The concept of intensive therapy is to provide rehabilitation interventions at higher dosages. The purpose of this is to align our therapy approaches with contemporary knowledge of neuroplasticity by harnessing principles of motor learning to acquire new skills. So really, what we are saying is lots of practice in a short period of time right? Well, not quite. Simply doing lots of practice of something doesn’t necessarily mean it is effective.
So then the question really becomes - how often, how long and what is the actual strategy?
To answer this question, we apply the 3 - 6 - 9 principle.
This means 3 sessions a week for 6 weeks whilst harnessing the 9 principles of motor learning. The next question is why?
There is a lot of work that needs to be done to establish the exact dosage of therapy that is required to make a change. It depends on the type of goals, age of the person, the type of training, the cost involved and importantly - what is feasible? The impact of a lot of sessions can place undue stress on family dynamics and excessively fatigue the individual undergoing intensive therapy making sessions less effective.
How often or Frequency: Where does the 3 sessions a week come from?
Training new skills, particularly if it involves strengthening or fitness involves muscles. Muscles that undergo strengthening need repetition, rest and recovery. For many children, new skills do require strengthening - whether it is walking, sitting or reaching, strengthening is an important component. If muscles haven’t been used adequately in specific positions for specific tasks, they need to be strengthened in the way that they need to be used. When strengthening muscles or when fitness needs to increase, it is recommended that training occurs with enough rest e.g. on non-consecutive days. Lots of practice and strengthening is fatiguing and it can mean that you won’t get the most out of every session. Three days a week is a great balance of enabling adequate practice to occur whilst also enabling rest and recovery.
How long or Duration: Where does the 6 weeks come from?
This has largely come from research we have conducted which is again informed by previous research and current recommendations on physical activity. In our iStride study, we found that 6 weeks was an ideal time to make significant improvements in gross motor and walking skills. In fact, we called week 5 - “magic week 5” because we consistently saw changes becoming obvious and by week 6, both children and their parents were ready for it to finish. Families in our study reported that 6 weeks was feasible in that it was do-able whilst balancing home life, school and work, any additional weeks was deemed as being too stressful. At Healthy Strides, we have adopted the 6 weeks largely because of these reasons and we see it as the minimum time to make a meaningful change. Yes you could decide to keep going for longer but this is costly and the additional effect is unknown.
For skills that don’t involve walking but rather focus on hand skills or task specific skills, research has suggested that more hours in a day over a shorter period of time can have some benefits. However it is unclear whether any gains made actually carry over beyond the intensive therapy period. There is likely a relationship between the number of minutes of practice and number of weeks of practice but this needs to be balanced with what is feasible for children and families. If durations are shorter i.e. same number of sessions over a shorter number of weeks, the impact of fatigue needs to be carefully considered.
What is the strategy? What are the 9 principles of neuroplasticity?
As mentioned earlier, just doing lots of therapy in a condensed period of time is intensive but it isn’t necessarily effective. Put simply, why would we do therapy if it doesn’t provide some sort of benefit?
Kleim and Jones published an influential article in 2008 outlining the 10 principles of motor learning that support neuroplasticity. Whilst 3-6-10 doesn't roll off the tongue quite as nicely as 3-6-9 ;) we have combined the Use it or lose it and Use it and Improve it principles.
The 9 principles includes:
All of these principles need to be part of every therapy session and over the entire intensive therapy program. At Healthy Strides, we integrate each of these principles into each session over the 6 weeks by following a 4 phase strategy.
The first phase is Elicitation where goals are set and all baseline assessments are completed. This is so important because it establishes the true baseline of where children are at so that the right program can be put in place as quickly as possible. Over a 6 week program or 18 sessions, the elicitation phase occurs in sessions 1 and 2.
The second phase is Stabilisation which occurs in sessions 3 to 5. This is where the formulation of a therapy program occurs with each of the principles intentionally integrated for each individual. This is such an important phase because it prepares for the very important consolidation phase.
The third phase, Consolidation, is where there is mass practice of the desired skill. This is where new skills develop and it is so important that the program is very targeted, intentional and specific. This phase occurs from session 6 to 15.
The fourth and final phase is Generalisation where the new skills are challenged and practiced in different settings. This prepares children to use their skills outside of the therapy setting so that the new skill can be used beyond the therapy program. This phase occurs from session 16 to 18.
As you can see, spreading the therapy sessions over 6 weeks gives children time to learn the skill whilst also enabling rest and recovery. However, if only shorter durations are possible, it is just important to establish what kind of goals are feasible and consider what additional practice is required outside of the therapy sessions in order to obtain adequate dosage.
Setting goals and expectations are important and in many cases, shorter durations might just mean that we can complete the Elicitation and Stabilisation phase only leaving the consolidation and generalisation to occur at home or school.
At Healthy Strides, each session has a purpose and the principle of 3-6-9 provides a framework that aims to optimise the achievement of goals and new skills whilst also balancing the needs of life outside of therapy because friends, family and fun are equally as important.