are on the cusp of significant
expansion in the understanding of the neurobiological/­
physiological basis of recovery after neurological and neu­
romuscular injury.268,269 The developing science suggests
that we can use our understanding of motor control and
motor learning to drive neural plasticity in both acute and
chronic stages of many neurological and neuromuscular
diseases.270–273 This science also challenges us to reevaluate
whether our interventions are sufficient, in terms of thera­
peutic approach, intensity, and duration, to trigger the neu­
roplastic changes that will improve function and quality
of life.274–276
The term neural plasticity refers to the dynamic ability of
the brain to structurally and functionally reorganize neural
circuits in response to activity and environmental demand:
such plasticity occurs during development in children, dur­
ing adulthood as one masters new motor skills and builds
knowledge base, as well as after any type of brain injury or
insult.271,276 Plasticity is driven by (i.e., is dependent on) the
process of learning, whether it be focused on new knowledge
or skills, or relearning of skills disrupted by illness or injury.
While the mechanisms underlying neuroplastic change are
not fully understood, exposure to learning opportunities of
sufficient intensity and duration contributes to remapping
of motor, perceptual, and communication areas within the
brain.271–273,277 Early in rehabilitation, as the effects of inflam­
mation and edema associated with CNS infarct or injury
diminish, activity-based interventions may help revive and
restore function in neural structures that were initially com­
promised; this is neural recovery.278 Even if there is potential
for neural recovery, at times the effort required to activate
recovering neural circuits is intensely difficult and frustrat­
ing. Without encouragement and opportunity to practice,
function may continue to be compromised due to learned
nonuse of a body part.279 As rehabilitation progresses, con­
tinued activity-based interventions may facilitate recruit­
ment of intact neighboring neural structures to supplement
function of damaged brain structures. Even though this is
actually a mechanism of neural compensation, it may be
perceived by the individual, family, and rehabilitation pro­
fessionals as functional recovery at the level of WHO-ICF
levels of body function and activity.271 If brain injury has
been so extensive that alternative ways of performing key
functional tasks is necessary, retraining leads to functional
compensation.271
Medical management of newly injured or compromised
brains has traditionally focused on preventing or limiting sec­
ondary sequelae that result from insult, whether traumatic,
ischemic, or infectious. Refer to Shumway-Cook & Woollacott,
2012, pp. 93-99 for a summary of the brain's cellular and func­
tional responses to injury.155 While evolving pharmacological
or interventional strategies (e.g., transcranial stimulation) now
target recovery of function, rehabilitation based on principles
of motor learning is currently the most powerful facilitator or
neural plasticity.270,280,281 The ­behavioral, sensory/perceptual,

56
Section I  Building Baseline Knowledge
Step 1: PREPARE AND NEGOTIATE (come to agreement)
• Identify salient/meaningful task or behavior
• Describe individual’s and therapist’s expectations
• Discuss and agree upon priorities
• Use task analysis to identify baseline abilities and potential problems
Step 2: DEFINE THE GOAL (articulate anticipated outcomes)
• ICF model: activity and participation level
• Be Specific: what task is to be mastered?
• Make it Measurable (quantifiable: time, distance, frequency)
• Attainable, yet ambitious
• Realistic and relevant
• Timed (defined target date for achievement)
Potential Modifiers:
• Disease-related constraints and impact of comorbidities
• Cognitive, physiological and psychological resources and constraints
• Availability of physical assistance and social supports
Step 3: PREPARE FOR INTERVENTION (develop a plan of care)
•
Design opportunity for effective motor learning of task/behavior
•
Set up effective learning environment
•
Consider initial practice and feedback schedules
•
Consider progression of activity based on progression of motor learning
Step 4: CARRY OUT GOAL-DIRECTED ACTIVITY (implement the plan)
• Provide effective modeling and social-comparative feedback
• Provide adequate practice to facilitate motor learning and plasticity
• Provide appropriate extrinsic feedback for stage of motor learning
• Provide opportunity for mental practice and imagery
• Progress level of challenge and opportunity for variability in practice
and performance
Potential Modifiers:
•
Level of frustration/effectiveness of coping resources
•
Physical and mental fatigue
•
Environmental culture and characteristics (e.g., adequacy of time)
•
Opportunity for sleep (memory consolidation)
MOTIVATION
GOAL-DIRECTED ACTION
TIME
EVALUATION
Step 5: ASSESS OUTCOMES (determine if the task been mastered)
•
Evaluate performance against the goal criteria (retention)
•
Assess patient’s view of progress and functional status
•
Evaluate carryover of learning to more complex environments and
subsequent tasks (ability to apply/adapt what has been learned)
•
Consider whether intervention was enough to influence neuroplasticity
Step 6: MODIFY GOALS AND INTERVENTIONS (define the “next step”)
•
Assess the individual’s satisfaction with progress and functional ability
•
Refine and update individual’s and therapist’s expectation
•
Revisit and refine priorities for intervention
•
Adjust goals, or establish new goals to guide upcoming intervention
development
FIGURE 3-9  A patient-centered model for setting goals for effective motivation and facilitation of
motor learning in rehabilitation. Initial efforts focus on building consensus between patient and ther­
apist on establishment of appropriate meaningful goals, and articulation of such goals so that they can
be later used to assess outcomes. Given understanding of motor learning, motor control, neuroplas­
ticity, and recovery of function, the therapist then designs and implement task-specific, goal-directed
rehabilitation interventions. Both the patient and therapist use agreed upon goals as markers of effi­
cacy of intervention, and modify or progress therapeutic activities and practice based on achievement
of the goals.

Chapter 3  Motor Control, Motor Learning, and Neural Plasticity in Orthotic and Prosthetic Rehabilitation
57
and cognitive aspects of functional and skilled movement
appear to effectively trigger neuroplastic processes in dam­
aged brains, in ways much like occurs in developing brains.270
Kleim and Jones270 have developed a set of 10 principles
that translates current best evidence about experience-depen­
dent neural plasticity from animal and human basic science
studies to inform development of motor learning-based
interventions for clinical rehabilitation practice (Table 3-2).
Discussion of each principle follows.
Use it or Lose it
Basic science research has clearly demonstrated that
impaired performance and eventual loss of skill and abil­
ity is likely if neural circuits are not consistently activated
by functional activity. This is the underlying assumption
of the learned nonuse theory that forms the foundation for
constraint-induced therapy targeting upper extremity use for
adults and children with hemiplegia.282,283 A similar principle
has been described as an explanation for decline in muscle
performance and endurance associated with sedentary life­
style and bed rest.284 Early in rehabilitation, individuals with
CNS dysfunction or disease may discover compensatory
or alternative movement strategies that are less difficult or
frustrating given their altered brain function, and the result­
ing paresis or altered muscle tone.11 Moving differently also
impacts muscle performance and flexibility, making develop­
ment of secondary impairments more likely. Thus, over time,
not only does neural circuitry necessary for normal move­
ment degrade, but also the individual's physical resources for
movement change. Both of these factors reinforce the altered
or abnormal movement pattern and the loss of premorbid
skill and activity.
Use it and Improve it
Animal models consistently show that, in both nonim­
paired and impaired circumstances, consistent or extended
training induces cortical plasticity as evidenced by reor­
ganization of cortical motor and sensory mapping and
synaptogenesis.285 The expectation is that behavioral expe­
rience will optimize neural plasticity in humans as well.273
Participating in extended training (i.e., practice, experi­
ence) of specific skills and functions enhances performance
in areas of the brain associated with those functions; this
is the outcome expectation for constraint-induced therapy
and task-specific paradigms used in stroke, brain injury,
and spinal cord injury rehabilitation programs.282,286,287
Specificity is Significant
In humans, the acquisition of particular motor skills (e.g.,
finger tapping) through physical practice leads to changes
in neural activity only in particular areas of motor cor­
tex and cerebellum (e.g., areas mapped to hand and fin­
gers) as evidenced on functional magnetic imaging.288
This demonstrates that the training experience that leads
to acquisition of a specific behavioral skill determines the
resulting type and extent of plasticity. Task-specific train­
ing has been evaluated extensively as an intervention for
recovery of upper extremity function and of locomotion
after stroke.289,290 It is important to note, however, that
neuroplastic changes associated with training of one skill
does not necessarily contribute to improvement in other
skills or changes in other areas of the brain. Nonskilled
movement appears to have little, if any, impact on neural
plasticity.
Repetition, Repetition, Repetition
One successful performance of a motor task does not mean
that the task has been skillfully mastered. In motor learning,
evidence of mastery is the transition to automaticity.105,166
An individual moves toward automaticity only after many
practice sessions. Sufficient repetition of new or relearned
behaviors is necessary for neuroplastic changes to become
well established. The underlying assumption is that the out­
come of such repetition is the establishment of neural cir­
cuitry that makes the effectively learned behavior less likely
to decay over time, when practice is infrequent.270 The role of
repetition for driving learning and neural plasticity is a crit­
ical one. Body weight–supported treadmill (TM) ­training
TABLE 3-2  Kleim and Jones’ Principles of
Experience-Dependent Neural Plasticity
Principle
Description
Use it or lose it
Failure to drive specific brain functions
can lead to functional degradation
Use it and improve it
Training that drives a specific brain
function can lead to enhancement
of that function
Specificity
The nature of the training experience
dictates the nature of the plasticity
Repetition matters
Induction of plasticity requires sufficient
repetition
Intensity matters
Induction of plasticity requires sufficient
training intensity
Time matters
Different forms of plasticity occur at
different times during training
Salience matters
The training experience must be
sufficiently salient to induce plasticity
Age matters
Training induced plasticity occurs more
readily in younger brains
Transference
Plasticity in response to one training
experience can enhance the acquisition
of similar behaviors
Interference

Plasticity in response to one experience
can interfere with acquisition of other
behaviors
Adapted with permission from Kleim JA, Jones TA. Principles of
experience-dependent neural plasticity: implications for rehabi­
litation after brain damage. J Speech Lang Hear Res 2008;51(1):
S225-S239.

58
Section I  Building Baseline Knowledge
is designed to provide opportunity for repeated practice
of locomotion that would not be possible in overground
walking early in rehabilitation after stroke and spinal cord
injury.291,292 TM training has the added benefit of inducing
cardiopulmonary/cardiovascular fitness, adding to overall
resources for movement available to the individual whose
CNS dysfunction may carry an associated secondary risk of
deconditioning.
Intensity is Important
In persons without brain injury, training intensity (dose,
number of repetitions, number of practice sessions) influ­
ences both degree and stability of the neuroplastic change
induced by practice.270 Both constraint-induced therapy for
upper extremity rehabilitation, and treadmill training for
recovery of locomotion are high-intensity interventions.
While the optimal “dosage” for rehabilitation intervention
is not well defined and may differ across diagnoses, it is
clear that outcomes of intervention are influenced by dose,
with high-intensity programs having the largest effect.293
Current rehabilitation practice models do not always pro­
vide the number of repetitions or dose intensity that might
be necessary to induce neural plasticity and cortical reor­
ganization.294 Much of the research on intensity of inter­
vention has involved persons who are medically stable, in
the chronic period after their neurological event. These
individuals appear to tolerate intense interventions with
little adverse consequence. What is not well understood,
however, is whether there may be sensitivity to overuse
in newly injured brains that is detrimental after a thresh­
old level of repetitions is exceeded.270,295 In the absence of
guidelines about level intensity for persons with recent CNS
insult, careful monitoring for signs of activity intolerance
of the brain and body (e.g., fatigue, irritability, distractibil­
ity, change in attention or alertness, as well as greater than
anticipated decrement in performance, among others) may
assist the therapist in keeping the intensity of intervention
within safe ranges.
Time and Timing
There are many molecular, cellular, structural, and physi­
ological contributors to the process of neuroplasticity; the
relationships and timing of changes at each of these levels
continues to be explored.270 Consolidation of motor mem­
ory, for example, requires “off-line” time after practice for
a newly learned skill to be effectively retained.281 As in
development, there may be windows of opportunity within
the typical pattern of recovery when interventions tar­
geting neuroplasticity are likely to be most effective.295,296
Delaying intervention (or providing intervention at sub­
optimal levels of intensity) may allow abnormal compen­
satory movement patterns to become established; and
rendering rehabilitation less effective.270 Certainly, there
is much more investigation needed regarding when neu­
roplasticity focused rehabilitation intervention would be
best implemented during the course of recovery following
CNS insult.
Salience is Substantial
Even a well-practiced activity will not successfully induce
neural plasticity unless it is perceived as meaningful and
important to the individual. Motivation, attention, and the
ability to learn are influenced by the relevance of and per­
ception of potential reward associated with a movement
task.297,298 Participation in rehabilitation interventions mod­
elled on motor learning in the context of neural plasticity
requires considerable investment and effort on the part of
the patient. If the goal and level of effort needed to achieve it
outweigh the perceived potential benefits or rewards of par­
ticipation, is it any wonder that little will be accomplished in
terms of skill development or facilitation of neural plasticity?
It is essential that there be discussion and, optimally, consen­
sus between the individual and the therapist about the likeli­
hood of improved functional performance at a level that the
individual perceives as valuable and important as a result of
intervention. Salience (meaningfulness) appears to impact
motor learning and recovery via the cholinergic system of the
basal forebrain.299
Considering the Life Span
While the brain is clearly most “plastic” in early life during
periods of rapid motor, perceptual, and cognitive develop­
ment, the brains of older adults continue to be responsive
to experience-driven catalysts of neural plasticity.300–302 Rich
physical, emotional, and cognitive experiences over the life
span appear to protect the older individual against decre­
ments in brain function typically thought to be the result
of aging.303,304 There are differences in the process of motor
learning and neural plasticity, however, at both ends of the
life span. Children may require longer periods of practice
and a more gradual reduction in frequency of feedback for
effective motor learning than adults to effect neuroplastic
change and consolidation of newly learned skills.305 Older
adults also require longer periods of practice and increased
number of repetitions, especially if attempting to replace
competing compensatory movement strategies after CNS
insult.306 When compared with younger adults, efficacy of the
motor learning process (and by extension, neural plasticity)
appears to be somewhat less for older adults in both acqui­
sition and retention of skilled sequential movements and
retention.307 This may be associated with age-related declines
in visuospatial working memory and of attentional focus.308
Nevertheless, older adults with stroke and other CNS dis­
eases do respond to appropriately targeted complex motor
skill training, demanding environmental contexts, and exer­
cise interventions in both acquisition and reinforcement of
skilled movement.291,309–311
Transference
Kleim and Jones270 describe transference as the ability of
plastic changes in one set of neural circuits to enhance con­
current or future neuroplastic changes in other neuronal cir­
cuits. Adding repetitive transcranial magnetic stimulation to
physical practice of salient motor skills appears to enhance
acquisition and retention of motor skills and promote more

Chapter 3  Motor Control, Motor Learning, and Neural Plasticity in Orthotic and Prosthetic Rehabilitation
59
extensive return of function during acute and chronic stages
while recovering from a stroke.312,313 Animal studies suggest
that living and functioning in complex enriched environ­
ments may also potentiate neuroplastic changes in the cortex
after brain injury.314 In humans, both enriched environments
and physical exercise appear to have a potentiating neuro­
plastic effect on the damaged brain, brainstem, cerebel­
lum, or spinal cord, contributing to angiogenesis mediated
by the release of brain-derived neurotrophic factors during
­activity.315,316 Repetitive physical activity and exercise during
rehabilitation has the potential to enhance neural plasticity,
as well as to improve muscle performance and cardiovascu­
lar/cardiopulmonary conditioning.
Interference
Just as some neuroplastic changes enable reorganization in
the process of transference, they also may block, interfere
with, or otherwise impede operation or reorganization of
other circuits, with a negative impact on the ability to learn.270
Kleim and Jones270 define interference as the ability of plas­
ticity in a particular neural circuit to impede the generation
of novel circuits or enactment of established circuits. How
does this translate into rehabilitation? The clearest example
is the detrimental impact that self-discovered compensatory
movement strategies (a neuroplastic change in which persons
with stroke have learned to move functionally using alter­
nate movement strategies) on learning more effective strate­
gies of movement during therapy.317,318 This interference has
also been demonstrated in persons with acute or chronic pain
who have learned to move in ways that avoid discomfort but
are not kinematically effective and are associated with likeli­
hood of additional dysfunction.319,320
Neuroplastic interference as described by Kleim and
Jones is a different concept than the contextual interference
that occurs during random practice discussed earlier in the
chapter as a facilitator of motor learning. Contextual interfer­
ence occurs as a result of the need to keep many options that
might solve a motor problem available in working memory
over time.174,192 The increased attentional demand associated
with contextual interference appears to augment, rather than
interfere, with the learning (and hence the neuroplastic) pro­
cess.197–199 From a motor learning perspective, neuroplastic
interference might occur if the type of practice or feedback
provided during a rehabilitation session is not appropriate
for a learner's specific needs or characteristics.321,322 Another
example of neuroplastic interference might be the impact of
learning of an additional novel complex motor task soon after
practice of a newly learned complex motor task; having little
“off-line” time may interfere with motor memory consolida­
tion of the newly learned task.323,324
Aerobic Exercise, Neuroplasticity,
and Neuroprotection
Exercise may be a rehabilitation professional's most potent
tool for facilitating neural plasticity. Fitness (aerobic) exer­
cise causes a cascade of events, at both molecular and
­cellular levels, that support the health and development of
neural ­circuits.325 This is thought to be due to the interplay
of ­central and peripheral mechanisms supporting energy
metabolism and homeostatis.326,327 During and for a short
time following a bout of aerobic exercise, the level of circulat­
ing neurotrophic factors increases, and is more available for
support of neuroplastic and neuroprotective changes in the
brain.325,328 Resistance (strengthening) exercise does not lead
to the degree of increase in neurotrophic factors that aerobic
exercise does.329 While rehabilitation professionals typically
endorse aerobic exercise as a means of building functional
capacity and activity tolerance, we may not be as aware of the
role that aerobic exercise may play in readiness of the brain
to learn. These are two powerful reasons that aerobic activity
should be included in plans of care for all persons with CNS
dysfunction, as well as any individual who must develop new
motor skills (e.g., learning to walk with a prosthesis).
Participation in treadmill training during rehabilitation
after stroke or incomplete spinal cord injury enhances motor
learning and neural plasticity in several ways: it is task-specific,
provides repetitive practice at high dosage, builds cardiovascu­
lar/cardiopulmonary fitness and (as a result) readies the brain
for functional modification of neural circuits.291,325 Aerobic fit­
ness is associated with greater neuroplasticity and better cogni­
tive performance in persons with multiple ­sclerosis.330,331 There
is growing evidence that aerobic exercise can enhance motor
performance and possibly slow progression of mobility impair­
ment in persons with Parkinson's disease.332–334 A bout of fit­
ness exercise appears to transiently improve cognitive function
in older adults, and participation in habitual cardiovascular
fitness appears to have a neuroprotective effect on cognition
and the ability to learn in later life.335–337 The neuroplastic and
neuroprotective effect of aerobic conditioning also appears to
improve or stabilize cognitive function and learning in persons
with mild cognitive impairment and dementia.338–342
Given current evidence about the ability of aerobic exercise
to potentiate and protect brain health and function, rehabili­
tation programs that fail to incorporate a fitness or condition­
ing component may miss the opportunity to enhance motor
learning and recovery of function. This applies to persons
with neurological problems, as well as those who may be
learning to use an orthosis or prosthesis as a result of neu­
romuscular and musculoskeletal impairment from trauma,
overuse, or disease.
APPLICATION: CASE EXAMPLES
The following case examples are presented as opportunities
for readers to apply the information presented in this chapter.
Readers are urged to take time to develop an appropriate plan
of care/therapeutic intervention within the framework of the
ICF Model, using the interactive person-task-­environment
(systems) framework of motor control and principles of
therapy/activity-driven neuroplasticity, in the context of the
modified version of Gentile's Taxonomy of Movement Tasks
presented in the chapter, and principles of goal-setting, prac­
tice and feedback for effective motor learning/acquisition of
skills that have been discussed.

60
Section I  Building Baseline Knowledge
Questions to Consider
The authors suggest that readers consider the following strat­
egies and questions to guide their planning.
Functional Considerations
• What tasks or activities are most appropriate or important
to address in developing a physical therapy plan of care for
the individual described in the case? (Prioritize three or
four tasks to be targeted by physical therapy intervention.)
• How can the therapist incorporate the goals and priorities of
the person into the development of goals and plan of care?
Motor Control Considerations
• What resources/buffers and impairments/constraints does
this individual bring to the situation? In what ways are
these helpful or constraining, given the person's neuro­
motor and musculoskeletal condition, cognitive and emo­
tional status, and level of fitness?
• What is the nature of the tasks that have been selected
(­stability, mobility, or quasimobility with or without
object manipulation)? What are the foundational skills
necessary to perform the task? What skills or abilities may
be difficult, given the impairments/constraints described
in the case?
• Under what environmental conditions would this indi­
vidual be best able to function at this time (closed/
predictable versus open/variable)? In what type of envi­
ronment does this individual need to be able to eventu­
ally function? How might you manipulate activities and
environmental conditions to achieve function in the real
environment?
• What is the emotional context of the environment? Can
you manipulate the emotional context to facilitate bet­
ter learning conditions? Does your patient require more
“emotional press” to problem solve with you on the task?
Does your patient require a stressful ­environmental
context to be reduced in order to have an appropriate
ready-to-learn context?
• How might you organize/prioritize a sequence of activi­
ties, using the modified Gentile's Taxonomy of Movement
Tasks (Stability/Transitional/Mobility), to prepare or prog­
ress the individual toward safe independent function in
the least restrictive environment?
Motor Learning Issues
Identify the purpose of the task trials that will be designed by
the therapist:
• Is this a task that needs to be acquired (or reacquired post-
amputation or post-incidence) or is this a task that needs
to be refined?
• In what stage of motor learning is the individual as related
to the above defined task?
• Does the individual have an understanding or familiarity
with the task, or is it completely novel?
• Is current task performance sufficient for the task to be
functional?
• Is performance efficient or optimal?
• Is performance automated or variable? Can the individual
use a variety of multiple motor strategies to accomplish or
address this task?
• Can the person respond to changing environmental
variables or task demands that warrant adaptability in
performance?
• Can this task be broken into discrete parts? Would it be
better to practice the task as a whole? Why or why not?
• Is performance of a particular part of the task problematic
(mechanics of the task, fluidity between the components
of the task)?
• Is performance of the task as a whole problematic (com­
pletion, speed, endurance)?
On the basis of your thoughts about the task trials, identify the
best practice conditions for achieving the desired outcome:
• Is the primary goal of practice retention of motor behavior
across practice sessions or improving performance within a
practice session?
• Which practice condition or combination of practice con­
ditions (blocked, random, or serial; massed or distributed;
part- or whole-task training) would you use to assist reten­
tion of the skill? Why have you chosen these strategies?
• Which practice condition or combination of practice con­
ditions (blocked, random, or serial; massed or distributed;
part- or whole-task training) would assist improved per­
formance? Why have you chosen these strategies?
• How might contextual interference influence the learning
process?
• What type of augmented information should be included
during practice of the tasks to achieve the desired
outcome?
• What modes of information should be used for this indi­
vidual (visual cues and demonstration, verbal prompting,
physical prompt/facilitation)? Why has this augmented
information strategy or combination of strategies been
selected?
• What effect will the information have on the client's ability
to recognize errors and self-correct motor behavior?
• What delivery scheme (KR or KP) should be used to pro­
vide augmented feedback?
• What is the anticipated effect of the selected delivery
scheme (KR or KP) on retention versus performance of
the motor skill being targeted?
• Can visual imagery or mental practice enhance the perfor­
mance? What images would a rehabilitation professional
want the client to visualize? What effect will imagery have
on performance and on retention of the motor skill?
• What components can the client practice mentally? What
effect will mental practice have on performance and on
retention of the motor skill?
• How can the therapist incorporate understanding of neu­
ral plasticity into goal-directed activity and intervention?
What aspects of the task are most vulnerable to degradation
associated with learned non-use?
• How do activities and tasks included in the plan of care
solidify the desired neuroplastic changes to enhance
recovery of function?

Chapter 3  Motor Control, Motor Learning, and Neural Plasticity in Orthotic and Prosthetic Rehabilitation
61
• Are the activities and tasks included in the plan of care
sufficient in repetition and intensity to influence neural
plasticity?
• What evidence is available to guide decisions about
potential windows of opportunity to time intervention
for optimal neuroplastic effect in patients with similar
diagnoses?
• Are the activities and tasks included in the plan of care
important (salient) and meaningful to the patient, so
that both experience- and motor learning–related neural
­plasticity is likely to occur?
• How should the plan of care be influenced by the age of the
patient, in terms of facilitation of motor learning and neu­
ral plasticity?
• What additional medical interventions, environmental
conditions, or principles of exercise can potentiate motor
learning and neural plasticity for recovery of function?
• Are there other factors or activities that may interfere with
effective motor learning and neural plasticity for recovery
of function? How might the plan of care be modified to
reduce the influence of these interfering factors?
SUMMARY
This chapter explores the concepts that shape current under­
standing of human motor control, focusing on the dynamic
and adaptive characteristics of the body as a biological sys­
tem. Rehabilitation professionals use their understanding of
(1) an individual's resources and characteristics, (2) envi­
ronmental conditions, and (3) the nature and constraints of
functional tasks to develop appropriate interventions aimed
at improving or adapting individuals’ abilities to move effec­
tively, in ways that are safe and efficient, to accomplish what
is important for them to do.
The chapter also considers the process of motor learn­
ing, the ways in which individuals come to understand and
approach a novel task or adapt a familiar task in differing
environmental conditions or following injury or illness that
changes personal resources. Using their understanding of
the stages of motor learning, the purpose of augmented
information, types and timing of feedback/feedforward
information, and types of practice conditions and other
factors that enhance motor learning, physical therapists
and other rehabilitation professionals can construct inter­
ventions that will effectively enhance retention of motor
learning or refine performance for persons with movement
dysfunction.
The chapter concludes with a discussion of the emerging
field of neuroplasticity, which links recovery of motor control
and motor learning, considering rehabilitation as a mecha­
nism to trigger neural plasticity and recovery of function
after insult or injury to the CNS. As understanding of neuro­
plasticity grows, rehabilitation professionals must reevaluate
whether the interventions designed to enhance motor learn­
ing are sufficient to also drive neural plasticity and recovery
of function for persons recovering from events and diseases
that impact the structure and function of the brain.
CASE EXAMPLE 1
Adult with Right Hemiparesis Who Is Learning
to Use an Ankle-Foot Orthosis and Ambulatory
Assistive Device
A. F. is a slightly obese 78-year-old African-American woman
with a history of type 2 diabetes mellitus who had an ischemic
stroke of the L middle cerebral artery 3 weeks ago. A computed
tomography scan revealed a lacunar-shaped infarct from an
embolic occlusion of a deep branch of the middle cerebral
artery serving the internal capsule. A. F. was recently trans­
ferred to a skilled nursing facility for rehabilitation, particularly
to address transfers and ambulation. She had just received a
prefabricated solid ankle AFO before her arrival. She says that
the brace is intended to help control her “bad knee” and “lazy
foot” position so she can walk better. She has not had much
opportunity to use the orthosis and is concerned that it may
actually make it more difficult for her to walk. She indicates
that she prefers to use a rolling walker, although her therapist
in the hospital insisted she use a straight cane.
Chart review, interview, and physical therapy examina­
tion reveal the following:
• Psychosocial: A. F. lives alone in a two-story walk-up
apartment. Her immediate family lives out of state. She
retired 10 years ago from a position as a legal secretary
and is heavily involved in the outreach ministry of her
evangelical church.
• Baseline vital signs: heart rate: 82 beats per minute; blood
pressure: 132/94 mmHg; respiratory rate: 16 breaths
per minute.
• Cognitive status: alert and oriented times 3.
• Communication: some slurring of words; has trouble
finding the words she wants to say, but comprehension
appears intact.
• Vision: intact; typically wears trifocals.
• Sensory system: cranial nerves intact, normal responses
to light touch, pin prick, proprioception all extremities.
• Neuromotor status:
• Tone: moderate spasticity of right (R) upper extrem­
ity (UE) and lower extremity (LE); 1+ on the
Modified Ashworth Scale.
• Range of motion (ROM): Passive ROM within nor­
mal limits for all extremities.
• Strength: L extremities 4+/5 throughout.
• R UE: shoulder elevation 2+/5; hand grip 2/5; elbow
flexion 2/5; R LE: function strength grades include
ankle pf 3/5; ankle dorsiflexion 1/5; knee extension
2+/5; knee flexion 3/5; hip flexion 3/5; hip extension
3/5; hip abduction 3/5; and hip adduction 3+/5.
• Postural control: able to sit upright against gravity,
asymmetrical weight distribution with more weight
borne on left side. Anticipatory posture changes are
adequate when reaching toward right, inadequate
when reaching toward left. Stands with supervision;
requires verbal and tactile cues to bear weight on R LE.
Continued

62
Section I  Building Baseline Knowledge
• Functional activities: rolls independently to both sides;
supine to sit over edge of bed with supervision; trans­
fers from bed to wheelchair with supervision; sit to
stand transitions with supervision.
• Ambulation: uses straight cane with moderate assist,
requiring both verbal cueing and physical prompt to
improve loading response on right leg and to minimize
genu recurvatum during forward advancement over
right foot.
Design a physical therapy plan of care that will focus
on development of motor skills necessary for safe and effi­
cient locomotion using the AFO and straight cane.
CASE EXAMPLE 2
Child with Cerebral Palsy Who Has Just Received
New (Bilateral) Articulating Ankle-Foot Orthoses
T. D. is a delightful 2½-year-old-boy with cerebral palsy
with moderate severity spastic diplegia. He was born pre­
maturely at 27 weeks’ gestation and remained in the neo­
natal intensive care unit for 10 weeks. By the time he was
18 months old, there were increasing indications of devel­
opmental delay and abnormal motor control. He currently
attends an early intervention program (EIP), receives indi­
vidual home visits from a physical therapist, and attends
a therapeutic play group run by an educator and occupa­
tional therapist weekly.
EIP examination findings include the following:
• Social: T. D. lives with both parents and an older
brother in a two-story, single-family home. He inter­
acts well with his family members and is on target for
social development. He plays side by side with peers
and occasionally interacts with them appropriately.
• Cognition: T. D. scores age appropriately for cogni­
tive tasks including cause and effect, object perma­
nence, means to end, early numeration, and sorting by
categories. His play with objects includes variety and
imagination.
• Language: T. D.'s comprehension, expression, and prag­
matic use of language are on target for his age. He has
an extensive vocabulary and uses language appropri­
ately in various situations.
• Fine motor/ADLs: T. D.'s reach, grasp, and release skills
are within the age-expected range. Bimanual skills and
object manipulation are also on target. Feeding skills
are appropriate; T. D. uses utensils and drinks from
a cup as expected for his age. His dressing skills are
slightly below age expectations largely due to balance
concerns in standing for putting on pants.
• Gross motor: T. D.'s gross motor skills fall below age
expectations. He has been walking independently with
bilateral solid ankle-foot orthoses (AFOs) for 6 months.
He can walk on multiple terrains including tile or wood
floors, carpets, grass, asphalt, and woodchips. He has
some difficulty with stairs, requiring a railing or one
hand held. Tripping and falling are issues with increas­
ing speeds during ambulation and with attempts at run­
ning. T. D.'s mother is most concerned about his safety
in ambulation at this point.
T. D. was having increasing difficulty with squatting
and transitions into and out of standing from the floor.
When discussing the problem, the rehabilitation team
decided that articulating AFOs would increase the avail­
ability of ankle range of motion for these transition tasks.
T. D. just received bilateral articulating AFOs with a plan­
tar flexion stop set at 10 degrees. He is currently having
trouble descending stairs in the new orthoses, refusing
to go down stairs unless both hands are held. He also has
increased frequency of tripping outside while ambulating
on the grass and rock driveway at home.
Design a physical therapy plan of care to help him mas­
ter locomotion and transitional activities with the less-
constraining articulating AFOs in the environments of a
typical 2½-year-old.
CASE EXAMPLE 3
Child with Congenital Upper Limb Deficiency
Learning to Use a Myoelectric Prosthesis
T. L. is a 3-year-old girl who has had a congenital right upper
extremity limb deficiency since birth. She has an intact
humerus and musculature of the upper limb with a func­
tional elbow joint. Her forearm is incomplete with a short­
ened ulna, missing radius, and no wrist or hand complex.
T. L. has been wearing a prosthesis with a passive terminal
device since she was 6 months old and uses her prosthesis
well in mobility tasks and to stabilize objects against her
body or a support surface during bimanual activities. T. L.
began a preschool program 2 months ago and has adjusted
well to socialization. She engages in play with her peers
appropriately. She has good functional use of her left upper
extremity (intact limb) and uses the residual limb to assist
herself in tasks, particularly for stabilizing objects.
T. L. has been working with her prosthetist and ther­
apists to learn to use a two-channel (voluntary closing/
voluntary opening) myoelectrically controlled terminal
device for the past 2 weeks. When she wears the myo­
electric prosthesis throughout the day, she primarily
uses it as she did her previous passive prosthesis. She has
not attempted to use the “hand” for play or ADLs unless
prompted by her parents or therapists. During her therapy
sessions, she is intrigued with her new ability to open and
close her “hand” but is inconsistent in controlling force of
grasp and has difficulty initiating release. In today's ses­
sion, she practiced picking up 1-inch blocks and placing
them in a bowl, achieving the desired result in two of five
trials. She was unsuccessful (and became frustrated) at

Chapter 3  Motor Control, Motor Learning, and Neural Plasticity in Orthotic and Prosthetic Rehabilitation
63
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picking up pegs that were much narrower than the blocks.
The rehabilitation team's goals for T. L. include functional
use of the prosthesis for grasp and release of household
objects for feeding and self-care and school objects for
play and participation in preschool activities. The team
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Design a rehabilitation plan of care to help T. L. master
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CASE EXAMPLE 4
Adolescent with Transtibial Amputation Working
on Returning to Competition in Track Events
W. P. is a 16-year-old junior in high school who has been
a star track athlete since he was a freshman. He currently
holds his high school records in the 100-meter and 200-
meter events, which he achieved during his sophomore
year. He also finished third in the state championships that
same year.
Three months ago during the summer, W. P. was seri­
ously injured when the garden tractor/lawnmower he was
operating rolled over and down an embankment as he was
making a fast turn while mowing the lawn. He sustained
deep lacerations to his right foot and lower leg from the
mower's blade, as well as third-degree burns from the muf­
fler. His injured limb was pinned under the tractor in a pile
of leaves and debris. In the emergency department, trauma
surgeons thought he did not meet criteria for limb sal­
vage and performed a long, open transtibial amputation.
After an intensive course of antibiotics, W. P. returned to
the operating room 1 week later for closure to the stan­
dard transtibial level, with equal anterior/posterior flaps.
When his residual limb healed without difficulty, W. P. was
fit with a patellar tendon–bearing prosthesis, with a sleeve
and pin suspension, and a Seattle Systems, Inc., dynamic
response foot. He quickly mastered ambulation without an
assistive device and returned to school in the winter of his
junior year.
W. P. is eager to return to track for his senior year.
His prosthetist has fabricated a special prosthesis for
him to wear in competition, an Otto Bock Healthcare
Sprinter prosthetic foot designed for track and field ath­
letes. He has begun training for his events and is pleased
that he can run again. He has two goals: to decrease his
performance time (hoping to meet the records he set
last year) and to become much more efficient at leaving
the starting block. He wants to master the new prosthe­
sis this year so he can concentrate on conditioning for
his senior year.
Develop a prosthetic training regimen focusing on
improving his performance as he prepares to return to
track competition.

64
Section I  Building Baseline Knowledge
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318. Fregni F, Pascual-Leone A. Hand motor recovery after stroke:
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319. van Vliet PM, Heneghan NR. Motor control and the man­
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72
4
An Evidence-Based Approach to Orthotic and Prosthetic
Rehabilitation
Kevin Chui, Rita A. Wong, and Michelle M. Lusardi
WHAT IS EVIDENCE-BASED PRACTICE?
Providing effective health and rehabilitative care requires that
practitioners be well informed about advances in assessment,
medical management, technology, theory, and rehabilitation
interventions. Relying on past experience or on the opinion
of experts is not enough. An effective health care provider
must also regularly update his or her knowledge base by
accessing the ever-growing information generated by clinical
researchers and their basic science colleagues.1 Providers in
all health care disciplines face a number of challenges, how­
ever, in efficiently and accurately locating, appraising, and
applying scientific evidence in the midst of their increasingly
hectic clinical practice schedules.2–4 Health care providers
who routinely use such skills and strategies demonstrate an
evidence-based approach to patient care. This chapter pro­
vides guidance to the practitioner in overcoming these chal­
lenges to engaging in evidence-based practice (EBP).
David Sackett, MD, the father of evidence-based medicine,
described this approach as the “integration of best research
evidence with clinical expertise and patient values.”4 EBP is
a broader concept that applies Sackett's physician-oriented
concepts to a wide range of health professions.4 Both mod­
els identify three major elements of evidence that are interac­
tive and valuable, as well as a set of skills necessary to integrate
each resource into an effective and informed clinical decision
(Figure 4-1). The three major elements are the following:
1. Best available information from up-to-date, clinically
­relevant research
2. The skilled and experienced practitioner who can accu­
rately perform diagnostic procedures and interventions,
integrate findings to efficiently determine correct diagno­
sis, and engage in reflective clinical practice
3. The integration of the patient's and family's issues, con­
cerns, and hopes into the care plan
All three elements are equally important for an effective
clinical decision making process; optimal health care out­
comes are grounded on integration of perspectives and pri­
orities that each source of information brings to bear.
To make an informed clinical decision, the evidence-based
rehabilitation professional must possess the skills to do the
following:
1. Effectively search for and access relevant scientific evi­
dence in the professional literature.5
2. Assess the strength and value of the scientific evidence
that will support the decision to be made.6
3. Apply results of an accurate clinical examination, as well as
the evidence from the literature, in the process of diagno­
sis, evaluation, prognosis, and development of an appro­
priate plan of care.7
4. Assess and incorporate the patient's or client's values,
knowledge, preferences, and motivation into the interven­
tion and anticipated outcomes.8
THE PROCESS OF EVIDENCE-BASED
PRACTICE
EBP is essentially an orientation to clinical decision making
that incorporates the best available sources of evidence into
the process of assessment, intervention planning, and evalu­
ation of outcomes. The skill set necessary for effective EBP
develops over time, with practice and experience.
4
LEARNING OBJECTIVES
On completion of this chapter, the reader will be able to do
the following:
1. Describe the basic principles of evidence-based prac­
tice and apply these principles to orthotic and prosthetic
rehabilitation.
2. Ask well-formulated, clearly defined, and clinically
important questions applicable to orthotic and prosthetic
rehabilitation.
3. Efficiently locate meaningful research specific to orthotic
and prosthetic rehabilitation.
4. Critically appraise the evidence for validity and clinical
importance.
5. Use the orthotic and prosthetic research evidence to
make evidence-based clinical judgments that affect your
practice.
6. Describe strategies to encourage practitioners to engage
in greater use of evidence to inform their clinical decision
making and thus practice.

Chapter 4  An Evidence-Based Approach to Orthotic and Prosthetic Rehabilitation
73
An EBP approach to the scientific literature is a systematic
process with four primary steps1,4,9:
1. Posing a well-formulated, clinically important question
2. Locating meaningful research that is well targeted to the ques­
tion (i.e., developing effective and efficient search strategies)
3. Critically appraising the available evidence for validity and
clinical importance
4. Using the findings to make an evidence-based clini­
cal judgment about examination or intervention options
on the basis of the clinical relevance of the information
applied to the needs of the individual patient
STEP 1: FORMULATING AN ANSWERABLE
CLINICAL QUESTION
The questions posed by researchers and the questions posed
by clinicians, while similar in many respects, are asked and
answered at quite different levels. Research questions combine
information from groups (samples) of individuals to develop
evidence about relationships among characteristics, effective­
ness of examination strategies, or effectiveness of interven­
tion strategies for the group as a whole.10 In contrast, clinical
questions seek to apply this knowledge to a single person
with individual characteristics.4,5,9 For example, clinicians ask,
“Which examination strategy will provide the information
most important for the clinical decision-making process for
this particular individual?” and “Which intervention is likely
to have the optimal outcome for this particular individual?”
The first essential step in the EBP process is developing
a well-formulated, clinically important question. Sackett
identifies two categories of clinical questions: broad back­
ground questions and specifically focused foreground ques­
tions.4 Background questions expand our knowledge or
understanding of a disorder, impairment, or functional lim­
itation; they are often concerned with etiology, diagnosis,
prognosis, or typical clinical course. Patients and their fam­
ily members often ask health care practitioners background
questions. Answers to background questions expand the
general knowledge base used in clinical decision making.
Students and novice clinicians ask many background ques­
tions as they develop expertise in their field. Even expert cli­
nicians routinely need to seek answers to basic background
questions when they encounter an unfamiliar pathology
or novel category of intervention. Answers to background
questions do not, however, provide the specific evidence
necessary to make individualized patient care decisions.
Examples of broad background questions that might be
asked by clinicians providing prosthetic and orthotic reha­
bilitation care include the following:
• What is the typical postsurgical rehabilitation program
following a dysvascular transtibial amputation?
• What is peripheral arterial disease and why can it lead to
limb amputation?
• What neurological functions are affected with a C7 spinal
cord injury?
• What are the typical motor milestones of the first two years
of life, and when is the achievement of these milestones
considered delayed?
Foreground questions, in contrast, seek specific information
to help guide management for an individual patient.4,5,9 The
most effective way to frame an answerable foreground clinical
question follows the “PICO” model (Figure 4-2). It identifies
the patient population of interest (P), noting specific charac­
teristics (e.g., age, gender, diagnosis, acuity, severity) that will
link the evidence to the patient care situation prompting the
question. It then identifies the predictive factor, examination,
or intervention (I) that is being considered. If appropriate, it
Clinical judgment
“Best” external
evidence
Patient values &
perspectives
Effective clinical decisions
Reflective practice
Skill
Experience
Interpreting
Educating
Negotiating goals
Ask a clinical question
Search for evidence
Appraise the evidence
Integration & application
FIGURE 4-1  Model of three essential and interactive components
necessary for effective evidence-based health care approach to guide
clinical decision making, as well as the dimensions of each.
P Patient Patient diagnostic category or key
char acteristic
I Intervention Treatment group, or diagnostic tool,
or prognostic marker
C Comparison Applicable if comparison is wanted between
or among interventions, diagnostic tools, or
prognostic markers
O Outcome What is the outcome of interest: presence or
absence of disease? impairment? functional
limitation? of disability?
FIGURE 4-2  The PICO system for formulating clinical questions
includes consideration of the patient (P) who is receiving care; the
intervention (I) being considered; and, if available, the “gold stan­
dard” it is being compared with (C) and the anticipated outcomes
(O) (positive and negative) of the intervention being considered.

74
Section I  Building Baseline Knowledge
­identifies what comparisons (C) are being made to inform
choice of examination or intervention. Finally, it clearly defines
the outcomes (O) that might be expected for the given patient
on the basis of the best available evidence. Using the PICO
model, foreground questions that rehabilitation profession­
als might ask as they care for a specific individual in need of a
prosthesis or orthosis include the following:
• How much does advanced age (I) affect the ability to
become a functional ambulator (O) in an individual who
has a dysvascular transtibial amputation (P)?
• Does supported treadmill gait training (I) improve ambu­
lation endurance with a prosthesis (O) in older patients
with dysvascular transtibial amputation (P)?
• Does the addition of functional neuromuscular stimula­
tion (I) to a typical early rehabilitation intervention (C)
enhance active muscle control (O) in individuals with
incomplete spinal cord injury (P)?
• What factors predict (I) ambulation ability (O) in a young
child with spastic diplegic cerebral palsy (P)?
Patient Characteristics (P)
A well-focused clinical question narrows the scope of possi­
ble patient characteristics to ones most applicable to a specific
clinical problem or situation.4,9 It defines the key characteris­
tics that will best differentially guide the search for evidence.
Characteristics or categories that help focus a clinical question
related to orthotic or prosthetic management are summarized
in Table 4-1.
Intervention (I)
The term intervention is used broadly in the evidence-based
literature. In the EBP paradigm the intervention (I) and com­
parison intervention (C), described according to the PICO
system, refer to the central issue for which the clinician is
seeking an answer. This issue can typically revolve around an
intervention, a diagnosis, or a prognosis.
1. Intervention: a procedure or technique (e.g., a physical
modality, surgical procedure, medication) (I) that is com­
pared with alternative procedures or techniques (C).11,12
2. Diagnostic test: a test or measure (e.g., a bone mineral den­
sity test for identification of osteoporosis; the Berg Balance
Scale for identification of fall risk) (I) that correctly differen­
tiates patients with and without a specific condition (C).13,14
3. Prognostic marker: a specific set of characteristics or fac­
tors (I) that effectively predicts an outcome (O) for a given
patient problem (P).15
Defining the Outcome (O)
A good clinical question focuses on the outcome that is
most relevant to the patient care situation at hand. The Nagi
model of disablement or the World Health Organization
International Classification of Function (ICF) model pro­
vide frameworks for clinicians to define the outcome they are
most interested in: pathology or disease at the cellular level,
impairment of a physiological system, functional limitation at
the level of the individual, or disability or handicap that inter­
feres with the normal social role16,17 (see Figure 1-3).
CASE EXAMPLE 1
An Elderly Woman with Recent Transtibial Amputation
F. H. is an 89-year-old woman who had an elective transtib­
ial amputation 4 days prior, due to peripheral arterial disease
(PAD) unrelated to diabetes. Her postoperative pain is being
managed with a narcotic, and she has been mildly disoriented
and distractible during rehabilitation visits. At present she
requires moderate assistance in rising to standing and min­
imal assistance and directive cues to ambulate in a “hop to”
pattern with a rolling walker. Her medical history includes
mild congestive heart failure managed effectively with diuret­
ics, hypertension managed effectively with beta-blockers, and
a compression fracture (2 years ago) of the midthoracic spine
secondary to osteoporosis. She recently had lens implants for
cataracts. Before her hospitalization, she lived somewhat inde­
pendently in an assisted living complex, walking long func­
tional distances within the sprawling facility using a straight
cane and eating her noon and evening meals in the communal
dining room. She served as vice-chair of the Resident Council,
and was the organizer of an active bridge club and book dis­
cussion group. Her nearest living relative is a granddaughter
who is finishing medical residency at the hospital.
The amputation/prosthetic clinic team has been
charged with developing a plan for prosthetic rehabilita­
tion, including determining her potential for prosthetic
use, the optimal setting for rehabilitation intervention,
the likely duration of rehabilitative care, and preliminary
prosthetic prescription.
Questions to Consider
Possible clinical questions that the team would ask in order
to guide her plan of care include the following:
• Which strategies (pharmacological and nonpharmaco­
logical) for postamputation pain management (I, C) will
minimize risk of delirium and assist motor and cognitive
learning (O) in elderly individuals with multiple comor­
bidities (P)?
• Which functional and cognitive characteristics (I) pro­
vide the best indication of potential for prosthetic use
(O) in elderly individuals with multiple comorbidities?
• What intrinsic and extrinsic factors (I) influence the
duration of preprosthetic and prosthetic care (O) for
older adults with recent transtibial amputation (P)?
• Which prosthetic foot option (nonarticulating, articulat­
ing, or dynamic response) (C, I) and suspension system
­(silicone suspension sleeve with pin, supracondylar cuff,
waist belt, and forked-strap extension aid) (C, I) would
maximize potential for safe community ambulation (O) in
older patients with transtibial amputation, impaired pos­
tural ­control, and limited cardiovascular endurance (P)?

TABLE 4-1  Patient Characteristics that may be Used to Help Focus Literature Searches for Prosthetic and Orthotic
Rehabilitation
Domain
Characteristics
Search Terms
Underlying condition
Etiology
Acquired (traumatic injury, infectious process, autoimmune
disease, ischemia, vascular disease, neoplasm, cancer)
Congenital condition
Developmental delay
Hereditary disease
Systems affected
Musculoskeletal
Neuromuscular
Cardiovascular
Pulmonary, respiratory
Integumentary
Endocrine
Systemic physiological
Nature of condition
Chronic
Progressive
Degenerative
Developmental
Requiring remediation
Requiring accommodation
Comorbid conditions
Peripheral vascular disease
Diabetes mellitus
Systemic infections
Cancer care, chemotherapy, radiation
Heart disease
Pulmonary disease
Obesity
Depression, anxiety
Cognitive dysfunction
Smoking
Confounding factors
Alcohol use
Other substance abuse
Nutritional status
Family and lifespan development
Age category
Infant
Toddler
School-age child
Adolescent
Young adult
Midlife adult
Older adult
Family system
Roles
Responsibilities
Caregiver
Fitness/conditioning
Level of activity
Frail
Sedentary
Active
Elite athlete
Mobility
Use of assistive device
None
Ambulatory aid (cane, crutch, walker)
Wheelchair
Adaptive equipment
Requiring human assistance
Environmental issues






Environment
School
Home
Work
Leisure
Accessible/inaccessible
Living arrangements

Community dwelling (alone, independent, with caregivers or family)
Assisted living setting
Skilled nursing

76
Section I  Building Baseline Knowledge
CASE EXAMPLE 2
A Young Adult with Incomplete Spinal Cord Injury
S. K. is a 19-year-old with incomplete C7 level spinal cord
injury who has just been admitted to the rehabilitation
facility, 2 weeks after injury. S. K. was a backseat passenger
injured in a driving-under-the-influence motor vehicle acci­
dent following a Thanksgiving homecoming football game
victory at his high school. He was unconscious at the scene
and for several hours afterward. He was given methylpred­
nisolone in the emergency department 2 hours after injury.
Radiographs revealed an anterior wedge fracture of C6 ver­
tebra. After intubation, he was admitted to the neurologi­
cal intensive care unit; 2 days later he had surgical fusion
of C4 through C8, with immobilization in a cervical halo.
During the postoperative period, pneumonia developed, has
since resolved. Sensation is intact in all sacral and lumbar
3 to 5 dermatomes, and he has 2/5 strength in dorsiflexion
and plantar flexion bilaterally, with hyperactive deep ten­
don reflex at the knee. He can tolerate sitting in a bedside
recliner or high-back reclining wheelchair for approximately
45 minutes. He is anxious to know whether he will be able to
walk again, and although frightened by what has occurred,
appears to be motivated to begin his rehabilitation.
Before his injury, S. K. lived at home while attending a
nearby state university as a biology major. His intention was
to eventually apply to medical school to become an orthope­
dic surgeon. His parents and younger sister are involved in
his care; a family member is with him for most of the day. He
has a cousin, now in law school, who was born with spina
bifida and uses a wheelchair for primary mobility.
Questions to Consider
Possible clinical questions that the team might ask to guide
his plan of care might include the following:
• What are the most powerful indicators (I) of potential
for return to functional ambulation (O) in patients with
incomplete cervical spinal cord injury (P)?
• Which physical therapy interventions (I, C) will best
improve functional lower extremity strength (O) in
patients with incomplete cervical spinal cord injury who
are immobilized in a cervical halo (P)?
• What strategies (pharmacological and nonpharmaco­
logical) (I, C) are effective in managing abnormal tone
without compromising potential for strengthening (O) in
patients with incomplete cervical spinal cord injury (P)?
• Will functional neuromuscular stimulation (I) reduce
orthotic need and improve quality of gait (O) in patients
with incomplete cervical spinal cord injury (P)?
CASE EXAMPLE 3
A Toddler with Spastic Diplegic Cerebral Palsy
E. C. is an 18-month-old with spastic diplegic cerebral palsy
being cared for by an interdisciplinary early intervention
team. E. C. was born prematurely at 34 weeks of gestation
after her mom's high-risk first pregnancy. Her course in
the neonatal intensive care unit was relatively uneventful:
She did not require ventilatory assistance but did have peri­
odic episodes of apnea and bradycardia until she reached a
weight of 4 lb. She was discharged to home at 3 weeks of age
and appeared to be developing fairly typically until about
8 or 9 months of age. Her parents noted increasing “stiff­
ness” of her lower extremities when in supported stand­
ing, a tendency toward “bunny hop” rather than reciprocal
creeping, and overreliance on upper extremities to pull to
stand (as compared with her cousins and babies in her play­
group). Her pediatrician referred the family to a pediatric
neurologist, who found mild to moderate hyperreflexia and
decorticate pattern hypertonicity in her lower extremi­
ties. She has been followed in the early intervention pro­
gram for 7 months; the team is charged with determining
whether this is an appropriate time for orthotic interven­
tion, because she is ready to begin gait training.
Questions to Consider
Questions that might be asked to guide her plan of care
include the following:
• What are the minimal levels of muscle performance
and range of motion at the hip and knee (I) necessary
for effective ambulation with an articulating ankle-foot
orthosis (AFO) (O) in children with spastic diplegic
cerebral palsy (P)?
• Which type of therapeutic activity or approach (e.g., neu­
rodevelopmental [NDT], sensory integration, proprio­
ceptive neuromuscular facilitation [PNF]) (I) is most
effective in assisting dynamic postural control of the
lower trunk and lower extremities during transitional
and locomotor tasks (O) in children with spastic diplegic
cerebral palsy (P)?
• What accommodations or adaptations of the home envi­
ronment (I) will best assist safety, as well as develop­
mental progression (O), in children with spastic diplegic
cerebral palsy (P)?

Chapter 4  An Evidence-Based Approach to Orthotic and Prosthetic Rehabilitation
77
STEP 2: LOCATING AND ACCESSING
THE BEST EVIDENCE
Once the clinical question has been clearly identified and
articulated, the next step is to search the rehabilitation
research literature for relevant information. The second step
is to access full text articles, access their quality, and read
those might that inform decision making .18–21 Among the
many ways to find citations and (hopefully) the full text of the
article are the following:
• Regularly visit key journal websites to review what has
been recently published or published ahead of print
that might be relevant to the question. The Journal of
Prosthetics and Orthotics (), for
example, allows full access to any journal article published
in the years previous to the current year. This strategy can
be somewhat “hit or miss” in terms of effectiveness.
• Use the index in the back of up-to-date textbooks as a reli­
able secondary source of information; this can be espe­
cially useful to answer background questions.
• Use an Internet search engine such as Google.scholar
( free access), which provides
both unjuried and juried resources and requires the abil­
ity to carefully assess the quality of the source and of the
information that has been located.
• Use electronic databases of peer-reviewed journals such as
PubMed/Medline/OVID (
free access ), or the Physiotherapy Evidence Database (PEDro;
free access) using appropriate key words.
Professional organizations such as the American Physical Therapy
Association provide links to search engines (
org/OpenDoor), abstracted article reviews (
hookedonevidence.org) or synthesized evidence (
apta.org/PTNow) for organization members. Many medical
libraries maintain subscriptions to multiple medical ­databases
through services such as EBSCO (
com/­biomedical-libraries; subscription access) or ProQuest
(
detail/pq_health_med_comp.shtml), among others.
• Subscribe to online Table of Content (eTOC) alerts from
research journals relevant to their practice areas. For
­example, the Physical Therapy Journal (
org/site/subscriptions/etoc.xhtml), the Journal of Geriatric
Physical Therapy (), the Journal of Neurologic
Physical (), Clinical Biomechanics (
clinbiomech.com/user/alerts), and the Archives of Physical
Medicine and Rehabilitation (
user/alerts/savetocalert), among many others will send table
of contents for current issues to email, cell phone, iPads,
e-readers, and other devices.
Each strategy has pros and cons in terms of efficiency and
availability. Health professionals who use an evidence-based
approach to patient care develop, over time, an information
seeking strategy that works within their time constraints and
accessible resources.22–24
Sources of Evidence
Clinicians can access information from the research literature
in a variety of formats and from a variety of sources. One of
the most accessible formats is a journal article.25,26 Table 4-2
provides a list of the journals particularly relevant to orthotic
and prosthetic rehabilitation. These journals often contain
original clinical research, reviews of the literature, and case
reports focused on issues most relevant to the particular pro­
fessional group.
The medical literature is divided into primary and second­
ary sources of information. Primary sources are the reports
of original scientific work, commonly published as journal
articles. Secondary sources are summary reviews of the pri­
mary literature on given topics. Secondary sources include
textbooks, review articles, systematic reviews such as meta-
analyses, critical reviews of individual articles, clinical prac­
tice guidelines, and website summaries. Research studies
are the foundation of meaningful evidence. Academic text­
books, biomedical journals, and Internet websites aimed at
health professionals and biomedical researchers are common
sources of research evidence.
TABLE 4-2  Journals Relevant to Orthotic and Prosthetic Rehabilitation
Journal Title
Abbreviation
American Journal of Occupational Therapy
Am J Occup Ther
American Journal of Physical Medicine & Rehabilitation
Am J Phys Med Rehabil
American Journal of Podiatric Medicine
Am J Podiatr Med
American Journal of Surgery
Am J Surg
American Rehabilitation
Am Rehabil
Annals of Physical Medicine
Ann Phys Med
Archives of Neurology
Arch Neurol
Archives of Physical Medicine and Rehabilitation
Arch Phys Med Rehabil
Archives of Surgery
Arch Surg
Assistive Technology
Assist Tech
Athletic Training
Athletic Training
Australian Journal of Physical Therapy
Aust J Physiother
(Continued)

78
Section I  Building Baseline Knowledge
Journal Title
Abbreviation
Biomechanics
Biomechanics
British Journal of Sports Medicine
Br J Sports Med
Bulletin of Prosthetic Research
Bull Prosthet Res
Canadian Journal of Occupational Therapy
Can J Occup Ther
Clinical Biomechanics
Clin Biomech
Clinics in Orthopedics and Related Research
Clin Orthop Rel Res
Clinics in Podiatric Medicine and Surgery
Clin Podiatr Med Surg
Clinics in Prosthetics and Orthotics
Clin Prosthet Orthot
Developmental Medicine & Child Neurology
Dev Med Child Neurol
Diabetes Care
Diabetes Care
Diabetic Foot
Diabe Foot
Diabetic Medicine
Diabe Med
Disability and Rehabilitation
Disabil Rehabil
Foot and Ankle Clinics
Foot Ankle Clin
Foot and Ankle International
Foot Ankle Int
Gait and Posture
Gait Posture
Interdisciplinary Science Reviews
Interdisc Sci Rev
International Journal of Rehabilitation Research
Int J Rehabil Res
Journal of Allied Health
J Allied Health
Journal of Applied Biomechanics
J Appl Biomech
Journal of Biomechanical Engineering
J Biomech Eng
Journal of Biomechanics
J Biomech
Journal of Bone and Joint Surgery
J Bone Joint Surg
Journal of Geriatric Physical Therapy
J Geriatr Phys Ther
Journal of Head Trauma and Rehabilitation
J Head Trauma Rehabil
Journal of Medical Engineering and Technology
J Med Eng Tech
Journal of Musculoskeletal Medicine
J Musculoskel Med
Journal of Neurologic Physical Therapy
J Neuro Phys Ther
Journal of Orthopaedic and Sports Physical Therapy
J Orthop Sports Phys Ther
Journal of Pediatric Orthopedics
J Pediatr Orthop
Journal of Prosthetics and Orthotics
J Prosthet Orthot
Journal of Rehabilitation
J Rehabil
Journal of Rehabilitation Medicine
J Rehabil Med
Journal of Rehabilitation Research and Development
J Rehabil Res Dev
Journal of Spinal Disorders
J Spinal Disord
Journal of the American Geriatrics Society
J Am Geriatr Soc
Journal of the American Medical Association
JAMA
Journal of the American Podiatry Association
J Am Podiatry Assoc
Journal of Trauma
J Trauma
Medical and Biological Engineering
Med Biol Eng Comp
Orthopedic Clinics of North America
Orthop Clin North Am
Paraplegia
Paraplegia
Physiotherapy Canada
Physiother Can
Physical and Occupational Therapy in Geriatrics
Phys Occup Ther Geriatr
Physical and Occupational Therapy in Pediatrics
Phys Occup Ther Pediatr
Physical Medicine & Rehabilitation Clinics of North America
Phys Med Rehabil Clin N Am
Physical Medicine & Rehabilitation: State of the Art Reviews
Phys Med Rehabil State Art Rev
Physical Therapy
Phys Ther
Physiotherapy
Physiotherapy
Physiotherapy Research International
Physiother Res Int
Prosthetics and Orthotics International
Prosthet Orthot Int
Rehabilitation Nursing
Rehabil Nurs
Rehabilitation Psychology
Rehabil Psychol
Scandinavian Journal of Rehabilitation Medicine
Scand J Rehabil Med
Spinal Cord
Spinal Cord
Spine
Spine
Topics in Stroke Rehabilitation
Top Stroke Rehabil
TABLE 4-2  Journals Relevant to Orthotic and Prosthetic Rehabilitation—cont'd

Chapter 4  An Evidence-Based Approach to Orthotic and Prosthetic Rehabilitation
79
Textbooks
Academic textbooks can be a good starting point for locat­
ing background information, particularly for content areas
that change slowly (e.g., gross anatomy or biomechanics).
Evidence-based textbooks are well referenced, go through a
review process, and are typically updated every 3 to 5 years.
They summarize clinical studies and opinions of experts,
and analyze/synthesize the impact of the research and expert
opinion on the topic. Some textbooks are now available
online, which provides the advantage of frequent updating of
specific sections as new research evidence emerges and allows
the reader to immediately hyperlink to primary research
article sources. The website FreeBooks4Doctors! (
freebooks4doctors.com) provides hyperlinks to many key
medical textbooks free of charge online. Many other online
textbooks are available for purchase. Box 4-1 lists key indica­
tors of quality in academic textbooks.
Primary Sources: Journal Articles
Journal articles may serve as either primary or secondary
literature sources. They can be useful for both background
and foreground clinical questions. Primary research articles
are those in which the author presents the findings of a spe­
cific original study.27,28 It is best to use this category of evi­
dence when dealing with rapidly evolving areas of health care
(which many clinical practice questions fall into). Identifying
two or three high-quality primary research articles that, in
general, provide similar supporting evidence offers strong
evidence on which to base a clinical decision. Searching, cri­
tiquing, and synthesizing primary research sources is a time-
intensive task.
Secondary Sources: Integrative and Systematic
Review Articles
Use of high-quality secondary source journal articles to guide
evidence-based determinations can be a time-efficient strat­
egy for clinicians.29,30 Quality indicators for secondary source
articles include a comprehensive search of the literature
(using an explicit search strategy) to identify existing studies,
an unbiased analysis of these studies, and objective conclu­
sions and recommendations on the basis of the analysis and
synthesis.31 Secondary sources are available in a variety of for­
mats: integrative narrative review, systematic review, meta-
analysis, and clinical practice guideline (CPG). Each of these
summative resources can be an effective and time-efficient
method to obtain a critical assessment of a specific body of
knowledge. However, there are benefits and drawbacks asso­
ciated with each type of ­summative resource.
In an integrative review article the author reviews and sum­
marizes, and sometimes analyzes or synthesizes, the work of
a number of primary authors.32 These narrative reviews are
often broad in scope, may or may not describe how articles
were chosen for inclusion in the review, and present a qual­
itative analysis of previous research findings. The quality
(validity) of the narrative review varies with the expertise of
the reviewer and requires careful assessment by the reader.
Systematic reviews are particularly powerful secondary
sources of evidence that typically analyze and synthesize con­
trolled clinical trials.29,31,33 Well-done systematic reviews are
valuable sources of evidence and should always be sought
when initiating a search. Box 4-2 lists key indicators of a quality
systematic review. Systematic reviews are typically focused on
a fairly narrow clinical question, are based on a comprehensive
search of relevant literature, and use well-defined inclusion
and exclusion criteria to select high-quality studies (typically
randomized controlled trials) for inclusion in the review. Each
study included in the review is carefully appraised for qual­
ity and relevance to the specific clinical topic. The author
attempts to identify commonalities among study methods and
outcomes, as well as account for differences in approaches and
findings. A good systematic review is labor intensive to pre­
pare; thus only about 1.5% of all journal articles referenced in
Medline are true systematic reviews.34 Although the numbers
are low, increasing numbers of systematic reviews are being
published, including ones on topics relevant to orthotics and
prosthetics. For example, a PubMed search from 2006 to July
2011 of the literature using the terms “limb amputation AND
rehabilitation” combining the limits (a) review and (b) English
yielded 49 applicable reviews (Appendix 4-1).
A meta-analysis is a type of systematic review that quantita­
tively aggregates outcome data from multiple studies to analyze
treatment effects (typically using the “odds ratio” statistic) as if
the data represented one large sample (thus with greater statistics
power) rather than multiple small samples of ­individuals.29,31,35
The limitation to performing a meta-analysis is that, in order
to combine studies, the category of patients, the interventions,
and the outcome measures across the studies must all be simi­
lar. Meta-analyses can provide more powerful statements of the
strength of the evidence either supporting or refuting a given
treatment effect than the separate assessment of each study.
Because of the ­difficulty in identifying studies with enough
similarity to combine data, only a small subset of ­systematic
• Credentials of the authors
• Quality of references
• Recent/regular updating
• Endorsement by respected groups
• Peer reviewed
• Disclosure of funding source
BOX 4-1  Quality Indicators for Textbooks and
Internet Sources of Evidence
• Exhaustive search for evidence
• Clearly identified quality criteria for inclusion
• Multiple authors with independent judgments
• Impartial, unbiased summary
• Clearly stated conclusions: ready for clinical application
• If meta-analysis: statistical manipulation across studies
BOX 4-2  Quality Indicators for Systematic
Review Articles

80
Section I  Building Baseline Knowledge
reviews have been carried to the level of a meta-analysis. One
meta-analysis was identified in PubMed using the terms “limb
amputation AND rehabilitation” combined the limits a) meta-
analysis, b) English, and c) published in last 5 years.36
Secondary Sources: Clinical Practice Guidelines
Another secondary resource for clinicians may be CPGs that
have been developed for application to clinical practice on the
basis of the best available current evidence.37 Most existing
CPGs have been developed for screening, diagnosis, and inter­
vention in medical practice. CPGs are intended to direct clini­
cal decision making about appropriate health care for specific
diseases among specific populations of patients. The best avail­
able evidence upon which CPGs are typically based combines
expert consensus and review of clinical research ­literature.38
Most are interpreted as prescriptive, using algorithms to assist
decision making for appropriate examination and interven­
tion strategies for patients with given characteristics. Examples
of CPGs that may be relevant to orthotic and prosthetic reha­
bilitation are listed in Appendix 4-2. The National Guidelines
Clearinghouse is the most comprehensive database in the
United States for CPGs ().
Electronic Resources and Search Strategies
A number of electronic databases can assist clinicians in quickly
locating primary and secondary sources of evidence to guide
clinical decision making (Table 4-3). When seeking articles, it
is often helpful to use several different databases. The American
Physical Therapy Association provides access to many elec­
tronic resources described below as a service to APTA mem­
bers via its Open Door portal on the website
Using an electronic database effectively is a two-step pro­
cess. First, the searcher must locate applicable citations that
provide the title of the article, author, and other key iden­
tifying information (e.g., journal, issue, year, pages). Most
often, these citations also provide an abstract of the arti­
cle. Sometimes the searcher can gather enough information
about the applicability of the article for his or her needs purely
on the basis of the information found in the title and abstract.
Most often, however, the searcher must access the full-text
article in order to adequately assess the findings of the study.
Citations and abstracts are readily available free of charge
from numerous databases. However, access to the full text of
articles often requires a paid subscription to search databases.
Locating Citations
The National Library of Medicine, through the database
PubMed, produces and maintains Medline, the largest publicly
available database of English language biomedical references
in the world. PubMed references more than 4600 journals
including many key non–English language biomedical jour­
nals. These journals, in the aggregate, include more than
15 million individual journal article citations. This database
is also a rich source of citations for quality systematic reviews.
TABLE 4-3  Electronic Databases Used to Search for Relevant Evidence
Acronym
Database Information
Access
—
Academic Search Premier
By library access
Best Evidence
ACP Journal Club and Evidence Based Medicine (critical and
systematic reviews)

CCTR
Cochrane Controlled Trials Register
By subscription or library access
CDSR
Cochrane Database of Systematic Reviews
By subscription or library access
CHID
Combined Health Information Data Base (titles, abstracts,
resources, program descriptions not indexed elsewhere)

CINAHL
Cumulative Index of Nursing and Allied Health Literature
(citations and abstracts)
By subscription or library access
()
DARE
Cochrane Database of Abstracts of Reviews of Effectiveness
By subscription or library access
EBM Online
Evidence-based Medicine for Primary Care and Internal
Medicine (critical reviews and systematic reviews)
By subscription ()
Embase
Embase/Elsevier Science (Citations and abstracts)
By subscription ()
—
Hooked on Evidence/American Physical Therapy Association
(citations, abstracts, annotations)
By membership in American Physical Therapy
Association ()
Medline
National Library of Medicine (abstracts)
By library access
OVID
A collection of health and medical subject databases
(abstracts and full text)
By subscription or library access
()
PEDro
The Physiotherapy Evidence Database (systematic reviews)

PubMed
National Library of Medicine (abstracts)
(no charge)

Chapter 4  An Evidence-Based Approach to Orthotic and Prosthetic Rehabilitation
81
Journals indexed in PubMed must meet rigorous standards for
their level of peer review and the quality of the articles pub­
lished in the journal; this gives the searcher some confidence in
the information that is located through PubMed. PubMed can
be accessed through the National Library of Medicine's web­
site (). OVID is another Medline resource;
it is typically accessed via library subscription and often links
full text articles.
The Cumulative Index of Nursing and Allied Health
Literature (CINAHL) includes journal citations from a larger
pool of nursing and allied health fields than is found in
Medline. Many of these journals have a much smaller circula­
tion than the typical Medline cited journals, and the quality
of these smaller circulation journals may not meet PubMed
requirements. Thus the reader must be aware that closer
scrutiny of validity and methodological quality may be neces­
sary. However, the greater inclusion of ­rehabilitation-focused
journals in the CINAHL database makes this an impor­
tant database for rehabilitation professionals. This database
is only available to paid subscribers (library or individual
subscriptions).
Hooked on Evidence is a database of the American Physical
Therapy Association (APTA) and is available free of charge to
members of the association ().
Presently Hooked on Evidence consists of primary interven­
tion studies only. Articles in Hooked on Evidence have been
reviewed and abstracted by physical therapy academicians
and researchers, graduate students, and clinicians. These
abstracts may be sought by selecting a practice pattern group,
condition, and clinical scenario.
PEDro is a database of the Centre for Evidence-based
Physiotherapy at the University of Sydney, Australia, and is
available to the public free of charge ().
PEDro lists clinical practice guidelines, systematic reviews,
and clinical trials. An advanced search allows the searcher to
select the type of therapy, problem, body part, and subdis­
cipline. Both the Hooked on Evidence and PEDro databases
focus exclusively on high-quality studies related to physical
therapy. Their benefit is ease of identifying citations appli­
cable to physical therapy and rehabilitation. To search either
database successfully, the research question should be fairly
broad, using synonyms that represent words in the title. Both
databases contain only a fraction of the citations found in
PubMed; all of the citations, however, are directly applicable to
rehabilitation. A search of PEDro using “orthoses” ­identified
one practice guideline, 23 systematic reviews, and 26 clinical
trials, all relevant to physical therapy (Appendix 4-3). A simi­
lar search in Hooked on Evidence found 77 reviews of clinical
trials, 29 of which were published since 2006 (Appendix 4-4).
The Cochrane Database of Systematic Reviews (www.
cochrane.org/cochrane-reviews) is widely accepted as the
gold standard for systematic reviews. Groups of experts
perform comprehensive and quantitative analysis and syn­
thesis of the existing research on well-focused topics and
distill the findings into scientifically supported recommenda­
tions. Cochrane reviews use a standardized format and care­
fully follow rules to decrease bias in the choice of articles to
review and in the interpretation of the evidence. Although
few address physical therapy exclusively, rehabilitation pro­
cedures and approaches are a component of many of these
reviews. The findings are reported in structured abstracts that
summarize the key aspects of the full review including the
authors’ conclusions about the strength of the evidence and
their recommendations. These structured abstracts are avail­
able free online. Access to full-text review articles requires a
paid subscription, however.
Finding valuable secondary references on the web is
increasingly possible. However, searchers must carefully
scrutinize these materials as there is wide variability in accu­
racy and objectivity of the published information.39 This
evidence represents such varied sources as reports of origi­
nal research, research reviews from trusted experts, student
summaries that are non–peer reviewed, marketing advertise­
ments (sometimes presented visually to appear to be a peer-
reviewed research report), and lobbying groups’ perspectives
and persuasive arguments. There are many patient-focused
sites and fewer practitioner-focused ones. The quality indica­
tors identified in Table 4-2 are applicable to Internet websites
as well as textbooks.
Executing Search Strategies
Often, the first search for citations results in one of two
extremes: hundreds or thousands of citations, with only a
few related to the clinical question being asked, or almost
no citations focused on the topic of interest.18,40,41 Searchers
should look carefully at the citations that result from a search.
In the search that is too broad, the searcher must examine
closely what he or she is really looking for, comparing titles
and key words that have resulted from the search. Often, the
search is repeated, by rewording or setting limiters to narrow
results and omit the previously identified unrelated citations.
A searcher who uses the search term prosthesis may find that
the results the search include articles about such diverse top­
ics as joint prostheses, dental prostheses, and skin prostheses,
as well as limb prostheses. Search terms should be as appli­
cable to the specific clinical question being posed as possi­
ble; using more precise search terms such as limb prosthesis,
leg prosthesis, arm prosthesis, or artificial limb may be more
effective.
Searchers should recognize that the search engine is sim­
ply matching the search words that the searcher has entered
with subject headings linked to the article by the database
administrator or librarian using predefined medical subject
heading names or words included in the title or abstract.
Searchers may need to adjust search terms to find applicable
references. For example, a PubMed (
pubmed/) search of the English language literature published
in the past 5 years (between July 2006 and July 2011) using
the search terms below-knee amputation combined with the
search term prosthetic rehabilitation yielded five citations. The
same search using the term transtibial amputation rather than
below-knee amputation yielded 45 citations, with no overlap
between the two sets of citations. A third search using the
term trans-­tibial amputation in place of transtibial ­amputation

82
Section I  Building Baseline Knowledge
yielded 12 ­citations, none of which overlapped with the first
search and one that overlapped with the ­second search.
A search can be unforgiving to misspellings or, as described
earlier, slight differences in search terms. If the searcher
finds one citation that is on target for the topic of interest,
repeating the search using terms from that article's title or
abstract, as well as subject headings (key words), may yield
additional appropriate citations. Using a variety of synonyms
or Medical Subject Headings ()
when rep­eating the search can help the searcher be more
confident that the correct concepts are being targeted.
Searchers should note the search terms that result in
successful searches so that future searches can be most effi­
cient. Searchers using PubMed can set up a permanent search
by establishing a “cubby.” This service is free and fully avail­
able via Internet connection to PubMed. Online directions
help users set up cubbies that save search terms. Searchers
can periodically check their cubbies and ask for literature
updates on the topic.
In addition to the search topic, a good clinical question will
often focus on one of three broad categories of clinical ques­
tions: treatment/intervention/therapy, diagnosis, or progno­
sis.42 Searchers can use these terms to narrow their search as
needed. Searchers must recognize that each database uses its
own set of key words and may (or may not) include the title
words, abstract words, or common sense clinical terms in their
electronic search process. Familiarity with key headings used
by the database can minimize frustration during the search
process; combining words from the title or abstract (e.g., by
using Boolean operators such as “AND,” “OR,” or “NOT”), as
well as using synonyms for the clinical terms or concepts of
interest, can also assist the search process. In many databases,
searchers can choose to limit the search to systematic reviews
addressing their topic of interest.
Searching for Interventions
Words that are likely to limit the search to studies that focus
on interventions include the following43:
• Therapeutic use
• Clinical trials
• Therapy
• Comparative studies
• Randomized controlled trial (to limit search to arti­
cles of highest quality, only if there are many relevant
articles)
• Rehabilitation
Examples of search terms for therapeutic interventions
commonly used in prosthetics and orthotics include the
following:
• Prosthetic rehabilitation
• Orthotic use
• Physical therapy techniques
• Prosthetic fitting
• Prosthetic training
• Gait training
• Therapeutic exercise
• Edema management
• Balance training
• Skin care
• Strength training
Diagnosis as the Intervention
If the primary clinical question relates to making an accurate
and efficacious diagnosis about some aspect of the patient's
condition, or on screening patients to determine the need for
more specific assessment, the health practitioner may search
the “diagnosis” literature for relevant studies. General search
terms that help limit the search to general studies focusing on
diagnosis include the following42:
• Diagnosis (actual disease or disorder)
• Diagnostic use (tool used in diagnosis)
• Diagnosis, differential
• Sensitivity
• Specificity
• Accuracy
• Predictive value
• Construct validity
Natural History or Prognosis
Studies of the prognosis of medical pathologies and impair­
ments are becoming increasingly available. Such studies
attempt to predict who is most likely to benefit from spe­
cific treatment interventions or determine whether specific
characteristics of patients or their environment predict out­
comes. Search terms that are likely to limit the citations to
those focused on the ­general category of prognosis include
the following43:
• Experimental cohort studies
• Prognosis
• Prognostic factors
• Disease progression
• Recurrence
• Morbidity
• Mortality
• Incidence
• Prevalence
• Clinical course
• Outcomes
Systematic Review
Currently PubMed does not identify systematic review as a
specific “publication type.” The searcher must use the limits
“meta-analysis” or “review” under the Type of Article option.
When “systematic review” is used as a search term, several
types of reviews are retrieved, not limited to actual systematic
reviews. Articles commonly identified as review-academic,
CPGs, review-tutorial, meta-analysis, guideline, and consen­
sus development conference are all categorized in PubMed
under the term systematic review. Search terms that are
likely to limit the citations to ones focused on true systematic
reviews include the following:
• Systematic review (as a title word [tw])
• Systematic (as a key word)
• Meta-analysis

Chapter 4  An Evidence-Based Approach to Orthotic and Prosthetic Rehabilitation
83
• Development
• Validation
• Cochrane database of systematic reviews (as a journal
name [jn])
Locating Full-Text Articles
Once appropriate citations have been found via a search of
the literature, the next step is to locate the full text of arti­
cles that appear to be most closely related to the clinical
question of concern. Individual journals are published and
owned by publishing companies that support themselves by
paid journal subscriptions. Each journal has its own mech­
anism for providing access to the articles it contains. If the
journal is published by a specific professional organiza­
tion, members of that organization typically have access to
a delivered hard copy of the journal or access via the orga­
nization's website (by entering an assigned user name and
password).
Libraries purchase hard copy and online access to specific
journals, either bundled together as part of an intermediary
company service (e.g., EBSCO or Proquest), as stand-alone
subscriptions, or as a publisher aggregated offering of sev­
eral or all of its journals at a specified price. Libraries make
the online copies of these journals available to their library
patrons, either free of charge or for a specified library fee.
Some journals provide full text free to the public via the
Internet, either for all issues or for articles published after
a certain period of time (e.g., 1 to 2 years after publication).
Most journals provide full text of individual articles for a
fee; this fee may be as much as $20 to $25 per article. One
benefit of searching the literature on PubMed is that this
database provides a link to any online access to a specific
citation, both those with free access sources and those with
a fee attached. The website
lists the various biomedical journals that provide full text
free, provides the hyperlink to the journal website, and iden­
tifies any limitations to free access (often time since pub­
lication). Health care practitioners should search out the
availability of full-text biomedical journal articles (either
hard copy or online) from the libraries to which they have
regular access. Access will vary widely on the basis of the
work setting and the mission of the library at the health
facility or in the community.
STEP 3: CRITICALLY APPRAISING
THE EVIDENCE
Once the clinician has located and screened the article to
ensure that it is reasonably focused on the clinical research
question of interest and applicable to the patients in his or
her clinical practice, the clinician must critically appraise
the methodological and analytical quality of the research
process used in the study.44 This is a skill that clinicians
can develop with consistent practice, over time, and is well
worth the effort involved.22,23 Participation in study groups
or journal clubs often helps development of this useful
EBP skill.45,46
Overall Methodological Quality
The best quality research evidence comes from studies with
a carefully articulated research question, an appropriate
design and methodology, and a sample representative of the
population of interest. No clinical research study or article
is perfect, and the critical appraiser of the research litera­
ture must develop skills to weigh the evidence that an article
­provides to determine whether the information is accurate,
relevant, and clinically important for his or her patients.44,47
Just because something is published and in print does not
ensure that it provides valuable or accurate information.
Whether the clinical study focuses on treatment/interven­
tion, prognosis, or diagnosis, the overall purpose of criti­
cal appraisal is to determine the extent to which threats to
internal and external validity of the study bias, and poten­
tially invalidate, the findings of the study.48 The clinician
is interested in determining whether, and to what degree,
the findings of the study truly represent the answer to the
research question asked in the study. Box 4-3 lists a series
of questions about the overall quality and applicability of
primary research studies. Some questions are applicable
across all categories of primary research; others are specific
to certain categories. Box 4-4 identifies quality assessment
questions applicable to the secondary source category of
systematic review.
The Sample: Adequacy and Appropriateness
Sample size must be considered when making judgments
about the methodological quality of a study. In studies with
small sample sizes, a few nonrepresentative subjects can skew
data substantially and lead to statistical findings that are non­
representative of the parent group.49 Additionally, the natu­
ral variability between subjects may end up masking real
­differences when sample size is low. There is no absolute
minimum number of subjects identified quantitatively as the
minimum needed for a legitimate study. However, research
textbooks often recommend 8 to 15 subjects per group as a
minimum number to ensure that the statistical analysis has
at least a reasonable opportunity of demonstrating real dif­
ferences or real relationships if they are present.10,50 The larger
the sample size, the more likely that the sample will represent
the population from which it has been drawn.
Researchers, as well as readers of research articles, can
use a power analysis to evaluate adequacy of the sample size.
A power analysis provides an objective estimate of the mini­
mum sample size necessary to demonstrate real differences
or relationships, between and among groups.51–53 Inclusion
of a power analysis as a standard part of the research design
is a fairly new concept. Thus although the presence of a
power analysis is helpful in assessing the adequacy of the
sample size, lack of a specifically identified power analysis—
particularly in older studies—does not necessarily indicate
a weak study.
A power level (β) of 0.8 (80%) is generally considered
acceptable in assuring that, if real group differences (or rela­
tionships) are present, the study design is sensitive enough to
pick them up. A power analysis considers five factors in the

84
Section I  Building Baseline Knowledge
FOR ALL STUDIES
• What criteria were in place in the database used to find
the study? (e.g., journal referenced in PubMed have met
stringent quality criteria)
• How up to date (recent) is the study?
• Is the purpose of the study clearly stated? How closely does
the purpose of the study address the clinical question of
concern?
• How comprehensive is the review of the literature? How
up to date and relevant are the references cited in the arti­
cle? Does the review of the literature support the need for
the study that is being reported?
• Are the outcome measurement tools used in the study
described sufficiently? Are they appropriate to the clini­
cal question of concern?
• Is evidence of the reliability and validity of each outcome
measurement tool presented? Is the evidence adequate
for the clinical question of concern?
FOR STUDIES OF INTERVENTIONS/
TREATMENTS/THERAPY
• Have subjects been randomly assigned to groups?
• Is there a control group (or placebo or standard
care group) used to compare with the experimental
group?
• Are the researchers collecting outcome data blind to sub­
ject group assignment?
• As feasible, subjects should be blinded to their group
assignment?
• How similar are the experiment and control groups?
Optimally, the only difference should be the intervention.
• Do confounding variables make the groups different
before intervention?
FOR STUDIES CONCERNED WITH PROGNOSIS
• Are the researchers collecting outcome data blind to each
subject's score on prognostic factors?
• Is the period of follow-up sufficiently long to ensure that
the outcome of interest is captured?
• Is there evidence from repeated analysis with a second
group of subjects, with similar results, to provide confir­
mation of the prognostic factors being investigated?
FOR STUDIES CONCERNED WITH DIAGNOSIS
• Has the new diagnostic test been compared with an
accepted gold standard?
• Is the researcher performing the new diagnostic test
blind to each subject's score on the gold standard?
• Is there evidence from repeated analysis with a second
group of subjects, with similar results, to provide confir­
mation of the accuracy of the new diagnostic test?
BOX 4-3  Questions to Consider in the Critical Appraisal of a Research or Review Article
FORMULATION OF OBJECTIVES
• Is the topic (purpose of the review) well defined?
• The intervention
• The patients
• The outcomes of interest
LITERATURE SEARCH FOR STUDIES
• Was the search for papers thorough?
• Use of search terms that fully capture key concepts
• Identification of databases or citation sources used
• Search methods exhaustive, international in scope
• Search methods described in enough detail to replicate
• International in scope
• Search terms that fully capture search concepts
STUDY SELECTION
• Were study inclusion criteria clearly described and fairly
applied?
• Explicit inclusion and exclusion criteria
• Criteria should be applicable to the topic
• Selection criteria are applied in a manner that limits bias
• Account for studies that are rejected
ASSESSING QUALITY OF DESIGN AND METHODS
• Was study quality assessed by blinded or independent
reviewers?
• Was missing information sought from the original study
investigators?
• Do the included studies seem to indicate similar effects?
• Were the overall findings assessed for their robustness?
• Was the play of chance adequately assessed?
DATA GATHERING
• Was information from each article extracted using a
standardized format?
• Does the information gathered from each article include
the following?
• Type of study (e.g., randomized, controlled trial)
• Characteristics of the intervention for experimental and
control groups
• Key demographics of all subjects
• Primary outcome of importance
• An accounting for missing data
POOLING METHOD
• Are selected studies similar enough to be pooled for analysis?
• In design
• In interventions
• In operational definition of outcome variable
DISCUSSION, CONCLUSIONS,
RECOMMENDATIONS
• Are recommendations based firmly on the quality of the
evidence presented?
• Are conclusions and recommendations justified on the
basis of the analysis performed?
BOX 4-4  Questions Used to Assess Quality of a Systematic Review

Chapter 4  An Evidence-Based Approach to Orthotic and Prosthetic Rehabilitation
85
determination of power. Knowing any four of these five fac­
tors allows the reader to calculate the final factor.52 The five
factors include the following:
1. The significance level (a coefficient) set for the statistical
analysis of the outcome variable
2. Anticipated variance (e.g., standard deviation) within each
group of subjects related to the outcome variable
3. Sample and group size
4. The anticipated effect size for the intervention or relation­
ship; how large a difference or a correlation does there
need to be to ensure than the outcome under review is
important or clinically meaningful?
5. The desired level of power (b coefficient), an estimate of
the likelihood that a real difference between groups will be
demonstrated if it exists (avoiding a type II error)
Power analysis performed in preparation for a study
(i.e., before subject recruitment, data collection, or analy­
sis) identifies the ideal number of subjects that should be
in each group.29 When a power analysis is performed after
the data analysis has been completed, it is used to determine
the ­likelihood that small sample size affected the statistical
analysis when insignificant findings occurred.54
When a power analysis is performed before implementa­
tion of a study, most employ a significance level of α = 0.05
or lower and the power level of b = 0.8 or higher. The score
for effect size and anticipated group variance will be study
specific. Typically, researchers provide references from prior
research or their own pilot data to justify their choices of
effect size and variance. This use of power analysis provides
evidence of a rigorous research design and helps the clinician
trust the findings of the study.
The next important appraisal of the sample concerns its rep­
resentativeness: to what extent are the subjects in the sample
similar to (and therefore representative of) the “population” of
interest and to the individual for whom the clinician is caring?
The goal of all research studies is to make decisions about a
general population of people on the basis of the findings of a
representative sample from that population. How well a sample
represents the larger group to which results will be generalized
is a function of subject recruitment, selection, and retention.55,56
In appraising an article to use as evidence for clinical decision
making, the health professional must consider how subjects
were selected and assigned to groups (hopefully randomly),
what criteria were used to determine whether a possible subject
was included or excluded from the study, and the reasons that
subjects who started the study may have dropped out before
data collection was completed. Study results will be biased if
the sample used for the study is not representative of the under­
lying population. Small variations, randomly occurring across
all subject groups, may be acceptable. Larger variations, par­
ticularly ones that systematically affect one subject group more
than others, may introduce unacceptable amounts of bias.
As a critical appraiser of the research, the evidence-based
practitioner must be on the alert for sampling bias.57,58 In the
ideal world, any subject in the patient population of interest
should be equally likely to be chosen to be a subject in the
study. Realistically, this is rarely the case. No one researcher
has access to each older adult who has had a transtibial ampu­
tation, each child with cerebral palsy, or each young adult with
an incomplete spinal cord lesion. The researcher should pro­
vide enough evidence in his or her discussion of the study's
methodology that the reader can be reasonably comfortable
that the methods implemented for choosing subjects provided
access to subjects reasonably representative of the breadth of
subjects with the target characteristics under investigation.
The article typically provides descriptive evidence from
previous studies of the common characteristics of patients
with the pathology of interest. The researcher then compares
these known characteristics with the descriptive character­
istics of subjects in their particular study. Any differences
should be identified and discussed in the article. The critical
appraiser must use professional judgment to determine the
extent to which potential biasing factors influence the meth­
odological rigor of the study. If inequalities were detected, it
is possible to add steps to the statistical analysis to account
for the inequality. This should be reported in the study.
Attrition (subject dropout rate) also influences the research­
er's ability to generalize the findings of the study to the larger
population of individuals with the diagnosis or impairment.
A useful rule of thumb for readers who are critically apprais­
ing an article is that, if more than a 20% dropout rate has
occurred, then findings of the study are likely suspect. In a
strong research article, the researchers explain why and when
subjects were lost. Evidence-based practitioners want to know
whether subjects chose to leave the study because intervention
made them worse or because the intervention was too difficult
or painful to overcome its potential benefits. Another situa­
tion that may lead to attrition is based on a research design
so burdensome or difficult that subjects were unable to meet
participation requirements (so that only the most persistent
individuals in the sample completed the study). Researchers
attempt to account for dropouts either by performing an
“intention-to-treat” analysis or presenting descriptive statis­
tics that compare key characteristics of subjects who com­
pleted the study with those who did not complete the study.59
If the researcher can confirm that both groups of subjects are
not significantly different, particularly in terms of any char­
acteristic that might bias outcomes, then a study may still be
identified as having adequate methodological quality.
In an intention-to-treat analysis, all subjects who started
a study but did not finish it are assigned the most negative
outcome likely to occur with the measurement tool for the
purposes of statistical analysis.60 If a statistically significant
finding still occurs in the presence of an intention-to-treat
analysis, then even assuming that all dropouts had a bad out­
come, the study still demonstrated significant effects.
Outcome Measures
In assessing methodological quality of a study's outcome
measurement tools, three questions must be addressed:
• Are the outcome tools described well enough for the
­evidence-based practitioner to make an informed and
realistic judgment about their appropriateness for assess­
ing the variables of interest for this study?

86
Section I  Building Baseline Knowledge
• Are the outcome tools reasonably valid and reliable?
• Are the outcome tools reasonably responsive and sensitive
to change?
A high-quality study describes the outcome measures
in enough detail for the reader to understand exactly what
was measured and to determine whether the tools are
appropriate to answer the research questions addressed in
the study.
The article should also provide sufficient detail to confirm
reliability and validity of each outcome measurement tool.
Reliability represents the consistency with which scores are
reproduced given repetition of the test with the same tester
or across numerous testers.61,62 Validity represents the accu­
racy with which the measurement tool taps into the construct
or characteristics that the test is purported to measure.61,63–65
Table 4-4 lists the various aspects of reliability and validity.
TABLE 4-4  Validity and Reliability
DETERMINATION OF A TEST OR MEASURES RELIABILITY
Type of Reliability
Question Being Addressed
Intra-rater
Will the same examiner make consistent ratings of the same individual?
Test-retest
Is the measure stable/accurate over time?
Interrater
Will different examiners make consistent ratings of the same individual?
Internal consistency
How well do each of the items contribute or reflect what the test intends to measure (how well do the
items hang together)?
Parallel forms
Are different versions of the test or measure equivalent?
RELIABILITY COEFFICIENTS
Parametric Analyses
Nonparametric Analyses
Strategis for Continuous
Measures
Types of Reliability
Evaluated
Strategies for Nominal
Measures
Strategies for Ordinal
Measures
Types of Reliability
Evaluated
Pearson product moment
(Pearson's r)
(association)
(.0 to 1.0)
Intra-rater
Test-retest
Interrater
Parallel forms
Percent agreement
(includes chance
agreement)
Percent agreement
(includes chance
agreement)
Intrarater
Test-retest
Interrater
Parallel forms
Coefficient of Variation
(SD/mean)
(< 10% suggests reliability)
Intrarater
Interrater
Kappa coefficient
(agreement beyond
chance)
Weighted percent
agreement (magnitude
of disparity) (includes
chance agreement)
Intrarater
Test-retest
Interrater
Parallel forms
Intraclass correlation coefficient
(ICC) (association and
agreement)
Intrarater
Test-retest
Interrater
Parallel forms

Weighted kappa
(agreement beyond
chance)
Intrarater
Test-retest
Interrater
Parallel forms
Cronbach's alpha
Internal consistency



DETERMINATION OF A TEST OR MEASURE'S VALIDITY
Type of Validity
Question Being Addressed
Continuous Measures
Content
How well are items on the test sample from the
domain being evaluated?
Content expert review of items
Concurrent or Criterion
How well does the measure reflect a particular event,
characteristic, or outcome?
Correlation (with gold standard measure of
characteristic or construct)
Predictive
How well does the measure predict a future event or
outcome?
Correlation (with outcome variable, measured
after a period of time)
Construct
Does the test measure a single underlying theoretical
concept or construct?
Correlation (with variables theoretically related
to the construct of interest)
How many underlying constructs are included in the
measure?
Confirmatory factor analysis
Discriminant or Divergent
How well does the test or measure differentiate
between/among groups?
T-test or analysis of variance

Chapter 4  An Evidence-Based Approach to Orthotic and Prosthetic Rehabilitation
87
If a test is reliable, it should perform consistently under simi­
lar testing situations regardless of who performs the test. Studies
of reliability usually report either correlation coefficients or
intraclass correlation coefficients as the statistical measure of
the accuracy with which scores are reproduced.66 There is no
absolute standard of minimally acceptable ­reliability.67 A score
of 1 indicates a complete reliability (and is rarely achieved); a
score of 0 represents a complete lack of reliability. A general
benchmark is that a score of r = 0.9 or better is strong evidence
of reliability of that measure. Coefficients between 0.75 and 0.89
suggest that the measure has moderate risk of error but may be
acceptable. Correlations of less than r = 0.75 are not typically
perceived as having acceptable reliability.
The researchers who are reporting their study should
provide an adequate description of the methodology of the
study for the critical appraiser to determine which aspects
of reliability are most important in this study (and there­
fore to determine whether the authors provided evidence of
the appropriate reliability). Intertester reliability should be
reported when more than one tester measures the same out­
come, and intratester reliability should be reported when the
same tester measures outcomes on more than one occasion.
Test-retest reliability provides evidence that the test performs
consistently when repeated under similar conditions.
In addition, readers are interested in whether the ­validity of
the measure has been assessed. To be considered valid, there
must be sufficient evidence to demonstrate that the test or tool
measures what it is purported to measure.63–65 The researchers
who have written the article must provide this evidence about
the measure so that the critical appraiser can be comfortable
that concerns about validity have been adequately addressed.
Just because a tool is reliable (consistent in its measurement
properties) does not mean that it is also valid (measures what
it intends to measure). A tool cannot be valid, however, if it is
not reliable in its measurement.61 Ideally, the tests or measures
used in the study demonstrate great consistency with high
reproducibility (i.e., reliability) and accurately assess the tar­
geted characteristic (validity).
Evidence of validity is especially important when the test
or tool measures an abstract concept (e.g., quality of life or
functional independence) rather than a physiological phe­
nomenon (e.g., heart rate, range of motion). A valid test or
measure contains enough items or questions related to the
concept or characteristic being evaluated that the clinician
can be confident that the results of testing will represent the
subject's status in relationship to the construct being assessed.
A test or measure found to be reliable in one patient popula­
tion is not automatically reliable in other populations.61
STEP 4: APPLICABILITY TO PATIENTS AND
CLINICAL PRACTICE
The final component of an EBP approach to rehabilitative
care is just as essential to provision of quality care as the abil­
ity to access and use available evidence and clinical exper­
tise. Without consideration of the unique goals, expectations,
values, and concerns that an individual in our care brings to
the health care encounter, even the “perfect” plan of action
will not be as efficacious as it might otherwise be. An indi­
vidual's perspective and values are influenced by a number
of factors including developmental issues and their position
in the lifespan, their family system and culture, their work
roles and responsibilities, their coping styles and strategies,
their willingness or ability to access whatever resources might
be available in their social support network, and their socio­
economic and educational resources.68,69 To be as effective as
possible in providing care, evidence-based practitioners must
consider what the pathology, impairment, functional limita­
tion, or disability means to the individual with respect to self-
concept and sociocultural roles.70
Clinical Relevance
Assessing clinical importance of a study has both objective and
subjective considerations. The clinician must look beyond the
statistical significance of the findings.71 Often this assessment is
based on professional judgment about the impact of the extent
of change. Does a statistically significant change in a functional
test score or pain level translate into a change that the patient
will perceive as important in daily life? Does long-term follow-
up occur? That is, does the author examine the effectiveness
of a given intervention 3 months, 6 months, or 1 year following
the intervention? If the article only provides evidence of short-
term benefits of the intervention, are these short-term benefits
worth the time and effort in the long run? Would other inter­
ventions have had a better long-term outcome?
Making the decision to implement new approaches to care
supported by the research literature requires the evidence-
based practitioner to answer several questions related to his
or her specific clinical environment72:
• How similar are the subjects used in the study to those in
his or her clinical practice?
• How do the patient's values and expectations interact with
or relate to effort, risks, and likely outcomes of the inter­
vention being considered?
For studies of interventions/therapy/treatment consider
the following:
• How likely is it that the patient will be willing and able to
comply with intervention activities suggested in the study?
For studies of diagnosis consider the following:
• Is the diagnostic test adequately available, affordable, ­accurate,
and precise for use in the clinician's setting?
• Is it likely that the patient will be willing and able to ­comply
with the testing procedures?
For studies of prognosis consider the following:
• Will knowing the predictor factors make a clinically impor­
tant difference in the way the clinician will care for his or
her patients?
INTEGRATING CLINICAL EXPERTISE
AND SKILL
Although research literature is a valuable and important
resource for evidence-based decision making, using evidence
from the literature is not sufficient for effective EBP. Practitioners

88
Section I  Building Baseline Knowledge
must also have strong examination, evaluation, and diagnostic
skills and should be able to incorporate these skills into reflec­
tive past experience and current research findings.73
What is clinical expertise? In rehabilitation, it is the combina­
tion and integration of (1) a multidimensional knowledge base
that is grounded in basic science, medical science, psychologi­
cal/sociocultural sciences, and movement sciences; (2) effective
clinical reasoning skills and an orientation toward function; (3)
well-developed and efficient psychomotor skills for examina­
tion and intervention; and (4) the desire or commitment to help
the individuals clinicians provide care for74–76 (Figure 4-3).
The first chapter of this text explores the educational prepara­
tion, roles, and responsibilities of individual health profession­
als involved in orthotic and prosthetic rehabilitation. Each has a
particular body of knowledge to bring to the care of individuals
needing a prosthesis or orthosis, as well as shared understanding
(albeit at various depths) of anatomy, kinesiology, biomechanics,
gait analysis, mobility training, motor control and motor learn­
ing, and principles of exercise. The authors have established that
effective interdisciplinary teaming, in which each profession's
perspective interacts so that the team becomes “more than the
sum of its parts,” is an essential component in the provision of
successful orthotic or prosthetic rehabilitative care.
The background knowledge important in orthotic and
prosthetic rehabilitation that enables clinicians to ask sound
clinical questions and apply evidence to patient care includes
a strong foundation in the following areas:
• Anatomy and physiology of the musculoskeletal, neuro­
muscular, cardiovascular, and cardiopulmonary systems
• Kinesiology and biomechanics of the human body
• Properties of orthotic and prosthetic materials
• Principles of motor control and motor learning
• Lifespan development
• Exercise prescription and assessment of exercise tolerance
• Determinants of normal gait and methods of gait assessment
How does the clinician gain knowledge necessary for expert
practice? Entry-level professional education is the baseline,
while on-the-job experience via trial and error practice and dis­
cussion/debate/collaboration with colleagues moves clinicians
from students toward novices.74,76 They become more compe­
tent in their roles and responsibilities as their experience grows;
they support and enhance their developing mastery and exper­
tise with continuing education, participation in journal clubs
and perusal of the clinical research literature, and postgraduate
education. Another important component of increasing com­
petence and developing expertise is the ability to actively listen
to the hopes and concerns of those they work with and incor­
porate these into decision making and plans of care.
Clinical expertise, then, allows health care providers to
quickly and efficiently identify an individual's rehabilitation
diagnosis and, based on their constellation of impairments
and functional limitations, select the strategies for remedia­
tion or accommodation that will assist the individual's return
to a preferred lifestyle.
Staying Current with the Literature
One proactive way that a clinician can keep informed about
new studies focused on his or her area of practice is to sign
up for an online service that automatically sends weekly or
monthly electronic updates of new articles from journals that
Knowledge
Entry-level education
Continuing education
Post-graduate education
Clinical experience
Collaboration with colleagues
Own experience as “patient”
Listening & observation
Movement
Functional orientation to care
Motor learning perspective
Psychomotor examination skills
Psychomotor intervention skills
Virtues & Values
Ethic of caring
Passion for clinical care
Enpowerment orientation
Value for relationships
Lifelong learning
Clinical Reasoning
Problem solving skills
Weighing research evidence
Integration of examination findings
Ability to evaluate
Ability to formulate prognosis
Determine appropriate plan of care
Patient-
Centered
Care
FIGURE  4-3  Expert patient-centered physical therapy practice requires integration and interac­
tion of a provider's underlying knowledge, values, examination and intervention skills, and clinical
reasoning.

Chapter 4  An Evidence-Based Approach to Orthotic and Prosthetic Rehabilitation
89
the clinician feels are important to read or content areas that
he or she wants to stay informed about. Professional organi­
zations often offer this service as a membership benefit. Many
journals allow readers to sign up for a service that electroni­
cally sends the table of contents via email whenever a new issue
of the journal is released. Another valuable service (without
charge) for evidence-based practitioners is available from an
information management company, Amedeo (
com). When an evidence-based practitioner subscribes to
Amedeo, he or she chooses from a list of topics for notifi­
cation of newly published articles linked to those selected
topics. Amedeo topics include rehabilitation, pain manage­
ment, vascular surgery, and stroke, among many others.
Amedeo routinely searches a large variety of high-quality
journals for new publications on the topics selected by sub­
scribers and sends weekly updates via email. This is a valuable
resource for busy clinicians who may not have ready access to
a medical library.
Two strategies, if routinely used, help health profession­
als to update and expand their expertise. The first is to select
two or three journals (see Table  4-2) that are particularly
appropriate for the clinician's area of professional interest and
practice and arrange (via the journal's website) to receive an
electronic copy of the table of contents of each issue. When
the update arrives, it will be well worth the clinician's time
and effort to scroll through the listing of articles and authors
to determine which would be worth tracking down to read.
The second strategy is to use whatever electronic literature
update service is available through professional organiza­
tions, PubMed cubby, or Amedeo to arrange to be notified
regularly of research reports published in the clinician's area
of interest. The final step is to actually (and consistently)
make time to read the resources that have been identified and
discuss and debate them with colleaguesin order to effectively
integrate the new information into clinical practice.
SUMMARY
This chapter explores the concepts underlying evidence-
based health care practice and illustrates strategies to develop
clear clinical questions, relevant to an individual patient who
is receiving care. The chapter also identifies various sources
of evidence available to clinicians and illustrates how elec­
tronic databases can assist the search process. The authors
suggest strategies that clinicians can use to develop criti­
cal appraisal skills and to update and expand their clinical
expertise. Although much of the chapter focuses on evidence
available in the research literature, it is the integration of
the best available scientific evidence; clinical expertise and
judgment; and the concerns, values, and expectations of the
individual who the clinicians care for that determines the
effectiveness of clinical decision making.

90
Section I  Building Baseline Knowledge
APPENDIX 4-1
Reviews Published from 2006 to July 2011, Identified by Searching PubMed Electronic Research Database Using Search Terms “Limb Amputation AND Rehabilitation”
and with the limits: a) review and b) English
Title
Authors
Journal
Moderators' summary: perceived performance differences; limb salvage
versus amputation in the lower extremity (session II)
Andersen RC, Swiontkowski MF
J Am Acad Orthop Surg 2011;19 Suppl 1:S20-2
The clinical aspects of mirror therapy in rehabilitation: a systematic
review of the literature
Rothgangel AS, Braun SM, Beurskens AJ, Seitz RJ, Wade DT
Int J Rehabil Res 2011;34(1):1-13
Neural interfaces for control of upper limb prostheses: the state
of the art and future possibilities
Schultz AE, Kuiken TA
PM R 2011;3(1):55-67
Traumatic and trauma-related amputations: Part II: Upper extremity
and future directions
Tintle SM, Baechler MF, Nanos GP, Forsberg JA, Potter BK
J Bone Joint Surg Am 2010;92(18):2934-45
Phantom limb pain: theories and therapies
Weeks SR, Anderson-Barnes VC, Tsao JW
Neurologist 2010;16(5):277-86
Evolving techniques in foot and ankle amputation
Ng VY, Berlet GC
J Am Acad Orthop Surg 2010;18(4):223-35
The role of physical therapy and occupational therapy in the
rehabilitation of pediatric and adolescent patients with osteosarcoma
Punzalan M, Hyden G
Cancer Treat Res 2009;152:367-84
Bone sarcomas: Overview of management, with a focus on surgical
treatment considerations
Lietman SA, Joyce MJ
Cleve Clin J Med 2010;77 Suppl 1:S8-12
Recent advances in lower extremity amputations and prosthetics
for the combat injured patient
Fergason J, Keeling JJ, Bluman EM
Foot Ankle Clin 2010;15(1):151-74
Biomechanical parameters of gait among transtibial amputees: a review
Soares AS, Yamaguti EY, Mochizuki L, Amadio AC, Serrao JC
Sao Paulo Med J 2009;127(5):302-9
Phantom limb related phenomena and their rehabilitation after lower
limb amputation
Casale R, Alaa L, Mallick M, Ring H
Eur J Phys Rehabil Med 2009;45(4):559-66
Mental practice for relearning locomotor skills
Malouin F, Richards CL
Phys Ther 2010;90(2):240-51
Advances in lower-limb prosthetic technology
Laferrier JZ, Gailey R
Phys Med Rehabil Clin N Am 2010;21(1):87-110
Systematic review of the effectiveness of mirror therapy in upper
extremity function
Ezendam D, Bongers RM, Jannink MJ
Disabil Rehabil 2009;31(26):2135-49
Peripheral arterial disease in women
Aronow WS
Maturitas 2009 Dec 20;64(4):204-11
Prosthetic rehabilitation issues in the diabetic and dysvascular
amputee
Uustal H
Phys Med Rehabil Clin N Am
2009;20(4):689-703
Clinical features and electrodiagnosis of diabetic peripheral neuropathy
in the dysvascular patient
Wooten K
Phys Med Rehabil Clin N Am 2009;20(4):657-76