title: Use of the challenge point framework to guide motor learning of stepping reactions for improved balance control in people with stroke: a case series.
abstract: OBJECTIVE
  Stepping reactions are important for walking balance and community-level mobility. Stepping reactions of people with stroke are characterized by slow reaction times, poor coordination of motor responses, and low amplitude of movements, which may contribute to their decreased ability to recover their balance when challenged. An important aspect of rehabilitation of mobility after stroke is optimizing the motor learning associated with retraining effective stepping reactions. The Challenge Point Framework (CPF) is a model that can be used to promote motor learning through manipulation of conditions of practice to modify task difficulty, that is, the interaction of the skill of the learner and the difficulty of the task to be learned. This case series illustrates how the retraining of multidirectional stepping reactions may be informed by the CPF to improve balance function in people with stroke.
  
  
  METHODS
  Four people (53-68 years of age) with chronic stroke (>1 year) and mild to moderate motor recovery received 4 weeks of multidirectional stepping reaction retraining. Important tenets of motor learning were optimized for each person during retraining in accordance with the CPF.
  
  
  RESULTS
  Participants demonstrated improved community-level walking balance, as determined with the Community Balance and Mobility Scale. These improvements were evident 1 year later. Aspects of balance-related self-efficacy and movement kinematics also showed improvements during the course of the intervention.
  
  
  CONCLUSIONS
  The application of CPF motor learning principles in the retraining of stepping reactions to improve community-level walking balance in people with chronic stroke appears to be promising. The CPF provides a plausible theoretical framework for the progression of functional task training in neurorehabilitation.
authors.affiliation: C.L. Pollock, PT, MSc, Graduate Programs in Rehabilitation Sciences, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Courtney L
authors.initials: CL
authors.lastname: Pollock
authors.forename: Lara A
authors.initials: LA
authors.lastname: Boyd
authors.forename: Michael A
authors.initials: MA
authors.lastname: Hunt
authors.forename: S Jayne
authors.initials: SJ
authors.lastname: Garland
mesh_terms: D000368:Aged; D015331:Cohort Studies; D005081:Exercise Therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D004856:Postural Balance / Q000502:physiology*; D020127:Recovery of Function; D020521:Stroke / Q000503:physiopathology* / Q000523:psychology; D000071939:Stroke Rehabilitation; D013647:Task Performance and Analysis; D016896:Treatment Outcome; D016138:Walking / Q000502:physiology*