Grounding Early Intervention: Physical Therapy

Cannot Just Be About Motor Skills Anymore

Michele A. Lobo, Regina T. Harbourne, Stacey C. Dusing
and Sarah Westcott McCoy
PHYS THER. 2013; 93:94-103.
Originally published online September 20, 2012
doi: 10.2522/ptj.20120158

The online version of this article, along with updated information and services, can be
found online at: http://ptjournal.apta.org/content/93/1/94

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Gait and Locomotion Training
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 Perspective

Grounding Early Intervention:

Physical Therapy Cannot Just Be
About Motor Skills Anymore
Michele A. Lobo, Regina T. Harbourne, Stacey C. Dusing, Sarah Westcott McCoy
M.A. Lobo, PT, PhD, Physical Ther-
apy Department, 329 McKinly This perspective article provides support for 4 interrelated tenets: grounded
Building, University of Delaware, perceptual-motor experience within cultural and social contexts forms cognition;
Newark, DE 19716 (USA). Address
all correspondence to Dr Lobo at: exploration through early behaviors, such as object interaction, sitting, and locomo-
malobo@udel.edu. tion, broadly facilitates development; infants and children with limited exploration
are at risk for global developmental impairments; and early interventions targeting
R.T. Harbourne, PT, PhD, PCS,
Munroe Meyer Institute, Univer- exploratory behaviors may be feasible and effective at advancing a range of abilities
sity of Nebraska Medical Center, across developmental domains and time. These tenets emphasize that through the
Omaha, Nebraska. promotion of early perceptual-motor behaviors, broader, more global developmental
S.C. Dusing, PT, PhD, Department advancements can be facilitated and future delays can be minimized across domains
of Physical Therapy, Virginia Com- for infants and children with special needs. Researchers, educators, and clinicians
monwealth University, Richmond, should build on these tenets to further demonstrate the effectiveness of targeted early
Virginia. interventions. The goals of these interventions should be not only to advance targeted
S.W. McCoy, PT, PhD, Program in perceptual-motor skills in the moment but also to more broadly advance future
Physical Therapy, Department of abilities and meet the early intervention goal of maximizing children’s learning
Rehabilitation Medicine, Univer- potential.
sity of Washington, Seattle,
Washington.

[Lobo MA, Harbourne RT, Dusing

SC, McCoy SW. Grounding early
intervention: physical therapy
cannot just be about motor skills
anymore. Phys Ther. 2013;93:
94 –103.]

© 2013 American Physical Therapy

Association

Published Ahead of Print:

September 20, 2012
Accepted: September 17, 2012
Submitted: April 2, 2012

Post a Rapid Response to

this article at:
ptjournal.apta.org

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 Grounding Early Intervention

T
he purpose of this article is to Depending on the theory of develop- experience on processes such as
support the proposition that ment used, the terms “development” myelination of axons,13 maturation
early intervention focused on and “learning” can represent differ- and connectivity of white matter,14
key perceptual-motor behaviors can ent processes. In this article, we use and temporal activation and volume
improve an individual’s ability to the term “development” to represent of gray matter.15 The grounded cog-
function and participate in the pres- the compilation of behaviors, abili- nition perspective has gained
ent moment, as well as advance his ties, and knowledge already learned increasing support in disciplines
or her future development across and established by an individual. We ranging from philosophy to cogni-
domains. First, we define cognition use the term “learning” to represent tive psychology, education, and
and defend the idea that cognition is the compilation of behaviors, abili- robotics.2,16,17 Research support
grounded in everyday experi- ties, and knowledge presently being over the past decades has demon-
ences.1,2 Second, we briefly review acquired by an individual. strated the influence of perceptual-
the literature on the effectiveness of motor experience on tasks involving
early intervention, noting the lack of A primary goal of early intervention memory, knowledge, language,
support for current perceptual- is to advance cognition and readi- thought, and social interaction.10,18
motor interventions. Third, we use ness to learn for infants and children The concept of grounded cognition
object interaction, sitting, and loco- with special needs. Achieving this is already embedded in certain theo-
motion as examples to demonstrate goal requires an empirically sup- retical frameworks, including
that exploration through early ported model for how these abilities dynamic systems theory and ecolog-
perceptual-motor behaviors signifi- emerge. In the 20th century, cogni- ical systems theory.19,20 As empirical
cantly affects future ability across tion was predominantly viewed as a support continues to grow for the
developmental domains,3,4 that process occurring independently of concept of grounded cognition and
infants with limited exploration are the body, environment, and other theories that encompass it, it is clear
at risk for a broad range of impair- people.8 Perceptual information that physical therapy interventions
ments,5,6 and that early intervention served as input and behavior should be redesigned on the basis of
programs targeting key exploratory resulted as output from a cognitive these theories; redesigned interven-
behaviors within social contexts (as system that was separate and unaf- tions should replace more tradi-
opposed to practicing less variable fected by perceptual-motor experi- tional, less effective interventions
behaviors in more isolated social sit- ence (Fig. 1A). This view has been based on theories lacking support,
uations and environments) may be challenged recently as proponents of such as those based primarily on
optimal for improving a range of abil- grounded, or embodied, cognition maturation, reflex control and inhi-
ities across developmental domains have argued that perceptual-motor bition, and more passive
and time. We conclude by discussing experience plays an integral role in experience.21
the implications of applying a cognition.8,9 In this view, rather than
grounded cognition lens to early serving simply as input and output Early Intervention
intervention practice, therapist edu- for an independent cognitive struc- Reviews of current early interven-
cation, and research. ture, perceptual-motor experience tion practices do not offer clear guid-
within environmental, social, and ance to those searching for a model
Grounded Cognition cultural contexts actively builds, for best practice. There is evidence
What does the term “cognition” maintains, and alters cognition that some early intervention pro-
encompass? According to Matlin,7 (Fig. 1B).2,10 This view revisits ideas grams are effective at advancing
“cognition or mental activity describes proposed more than 2,000 years ago long-term development, although to
the acquisition, storage, transforma- by ancient philosophers and more varying degrees. For instance, some
tion, and use of knowledge.” Cogni- recently by Piaget and Vygotsky.10 –12 early intervention programs can
tion includes a wide range of mental Although this concept of grounded
processes, such as those involved with cognition is not novel, what is new is
perception, action, memory, lan- that technology and research meth- Available With
guage, problem solving, reasoning, ods that allow scientific testing of This Article at
decision making, and social interac- this concept have been developed ptjournal.apta.org
tion. Therefore, when we discuss cog- over the past several decades.
• Discussion Podcast with Lisa
nition, we mean not only more tradi- Chiarello and authors Michele
tional cognitive abilities but also The concept of grounded cognition Lobo and Regina Harbourne.
broader perceptual-motor, language, is supported by mounting evidence Moderated by Jan Willem Gorter.
and social abilities. of the effects of perceptual-motor

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Grounding Early Intervention

of randomized trials of early inter-

vention for children at high risk
found that motor skills were not
consistently affected by early
intervention.28

It is clear that there is a gap in the

current knowledge about which
early interventions facilitate the best
outcomes. The costs of minimal effi-
cacy for early interventions are high
both financially and in quality of life
for families receiving services. There-
fore, identifying which interventions
can reliably improve perceptual-
motor ability, cognition, and readi-
ness to learn is imperative.

Object Interaction, Sitting,

and Locomotion as Models
for Grounded Cognition
Object interaction, sitting, and loco-
motion are examples of early
perceptual-motor behaviors that
allow infants to explore their envi-
ronment and to acquire knowledge.9
Here we describe how these behav-
iors broadly affect development,
thereby serving as models for
grounded cognitive theory. Next, we
provide evidence suggesting that
delays in each of these behaviors
Figure 1. can negatively affect development.
(A) More traditional view of cognition as something that exists outside of one’s everyday Finally, we suggest potential inter-
experiences. (B) Grounded view of cognition as something that is created, maintained, ventions to improve these behaviors.
and altered by everyday perceptual-motor experiences within social and cultural con-
texts.
These interventions are aimed at
improving targeted perceptual-
motor function to advance cognition
and to prepare children to learn in
have long-lasting effects on out- did not have better literacy out- school.
comes such as school perfor- comes in first and second grades
mance,22 psychosocial skills,23 and than children who received typical Object Interaction, Sitting, and
perceptual-motor skills.24 For infants Head Start services.27 A systematic Locomotion in Relation to
born preterm, some interventions review of the early intervention Grounded Cognition
provided in the first years of life may literature demonstrated that early Object interaction, sitting, and loco-
advance cognition, receptive lan- perceptual-motor interventions motor abilities are important
guage, visual-motor, and spatial skills based on the neurodevelopmental because they allow infants to gain
at preschool age.25,26 There also are treatment approach were not effec- information about the interrelation-
studies suggesting that other early tive at advancing development, ships among their bodies, objects,
intervention programs do not result whereas interventions focused on and people.3,29 These behaviors are
in long-term developmental advance- advancing general motor develop- complex, dynamic, and continually
ments. For instance, children who ment and enhancing caregiver- coevolving throughout the first years
participated in a special literacy pro- child interactions did advance devel- of life.30 Infants with typical devel-
gram in Head Start before school age opment.21 Similarly, a recent review

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 Grounding Early Intervention

opment begin to perform these objects to gain more knowledge.36 the mouth during oral exploration
behaviors sequentially during the For instance, infants who were leads to use of the vocal tracts in new
first year of life. Although develop- developing typically and who ways to produce novel types of
mental trajectories for these behav- reached earlier had more mature vocalizations with unique phonetic
iors can be variable, we outline here object exploration ability in the fol- characteristics.48 The performance
an example of what is typical. lowing months,37 and infants who of rhythmical arm movements (bang-
had experience using hook-and-loop ing) facilitates the emergence of bab-
Object interaction is the ability to mittens to help retrieve and explore bling.49 From 9 through 26 months
hold, manipulate, and explore objects earlier had greater object of age, the way in which infants use
objects. It begins with grasping at engagement and more sophisticated objects based on their specific prop-
birth and becomes increasingly more object exploration performance 1 erties for construction play is more
controlled and targeted to object year later.38 strongly associated with the emer-
properties throughout the first years gence of words and an increase in
of life.31 Infants with typical devel- Sitting advances cognition by provid- vocabulary size than is chronological
opment begin to retrieve desired ing infants with an improved ability age.50 Object interaction also affects
objects at approximately 4 or 5 to process visual information.39,40 receptive language abilities. For
months of age by reaching.32 In the The interaction of postural control instance, 20-month-old infants are
months after the onset of reaching, during sitting and visual attention in better able to learn the names of
infants are able to maintain a vertical infancy facilitates future cognitive objects when the objects can be
position as they learn to sit. This development because visual atten- explored using a greater number of
upright position allows infants a tion is a key factor in problem solv- actions.51
novel perceptual view of their ing.41 The coordination of improved
world, as well as a new play position gaze stabilization and manual skills The ability to explore objects also
on which they can impose their during sitting is accompanied by affects infants’ social interactions.
already developing object interac- increased possibilities for object For example, while infants spend
tion behaviors. In the months after interaction and learning.42 For exam- more time looking at people than
the onset of sitting, infants are able ple, sitting allows infants to use their objects before the onset of reaching,
to move around their environment, hands freely to put objects together they learn to share their attention
crawling at approximately 8 months and take them apart, a behavior that between people and objects and to
of age and walking at approximately forms the foundation for understand- involve objects in their social inter-
12 months of age. This freedom of ing important mathematical actions after the onset of reaching.52
movement greatly expands opportu- concepts.43 After the onset of reaching, caregiv-
nities to interact and learn, as infants ers use objects more in their play
move to desired objects, locations, In the second half of the first year of with infants, and infants show
and people who are out of their sta- life, infants demonstrate significant objects to others as tools to elicit
tionary reach. advances in problem solving and spa- social interactions.53
tial memory in association with loco-
Infants’ abilities to explore objects motor experience. For instance, The ability to sit also greatly affects
and to interact with people through infants with more locomotor experi- language development and social
object interaction, sitting, and loco- ence are more successful at spatial interaction. Sitting upright elicits
motion broadly affect their develop- problem solving and memory tasks, physical changes in respiratory and
ment. The frequency and variety of such as choosing the most efficient articulatory structures that affect the
interactions that infants and children path for reaching a desired goal and types of sounds that infants pro-
have with objects teach them about finding hidden targets.44,45 duce.54 Sitting is associated with a
object properties and how to repre- larger number of utterances per
sent or form memories of objects.33 Object interaction, sitting, and loco- breath, a decrease in simple vowel
Object interaction facilitates the abil- motor behaviors also affect language production, and greater variability of
ity to segregate or group objects, to development and social interaction. consonant-vowel utterances.55 In addi-
recognize objects when only parts of The information that infants gather tion, sitting upright prompts the
the objects are in view, and to rec- through object interaction aids in tongue to fall further forward in the
ognize objects that are familiar.34,35 infants’ learning to categorize and vocal tract, enhancing the production
Object interaction even teaches discriminate objects, 2 foundational of consonant-vowel utterances.46
infants novel, more sophisticated abilities for language develop-
ways in which they can act upon ment.46,47 Placement of objects in

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Grounding Early Intervention

The ability to locomote affects how Likewise, the amount of focused Some literature supports the idea
infants communicate and inter- examination of objects at 7 months that delays in sitting or locomotor
act.3,56 As infants gain locomotor of corrected age in infants born pre- abilities broadly and negatively affect
experience through crawling, they term was predictive of hyperactivity other areas of development. Infants
use more gestures to communicate or impulsivity problems and cogni- who were born preterm and had
with others, they demonstrate less tive disabilities through 5 years of abnormal sitting behaviors (charac-
negative affect (crying or fussing), age.59 At 9 months of corrected age, terized by excessive neck, arm, and
their parents perceive them as more infants born preterm at high risk had trunk extension) during infancy had
emotionally positive (smiling and less sophisticated object exploration poorer cognitive and problem-
laughing more), and they initiate ability, with less fingering, rotating, solving abilities at 18 months of age
interactions with others more often and transferring of objects between than did infants who were born pre-
during free play.3,56 Compared with hands, than infants born full-term or term but had normal sitting behav-
crawling infants, walking infants use preterm at low risk; this finding was iors during infancy.66 Children who
even more gestures and vocaliza- related to poorer cognitive perfor- had myelomeningocele monitored
tions as they engage in early shared mance at 24 months of age.6 from birth through 14 years of age
attention with people and objects.57 and who attained the ability to walk
Infants born with Down syndrome had significantly higher intelligence
Thus, the research strongly suggests had less sophisticated object explo- quotients than children who had
that early object interaction, sitting, ration behavior than infants with typ- myelomeningocele at similar neuro-
and locomotor behaviors are impor- ical development from 6 through 10 logic levels and similar brain abnor-
tant vehicles for promoting future cog- months of age.60 At 8 to 16 months malities but who did not attain the
nitive, perceptual-motor, language, of age, infants with Down syndrome ability to walk.67 Early delays in self-
and social-emotional development. had less object exploration behavior locomotion can negatively affect
and less coordinated attention with future school performance and
Object Interaction, Sitting, and people and objects than infants with accomplishment of activities of daily
Locomotion in Relation to typical development.61 At 22 months living. For instance, delays in higher-
Grounded Cognition in of age, infants with Down syndrome level motor skills such as locomotion
Populations at Risk for had decreased object engagement, were associated with diminished
Developmental Delays shorter sequences of goal-directed visuospatial abilities, perceptual-
A growing body of literature sug- behavior with objects, higher rates motor cognition, and attention in
gests that for infants and children at of object rejection, and less pleasure school-age children who were born
risk for and with developmental when their actions on objects caused preterm,68 and delays in locomotor
delays, object interaction, sitting, an associated reinforcement com- abilities were associated with poorer
and locomotor behaviors play similar pared with infants with typical future life habits in children with
key roles in development. Conse- development.62 cerebral palsy (CP).69 Thus, the liter-
quently, delays in the performance ature suggests that object interac-
of these behaviors would be Infants later diagnosed with autism tion, sitting, and locomotion are
expected to limit infants’ abilities to spent less time in functional and important early behaviors that facili-
gain information about the interrela- symbolic play with objects between tate global development and should
tionships among their bodies, 9 and 12 months of age.63,64 At 12 be a focus of early intervention.
objects, and people. months of age, infants later diag-
nosed with autism spent more time Potential Interventions to
Delays in the ability to interact with spinning, rotating, and performing Advance Object Interaction,
objects have been found to broadly unusual and persistent visual explo- Sitting, Locomotion, and
and negatively affect other areas rations with objects.65 These repeti- Grounded Cognition
of development. For example, tive behaviors with objects at 12 Recent studies suggest that interven-
4-month-old infants born preterm at months of age were significantly tions can be provided to infants to
high risk required longer time peri- related to future cognitive outcomes improve their object interaction, sit-
ods to explore objects before they and severity of symptoms at 36 ting, and locomotor behaviors and,
could recognize them as being famil- months of age. Thus, infants and chil- as a result, to more broadly advance
iar and had difficulty identifying dren with a variety of special needs their cognition. For example, the
other objects as being different; show delays and differences in their onset of reaching in infants with typ-
these infants then had poorer intelli- object interaction behaviors that are ical development can be advanced
gence quotients at 8 years of age.58 related to future cognitive abilities. by encouraging general arm move-

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 Grounding Early Intervention

ments through play involving tether- that parents used included bringing driven powered-mobility equipment.
ing an infant’s arms to an overhead the object into contact with the Studies have shown that cognitive,
toy that is out of reach yet moves child, vocalizing, moving the object social, and language development
when the infant’s arm moves.70 In within the child’s view, creating can be advanced through powered-
addition, reach onset as well as visual or sound effects for the object, mobility interventions for infants and
future object exploration and means- and moving their hands within the young children with myelomeningo-
end (cause-effect) learning abilities child’s view. cele, CP, and other developmental
can be advanced by performing early disabilities.77,78
reaching and object exploration play The literature also suggests that
with infants.29,37,70 A host of future there are ways to improve sitting Therefore, there is growing support
behaviors—from reach onset ability. For example, sitting ability in for the premise that object interac-
through object exploration, sitting, infants with typical development can tion, sitting, and locomotor behav-
and locomotion—in infants with typ- be improved by allowing the infants iors can be advanced in infants and
ical development can be advanced opportunities to reach for objects children with or at risk for disabili-
through a 3-week education pro- during play while sitting.73 Sitting ties if the appropriate interventions
gram for caregivers on how to han- ability and underlying postural con- are used. Such interventions are
dle and position their 2-month-old trol can be advanced in infants who characterized by their focus on
infants.4,37 are younger than 2 years of age and exploration, active trial and error
who have CP or are at risk for CP by hypothesis testing, variability of
A recent randomized clinical trial providing interventions that focus practice, high frequency of practice,
suggests that these same experi- on the exploration of one’s body, and caregiver education and involve-
ences provided for a longer duration objects, and others and that incorpo- ment.71,74,79 Building skills that are
are similarly beneficial for infants rate variability, complexity, and the valuable to the child and family can
born preterm.71 In that trial, infants refinement of multiple sitting strate- broadly support development and
born preterm were provided with gies.74 Such interventions have been improve learning.
these intervention experiences from more effective at advancing sitting
2 through 4 months of age. The pre- and postural control abilities than Conclusions and Clinical
term infants in the group receiving practice during static sitting with Implications
the intervention reached earlier, assistive equipment. These findings In this perspective article we sup-
reached more consistently, and suggest that the use of adapted seat- ported the proposal that early inter-
maintained contact with objects to ing for infants and children unable to vention providers should view
explore them for longer durations sit independently should be comple- perceptual-motor behaviors not only
than a control group of preterm mented with frequent opportunities as means to improve function and
infants who did not receive the to sit without assistive devices so participation in the present moment
intervention.71 that these infants and children can but also as vehicles to broadly facili-
develop the active learning and tate future development across
There may be ways to encourage movement adjustments required to domains and to advance readiness to
caregivers of children with autism to control sitting, to explore, and to learn in school (Fig. 2). We sup-
interact and play with their children learn. ported this view by highlighting evi-
to promote more advanced object dence demonstrating that cognition
exploration and cognitive develop- There is a growing body of literature is grounded in perceptual-motor
ment. For instance, a recent study highlighting some effective ways to experiences within social and cul-
showed that preschoolers with advance early locomotor behaviors. tural contexts. We presented object
autism performed increased object The onset of independent walking interaction, sitting, and locomotion
exploration with more sustained in infants with Down syndrome can as models to demonstrate that early
attention when their parents used 3 be advanced, and walking ability perceptual-motor behaviors can
or more cues to encourage them to in children born preterm and chil- broadly affect development. We pro-
maintain focus on the object in dren with CP can be improved vided evidence that delays in these
play.72 When parents used fewer through treadmill walking prac- behaviors often are present and are
cues or used cues that redirected tice.75,76 Another interesting and related to future broader delays in
children’s attention away from the growing area of research aims to pro- infants and children with a variety of
object of focus, the children were vide infants and young children with diagnoses. Finally, we provided
less likely to engage in sustained the developmental benefits of inde- examples from the literature of how
exploration of the object. The cues pendent locomotion through child- the development of these early

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Grounding Early Intervention

being “The child will sit indepen-

dently for 1 minute,” the goal could
be “The child will use sitting posture
to explore objects during group play
on the floor with peers for 1
minute.”

Physical therapists also should advo-

cate for the role of active experience
in learning and development by edu-
cating other team members, includ-
ing families, teachers, speech thera-
pists, occupational therapists, and
other physical therapists, who may
not be aware of the broad role that
perceptual-motor experience plays
in development. Recent studies have
Figure 2. linked interventions focused on edu-
Hypothetical trajectories from birth toward level of readiness to learn and participate in cation, family involvement, and
preschool at 3 years of age. The hypothetical onsets of object interaction, sitting, and active performance of variable,
locomotion behaviors are indicated by the circle, triangle, and square, respectively, on appropriately challenging tasks with
each trajectory. In the typical development trajectory, object interaction, sitting, and
locomotion emerge in the first year of life and act as vehicles to provide children with
more positive future developmental
the tools needed to be successful in school. In the trajectory for children who have outcomes.80 Because physical thera-
developmental delays and are provided ineffective or no early intervention services, pists have expert knowledge regard-
object interaction, sitting, and locomotion behaviors emerge later and are performed ing perceptual-motor behaviors, edu-
less frequently and less variably—resulting in poorer cognitive development and lack of cating government agencies and
readiness to learn and participate by preschool age. The trajectory for children with
developmental delays shows how this situation can be transformed with effective early
insurance companies that approve
intervention targeting early perceptual-motor behaviors to advance cognition and funding for services about the empir-
readiness to learn in school. ical support for grounded develop-
ment can help justify the need for
physical therapy services for infants
behaviors can be effectively research (Table). In pediatric clinical and children with special needs. To
advanced to increase participation practice, physical therapists should meet these goals, pediatric clinicians
and to address the primary goal of be aware of the impact of need to be uniquely qualified to
early intervention to promote readi- perceptual-motor experience on assess and intervene across tradi-
ness to learn. Understanding the con- other aspects of development and tional domains. They also need to be
cept of grounded cognition and its learning. They should account for able to translate scientific informa-
supporting evidence is important this in determining whether a child tion to a host of people—from chil-
because it can allow physical thera- requires physical therapy services dren to legislators—across a variety
pists and other early intervention and how those services should be of settings—from the playground to
providers to focus on minimizing provided. For instance, the concept legislative buildings.
future delays before they happen; to of grounded cognition reinforces the
target their interventions at behav- idea that it is not sufficient to assess Therapists should use the concept of
iors that are foundational in develop- whether a child can perform a grounded cognition in concert with
ment; and to reaffirm the signifi- behavior in isolation; it must be tools such as the International Clas-
cance of physical therapy in early determined how the child uses this sification of Functioning, Disability
intervention, where the focus is on behavior to explore objects, people, and Health (ICF) to guide their inter-
preparing children to be ready to and events in social situations ventions.81 These tools can guide
learn in school. because these are the processes therapists to think beyond impair-
through which learning and partici- ment and perceptual-motor function
We propose that the concept of pation occur.1 Goal setting should to participation in activities with
grounded cognition should be reflect the link between perceptual- objects, people, and events that
actively incorporated into physical motor experience and grounded afford learning. Furthermore, they
therapist practice, education, and cognition. Thus, instead of a goal can guide therapists to consider how

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 Grounding Early Intervention

this participation can broadly Table.

advance future development and Recommendations for Incorporating the Concept of Grounded Cognition Into Early
learning abilities. For instance, it is Intervention Practice, Education, and Research
not sufficient to provide interven- Domain Recommendation
tions to advance early locomotor Intervention—clinicians 1. Justify early intervention eligibility and service provision by
behavior in social and behavioral iso- should: educating government agencies and insurance companies about
lation. Therapists can best advance the broader role of active perceptual-motor experience in learning
and development.
future development for their clients
by setting goals and designing inter- 2. For assessment, goal setting, and intervention, ensure that
children can use perceptual-motor behaviors not in isolation but
ventions that allow clients frequent, in situations that allow them to explore objects, people, and
daily opportunities to use their events.
perceptual-motor abilities to maxi- 3. Provide people with frequent, daily opportunities to actively
mize their interactions with objects, use their perceptual-motor abilities to maximize their interactions
with objects, people, and events.
people, and events. Thus, in the case
of locomotion, 1 component of an 4. Think about and transition flexibly among impairment,
functional ability, participation, and current and future
intervention could be to educate development and learning across domains for each child to
team members to provide daily design and provide optimal interventions.
opportunities for a child to crawl or Education—physical 1. Redefine how teaching should be done in physical therapist
walk among caregivers and peers therapist educators education programs. Transition from teaching about motor
while gesturing, naming, turn taking, should: learning to teaching about grounded cognition and learning as
broader concepts across domains.
and exploring a variety of objects
2. Assimilate and share the growing body of research findings
rather than locomoting in isolated across disciplines by creating book chapters, review articles,
environments separate from peer perspective articles, and continuing education courses to make
interactions, play, and problem this information accessible to intervention providers and families.
solving. Research—physical 1. Review the literature more broadly for awareness of how
therapist researchers learning about the perceptual-motor behavior of focus can more
should: broadly affect development and learning across domains.
Incorporation of the concept of
grounded development into physical 2. Complement more focused perceptual-motor measurement
tools with assessment tools that more broadly capture changes in
therapist practice requires rethink- cognitive, social, language, and participation behaviors and
ing the way in which physical ther- abilities related to the perceptual-motor behavior being studied.
apist students and practicing physi- 3. Collaborate with experts in complementary fields to design and
cal therapists are taught about perform research studies to provide information about how to
maximally and broadly affect learning for people with perceptual-
learning. Currently, physical thera- motor delays.
pist education programs emphasize
and teach students about the con-
cepts of motor learning. Yet, mount- On the contrary, physical therapists cles, perspective articles, and con-
ing evidence for the proposal that need to be educated about the tinuing education courses. Physical
the broader construct of cognition is grounded cognition literature from therapists need to be aware of such
grounded in perceptual-motor expe- fields such as developmental psy- research to ensure that theories and
rience presents a challenge to think chology and education so that they methods of practice evolve to reflect
about learning less as a domain- can design the most effective inter- and keep pace with what current
specific phenomenon and more as a ventions and understand the broader science suggests is best practice.
phenomenon with consistencies impact of those interventions. Edu-
across domain and time. Thelen2 cators and researchers in the field of Finally, we propose that physical
argued that across the life span, the physical therapy are the best therapist researchers incorporate
processes at work when people equipped to assimilate and translate the concept of grounded cognition
learn perceptual-motor behaviors the growing body of research find- into their studies. Most research sup-
must be the same as those at work ings across disciplines, all of which porting this concept is fairly recent
when they learn cognitive skills. have their own challenging jargon, (within the last few decades) and has
Therefore, it is no longer sufficient so that clinicians can make use of the not been conducted in the field of
to teach about theories of motor most recent findings to benefit their physical therapy.10 Dynamical sys-
learning in isolation. clients. We encourage these profes- tems theory is likely a useful tool for
sionals to pursue these activities by capturing and describing the mind-
creating book chapters, review arti- body-world interconnections under-

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Grounding Early Intervention

lying the concept of grounded cog- tion on Pediatrics, Planning Grant 2008 15 Driemeyer J, Boyke J, Gaser C, et al.
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nition.2 Yet, although the dynamical ing—revisited. PLoS One. 2008;3:e2669.
ting Balance or Reaching in Infants Born Pre-
systems theory is predominant in 16 Nunez RE, Edwards LD, Matos JF. Embod-
term? Principal Investigator: Susan C. Dus-
much of the current physical therapy ing, PT, PhD, January 1, 2009 –July 1, 2011);
ied cognition as grounding for situated-
ness and context in mathematics educa-
literature, the concept of grounded and NIH/NCMRR/NICHD/NINDS grant tion. Educational Studies in
cognition has not been incorporated 1K12HD055931-01 (Multicenter Career Mathematics. 1999;39:45– 65.
into physical therapy research. Per- Development Program for Physical and 17 Smith L, Gasser M. The development of
Occupational Therapists and Comprehen- embodied cognition: six lessons from
haps the greatest challenge to incor- babies. Artificial Life. 2005;11:13–29.
sive Opportunities in Rehabilitation Research
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physical therapy research involves Michael Mueller, PT, PhD, FAPTA, Septem- principles from embodiment. Dev Rev.
2005;25:278 –298.
identifying the behaviors and abili- ber 15, 2007–August 31, 2012).
19 Thelen E, Schoner G, Scheier C, Smith LB.
ties across domains that may be influ- DOI: 10.2522/ptj.20120158 The dynamics of embodiment: a field the-
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American Physical Therapy Association, Sec-

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 Grounding Early Intervention

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 Grounding Early Intervention: Physical Therapy
Cannot Just Be About Motor Skills Anymore
Michele A. Lobo, Regina T. Harbourne, Stacey C. Dusing
and Sarah Westcott McCoy
PHYS THER. 2013; 93:94-103.
Originally published online September 20, 2012
doi: 10.2522/ptj.20120158

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