Paper II

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Paper II

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Infant Behavior & Development 46 (2017) 115–123

Contents lists available atScienceDirect

Infant Behavior and Development

Full Length Article

Let’s play! An observational study of primary care physical therapy with preterm infants aged 3–14 months

Ragnhild B. Håkstad

^a,∗

, Aud Obstfelder

^a,b

, Gunn Kristin Øberg

^a

aUiT The Arctic University of Norway, Faculty of Health Sciences, Department of Health and Care Sciences, Tromsoe, Norway

bNTNU Center for Care Research, Gjoevik, Norway

a r t i c l e i n f o

Article history:

Received 27 June 2016 Received in revised form 20 November 2016 Accepted 10 January 2017 Keywords:

Physical therapy Preterm infants Sensory-motor play Enactive theory

a b s t r a c t

Introduction:Sensory-motor play is at the core of child development and an important element in physical therapist(PT)s’ work to improve infants’ motor skills. In this study, we investigate how PTs scaffold and use play in physical therapy intervention with preterm infants at corrected age (CA) 3–14 months.

Material and methods:We collected data by observing 20 physical therapy sessions. In the analysis, we connected to enactive theory on cooperation.

Results:Successful use of sensory-motor play in physical therapy requires cooperation toward common goals. This is achieved via anenactive therapeutic sensory-motor play approach, in which the PTs plan and tailor the intervention to match the infant’s inter- ests; attune themselves to the infant’s intentions; and incorporate therapeutic measures in sensory-motor play interactions with the child.

Conclusions:Via cooperation and mutuality in therapeutic interactions, PTs can provide play situated learning opportunities that support the infants’ development and understanding of the world.

1. Introduction

Infants born preterm are at risk of developmental delays and impairments that can persist or aggravate during the ﬁrst years of life (Sansavini et al., 2014). In early infancy, preterm infants tend to be less attentive, less responsive and need more breaks from interaction than term infants (Wolf et al., 2002). As these children grow older, they are at risk of learning disabilities, which can in turn affect cognitive, motor and social competencies (Lobo & Galloway, 2013; Spittle et al., 2012). Studies indicate that preterm infants are also at risk of delayed play skills (Korja, Lehtonen, & Latva, 2012;

Vig, 2007). They proﬁt from caregivers’ structuring and scaffolding of play, by which they become more engaged, more attentive and more persistent in play activities (Childress, 2011; Cress et al., 2007). Furthermore, interactions characterized by caregiver sensitivity and synchronized dyadic interactions correlate with better developmental outcomes for preterm infants (Forcada-Guex, Pierrehumbert, Borghini, Moessinger, & Muller-Nix, 2006;Treyvaud et al., 2009).

Pediatric physical therapist (PT)s aim to alleviate preterm infants’ movement problems, enhance motor development and support the infants’ participation in age-appropriate activities (Blauw-Hospers, De Graaf-Peters, Dirks, Bos, & Hadders- Algra, 2007;Campbell, Palisano, & Orlin, 2012;Spittle et al., 2012). In this work, attention and motivation are key factors

∗ Corresponding author at: UiT The Arctic University of Norway, Faculty of Health Sciences, Department of Health and Care Sciences Forskningsparken, 9037 Tromsoe, Norway.

E-mail address:ragnhild.hakstad@uit.no(R.B. Håkstad).

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fortheinfants’motorlearning,masteryofnewskillsandsenseofself-efﬁcacy(Atun-Einy,Berger,&Scher,2013;Brodal, 2010).Sensory-motorplayisinherentlymotivatingforyounginfants,andservesasadrivingforceofinfants’motor,social, cognitiveandlanguagedevelopment(Lifter,Foster-Sanda,Arzamarski,Briesch,&McClure,2011).Viagraduallyadvancing ﬁneandgrosssensory-motorplay,infantscanexpresstheirintentions;discoveremergingcapabilitiesoftheirbody;and developtheirperceptionsandunderstandingsoftheworld(Adolph,2008;Lifter,Foster-Sandaetal.,2011;Lobo,Harbourne, Dusing,&McCoy,2013;Sheets-Johnstone,2011).Duringthisdevelopment,infants’interactionswithobjectsandpeople co-emergeandco-develop(Rossmanith,Costall,Reichelt,López,&Reddy,2014).Thisindicatesacloselinkbetweenplay, interactionandlearning;itisviainteractiveplaywithothersthatinfantslearnhowtomoveandactupontheirworld (Bigelow,MacLean,&Proctor,2004;Rossmanithetal.,2014).

Therefore, topromote learning and developmentfor preterminfantswith potentialattention,responsiveness and enduranceproblems;PTsneedtoengagetheseinfantsininteractivesensory-motorplayactivitiesandscaffoldtheinfants’

abilitytoplay.Motivation,playandsensitivityininteractionarerecognizedasimportantelementsinphysicaltherapy (Blanchard&Øberg,2015;Lifter,Foster-Sandaetal.,2011;Majnemer,2011;Øberg,Blanchard,&Obstfelder,2014).How- ever,playisprimarilyreferredtoasadevelopmentaldomainandacontextinwhichinterventionoccurs(Lifter,Foster-Sanda etal.,2011),andknowledgeislackingregardingtheuseofplayasatherapeutictoolininterventionsforchildrenwithdevel- opmentaldelays(Lifter,Mason,&Barton,2011).Inthisstudy,weexplorethismergingofplayandtherapybasedonthe researchquestion:

InwhatwaysdoPTsscaffoldandusepreterminfants’sensory-motorplayengagementintheirworktoachievetherapeutic goals?

1.1. Theoreticalframework

Inourinvestigation,we connecttoenactiveandphenomenological viewsoncooperation,attentionand intentions (Fantasia,DeJaegher,&Fasulo,2014;Fiebich&Gallagher,2013;Pacherie,2012).Incooperation,thesubjectstakeinto accounttheother’sinterestsandintentions,andacttocomplementtheother’sresponses(Fantasiaetal.,2014).Coop- eratingindividualscommunicatebyverbalandbodilyexpressions,movementsandbehavior.Thus,viatheseembodied interactions,cooperationispossibleevenforyounginfants.Evenmore,cooperationisfundamentaltoinfantdevelopment,in threeinterdependentways(Fantasiaetal.,2014).First,cooperationistheinfant’smodeofbeingwithothers.Second,within theframeworkofcooperationdevelopmentoccurs.Third,developmententailsanadvancementoftheinfant’scooperative abilities.

Cooperationbuildsonintentionsthataregeneratedandtransformedasinteractionproceeds(Fantasiaetal.,2014;Fiebich

&Gallagher,2013;Pacherie,2012).Thisrequiresjointattention,whichmovesfromsimpletomoresophisticatedformsas theinfantdevelops(Fiebich&Gallagher,2013);andengagement,inwhichthesubjectsconnecttoeachotherandallow theinteractiontoacquireitsownmomentum(Fantasiaetal.,2014).Furthermore,cooperationisdynamic;interactions ﬂuctuatebetweentheparticipants’mutualcoordinationwitheachotherandoneparticipant’suni-lateralcoordinationtothe other(Fantasiaetal.,2014).Consequently,cooperationisnotalwayssuccessful.Withinthemomentumanddynamicsof interaction,coordinationcanbreakdownandrepairsmustbemadeforcooperationtocontinue.

2. Materialandmethods 2.1. Studydesign

Thisisaninterpretivestudybasedonobservationaldatafromphysicaltherapysessions.Wevideorecordedthesessions toenableadetailedanalysisoftheinteractionalnatureofclinicalpractice(Heath,Hindmarsh,&Luff,2010).Thestudywas approvedbythereviewboardatNSD–NorwegianCentreforResearchData.

2.2. Studysetting

ThestudywasconductedintheNorwegianprimaryhealthcaresetting,wherepreterminfantsandtheirparentscan receivephysicaltherapybothasapreventiveandatherapeuticservice.MostfamiliesinNorwayreceivepaidmaternityor paternityleaveandstayathomeduringtheinfant’sﬁrstyearoflife.Thus,allphysicaltherapysessionswerewithoneorboth parentspresent.Thesessionstookplaceeitherinthefamily’shomeoratthePT’sworkplace.Floorspacewasanavailable andnaturalsitefortheconductionofphysicaltherapy.Theinfantsquicklyadaptedtotheresearcher’spresence.ThePTs andparentswereencouragedtoproceedwiththesessionasusualandnotmakechangestoaccommodatetheresearcher.

2.3. Studysamplingandrecruitment

PTsatthreehospitalsdistributedinquiriesofparticipationtoparentsofinfantsbornpretermwithagestationalage (GA)≤33weeks,whoreceivedprimarycarephysicaltherapy.Parentsgavetheirconsentviaregularmail,uponwhichthe ﬁrstauthorcontactedthefamiliesandobtainedconsentfromthelocalPT.Parentsof11infantsconsentedtothestudy.Due tocessationoftherapyorPTs’declinationofparticipation,7triadsofpreterminfant,parent(s)andPTwereﬁnallyincluded

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R.B.Håkstadetal./InfantBehavior&Development46(2017)115–123 117 Table1

Informationaboutstudyparticipants.

Infant^a Medicalconditionandmotor impairments

Frequencyofphysiotherapy PT’sexperience Researchervisits

John Bornat29weeksGA.Bilateral hemorrhages,grading unknown.DiagnosedwithCP^b at6monthsage.Severe spasticityinlegs,lowtruncal tone,asymmetricuseofarms.

1perweek 5–15years,mostlywith

children0–18years.

5,7and14monthsCA

Irene Bornat24weeksGA.Typical motordevelopment,minor deviationsinmovement quality.

1permonth 5–15years,mostlywith

children0–18years.

8,9and12monthsCA

Samuel Bornat28weeksGA.Delayed motordevelopment.

1–2perweek <5years,patientsofallages. 4,6and12monthsCA Leonard Bornat28weeksGA.Delayed

motordevelopmentduring infancy,ageadequateat12 monthsCA^c.

1–2perweek <5years,patientsofallages. 4,6and12monthsCA

Hannah Bornat26weeksGA.BPD^d, tracheostomyfrom3months CA.Delayedmotor developmentduringinfancy, ageadequateat13monthsCA.

1perweek–2permonth 15years+,mostlywith children0–18years.

3,8and13monthsCA

Vanessa Bornat29weeksGA.Typical motordevelopment,minor deviationsinmovement quality.

1permonth 5–15years,recentyearswith children0–18years.

3and6monthsCA

Anna Bornat27weeksGA.Left hemispherehemorrhagegrade IV.Delayedmotor

developmentduringinfancy, ageadequateat13monthsCA.

1perweek 5–15years,recentyearswith children0–18years.

6,9and13monthsCA

aInfantnamesareﬁctional.

bCP:Cerebralpalsy.

cCA:Correctedage.

dBPD:Bronchopulmonarydysplasia.

inthestudy(seeTable1).Eachtriadreceivedthreevisitsovera5–10monthsperiod,amountingto20physicaltherapy sessionobservations(duetocessationofphysicaltherapy,onetriadreceivedonlytwovisits).

2.4. Datacollection

Thephysicaltherapysessionswereobservedandvideorecordedbytheﬁrstauthor,fromDecember2012toNovember 2014.Thedurationofsessionsrangedfrom21to54min,withameanof33min.Withahandheldcamera,theresearcher stayedinthebackgroundbutmovedaroundasnecessarytomakeobservationsandrecordings.Videoanglingandzoomwere adjustedtocaptureinteractionsbetweenPT,infantandparent.Theobservationguidecovered(1)Thetreatmentsetting,(2) Contentofphysicaltherapy,(3)PT-Infant-Parentinteractions,and(4)Changesintheinfant’sfunctionduringsessions.

2.5. Dataanalysis

Intheinitial,inductivephaseofanalysiswesummarizedtheimpressionsfromobservationsandthetopicofplayemerged (Malterud,2012;Wang&Lien,2013).Next,allsequencesinvolvingplaywereviewed,transcribedandanalyzedwithafocus oninteractionalandtherapeuticaspectsofthesituations.Atthisstage,werecognizedthat thePTs’utilizationofplay hadtwomainpurposes:(1)Toobservetheinfant’smotorperformance,and(2)Intendingtoimprovetheinfant’smotor performance.Intheproceedinganalysiswefocusedonthelatter.UsingNVivo10(QSRInternationalPtyLtd,2012)asa sortingtool,wesystematicallycodedthecharacteristicsoftheseevents;andcomparedeventsinwhichthePTssucceeded withtheirintenttoimprovetheinfant’smotorperformance,withthecontrastingfailuresoffulfillingthisintention.Thereby, wewereabletoidentifykeyfactorsofthePTs’successfulmergingofplayandtherapy,andcouldusethecomparisonsto challenge,confirmandenrichourinterpretationsofthematerial.Allthreeauthorswatchedanddiscussedtheselected videosequencestogether.Thefirstauthorwasresponsibleforsummarizing,transcribingandcodingthedatamaterial.This writtenmaterialwasreviewedbytheco-authorsandtheanalysiswasdiscussedanddevelopedincollaborativemeetings withallthreeauthors.

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2.6. Trustworthinessandreﬂexivity

Effortstoestablishandmaintaintrustworthinessexistthroughoutthestudy.Thelongitudinaldesignandvarietyinthe infants’conditionsgavearich,nuanceddatamaterialandallowedforin-depthanalysesinaccordancewiththescopeof thestudy.Themaintenanceofanaturaltreatmentsettingwasconfirmedduringdebriefing;thePTsandparentsexpressed thattheobservationswererepresentativetotheirusualsessions.Inpreparationsforthesecondandthirdvisits,thefirst authorreviewednotesofimpressionsandthoughtsfromprevioussessions.Thisensuredspecificityandadaptabilitytoeach situation.Theinitialinductiveapproach,togetherwithsystematicanalyticalstepsanddiscussionofbiasesbetweenauthors;

providedanuancedandcomprehensiveanalysisofourdataandsupportedthevalidityofﬁndings(Malterud,2001).

TheﬁrstauthorisapediatricPTwithworkexperiencefromprimaryhealthcare.Thelastauthor,alsoapediatricPT,has herworkexperiencefromsecondaryhealthcare.Theirsharedinteresttowardinteractionalaspectsinphysicaltherapyhas guidedthedirectionofthestudy.Thesecondauthor,whoisanurseandsociologist,hascontributedtothestudyperspectives, applicationoftheoryandanalysis.

3. Results

Distinctiveinourmaterialweretheinstancesinwhichinteractivesensory-motorplaynotonlyservedasacontext,but actuallybecamepartofthePTs’interventionstrategy.Thisscaffoldinganduseofplayduringtherapywasconditionedbythe PTs’sensitivityininteraction,togetherwiththeintegrationoftargetedtherapeuticactionsintotheongoingsensory-motor playactivities.Theseinteractionprocesses,andtheirﬂuctuationsbetweenfailureandsuccess;reliedonthePT’sabilityto attendandrespondtotheinfant’sexpressionsofinitiative,engagementanddistress.

InouranalysisofthePTs’successfulmergingofplayandtherapy,ourfindingsweresortedintothreecategories:(1) Arrangingthetherapeuticspace,(2)Sensitivityininteractionand(3)Targetedtherapeuticactions.Inourpresentationof findingsweprovideexamplesfromsessionswithJohn,Hannah,AnnaandVanessa;whichillustratethevariationsand contrastsofourfindingsthroughoutthedatamaterial.Toprovidecoherencyandillustratetheinterdependencybetween categories,examplesfromthesessionwithJohnrunsasastorytrailthroughoutourpresentationofresults.

3.1. Arrangingthetherapeuticspace

BothatthePTs’ofﬁcesandinthefamilies’homes,thePTsorganizedatherapeuticplayarenawithequipmentandtoys thatenabledtherapeuticactivitiesinaccordancewiththeinfants’developmentalstageandinterests.Thisorganizationwas basedonthePT’spreviousknowledgeabouttheinfant,andoninformationretrievedfromtheparent(s)attheonsetof sessions.Assessionsproceeded,thePTsgraduallyadaptedthetherapeuticspacetointroducevariationsandnewchallenges totheinfants’playactivities.Fortheinfantswhohaddevelopedmobilityskills,thePTstypicallyarrangedtheroomwith toysontopoffoamblocksorfurnitureatdifferentheights,tomotivatetheinfants’practiceofmovementandtransitional skills.

Attheyoungerages,thePTswouldoftenstartthesessionbypositioningtheinfantinanalignedsupineposition,either onaplaymatoronthelapoftheparentorPT,andthenintroducetoysfortheinfanttolookatandpotentiallygrab.Thisis exempliﬁedinthesessionwithHannah,3monthsCA:

MomandthePTsitnexttoeachotheronthefamilycoach.HannahisheldinahalfsittingpositiononMom’slap, face-to-facewithMom,yetslightlyangledtowardthePT.“Lookatherlookingatyou”,thePTsays.Momsmilesand says:“Hey,heyyou!”ThePTcontinues:“Nowthat’sareallygoodcontactyou’vegotwithher.Butyoudoitlikethistoo, thatyouholdherhere?”ThePTgesticulatesplacingHannahinamoresymmetricpositiononMom’slap.“Yes,Ihold her,Isitalotlikethis”saysMom,andplacesHannahinbetteralignment,restinginmidlineagainstMom’selevated thighsbeforeshecontinues:“Withonehandbehindherheadtoreallygetherupright”.ThePTresponds:“Yes,right right”.ThePTturnstoHannah:“Himyfriend,hi!Nowyousawmeyouknow,yes.Hi!Lookatthat,nowyougotyourself up,yes.Thereyougo.”Next,thePTintroducesatoyinHannah’svisualﬁeld,butHannahismoreinterestedinthePT:

“Youwanttolookatme?That’sveryniceofyou.Yes.”Momjumpsin:“Yes,haha,likespeoplethemost.”ThePTswitches toasecondtoy,morecolorfulthantheﬁrstandwithrattlingsounds.ThistoycatchesHannah’sattention,shetracks itwithhereyesandheadasthePTmovesitindifferentdirections.

TurningtothesessionwithJohn,7monthsCA,thePTarrangesthetherapeuticspaceinaccordancewiththeirtherapeutic goalofachievingamorefunctionalproneposition.Johnhasresistedthepronepositionsincebirth.Heprefersanasymmetric posturewhenplacedinprone(seeFig.1)andquicklyfallsovertohisrightside.ThePTissearchingforwaystomotivate Johntoplayandimprovehismotorskillsinprone.FromprevioussessionssheisawareofJohn’sinterestinsoundsand music.Therefore,shehasbroughtanewkeyboardtomotivatehim.

ThePTplacesJohninproneonaplaymatonthefloor.AsthePTintroducesthekeyboard,shealsoarrangesforMom tojoinintheplayinteractionwithJohn:“Maybeyoucancomedownonthefloorandplayaroundwiththis?”Momsits downonthefloorfacingJohn:“Hello”,shesaysandpushesabuttontostartamelody.

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R.B.Håkstadetal./InfantBehavior&Development46(2017)115–123 119

Fig.1.John’sstartingpositioninprone.

3.2. Sensitivityininteraction

Theinfantscommunicatedtheirmotivation,interestandengagementviaarangeofbodilyexpressions;mimicking,gaze, vocalizations,respiration,bodyorientationandmovements.ThePTsattendedtotheseexpressionsandstrivedtoadjusttheir therapeuticstrategyaccordingtothem.Theycommunicatedwiththeinfantstosupporttheirplayengagement,allowedthe infantstoguidetheirﬁeldofattention;exploredandselectedtoystoengagetheinfant;andmadealterationstothetask andenvironmenttopromotetheinfants’activityandperformance.

InthesessionwithJohn,thePTquicklypicksuponhisinitialsignalsofdistressandmakesalterationstotheactivityto accommodatehim.AsJohnbecomesmoreengagedintheactivity,thePTattendscloselytohisbodilyexpressions,andboth MomandthePTcontinuouslyencouragehim:

John’sinitialresponsetothekeyboardisoneofdiscomfort;hemoansandsquirmswhilethekeyboardisplaying automaticmelodiesathighvolumes.ThePTretrievesthekeyboardfromMom,andsays:“Let’sseeif wecando somethingelsewithit”.Assheswitchestotheplayingofsingletuneswitheachkey,John’sengagementawakens.

EverytimethePTpressesanewkey,Johnmakescheerful‘Heeeh’sounds,liftshisheadandlooksinterchangeablyat thekeyboard,MomandthePT.Theybothrespondwithlaughter,smilesandsmalltalk.Momsays:‘Whatismylittle droolyboydoing?’Astheyproceedwiththeactivity,thePTmonitorsJohn’sgazeandheadpositiontodecidewhenhe isreadyforthenexttune,andboththePTandMomscaffoldJohn’sengagementwiththeirsmilesand‘Oh!’whenever thereisanewtune.Johncontinuestorespondwith‘Heeh’,smilesandgazesatMomandPT.‘Yes,you’redoingvery well’,saysthePTasJohnlooksather.

However,thePTs’responseswerenotalwayssupportiveoftheinfants’engagement.WhenthePTswerepreoccupied bytheirownagenda,theywerelessattentivetowardtheinfants’engagementandsometimesdisruptedtheinfants’play activity.AsanexamplewepresentasituationfromthesessionwithAnna,9monthsCA.WhileDadandthePThavebeen conversing,Annahasbeenplayinginsolitude.Now,thePTwantstoundressAnnabeforethecontinuationofthesession:

Annaislayinginproneinfrontofamirror,sheismakinglow,babblingsoundsandclapsatherownreﬂection.ThePT approachesher:“Arewegrown-upsjusttalkingnow?Andyoufoundagirlthere,didyou?”ThePTgrabsAnna,turnsher awayfromthemirrorandpushesasquaredcushioninfrontit.“Nowitwasgone,yesyes,ohwell”,saysthePT.Anna moansandtriestopullherselfuptothecushion.ThePTresponds:“Yesyes,Iknowyouunderstandthereissomeone there,butit’sgonenowyouknow”.Afterterminatingthemirroractivity,thePTstartstopullsatoyacrosstheﬂoor.

Annagetsinterestedandstartscrawlingtowardit.BeforeAnnareachesthetoy,thePTtakesholdofher,rollsherover tosupineandsays:“Yes,nowwe’regoingtotrytotakeoffsomeclothes”.Afterherbodysuitisremoved,thePTagain introducesthetoyandenticesAnnatorollintopronetofetchit.ButAnnamerelyglancesatthetoyandremains passiveinthesupineposition.

3.3. Targetedtherapeuticactions

Forsensory-motorplaytobecomemorethanacontextforintervention,thePTshadtoincorporatetherapeuticmeasures towardmotorgoalsintotheactivities.AsthePTsidentiﬁedtheinfant’smotorproblemsanddecidedonanadequatestrategy forimprovingtheinfant’sfunctionalskills,theymademodiﬁcationsandintroducednewmotorchallengestotheactivities.

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Fig.2.John’simprovedelbowsupportandheadstabilityinprone.

Therapeutichandlingwasakeyfeatureofthisincorporationoftherapeuticmeasuresintoplay.Fortheinfants,therapeutic handlingcouldimprovetheirmotorperformanceandenabletheirdiscoveryandpursuanceofnewsensory-motorplay possibilities.ForthePTs,handlingenabledtheirdetectionoftheinfant’sdirectionalmovements,useofforceandchanges inmuscletone;allofwhichinformedPTsabouttheinfant’sengagement,complianceandcapacityduringtheplayactivity.

InthekeyboardplaywithJohn,thePTincorporatedhertargetedtherapeuticactionstowardafunctionalproneposition forJohn.TherapeutichandlinginformedheraboutJohn’scapabilitiesandcompliance,andfacilitatedJohn’splayengagement andmotorabilities:

Duringthekeyboardplay,thePTrepeatedlypositionsJohn’sarmstoprovidehimwithbilateralelbowsupport,but everytimeJohnmoansandwigglesbackintohispreferredposition(seeFig.1)withhisleftarmﬂexedunderhis chest,hisrightarmextendedandslightlyacrossmidline,andhisheadrotatedleft.Inspiteofhisstrongengagement withthekeyboardplay,John’sheadfrequentlydrops,hestartstocomplainandisgivenabreak.Laterinthesession theyreturntothekeyboard.Again,Johnresistspositioningofhisarms.Thistime,Momadministersthekeyboard.As Johngraduallybecomesabsorbedwithherplaying,thePTisabletoalignhisarmsandshoulders.ThePTcontinuesto supporthisshoulderstohelphimmaintaintheposition,andpushesgentlydownthroughhisshoulderstofacilitate hisactiveelbowsupport(seeFig.2).MomengageswithJohnandplaysshortmelodies,whileJohnholdsastableand symmetricpronepositionandswitcheshisgazebetweenMomandthekeyboard.WhenthePTremovesherhands, John’scomplaintsincreaseandhisheadquicklydrops.ThePTbringsherhandsbacktohisshoulders,andJohn’sneck extensionimmediatelyimproves.“Hello!”saysMomwithacheerfulvoiceassheplaysacoupleoftunes.Johnliftshis headandsmilesather,thenreturnshisgazetothekeyboardandstaresintenselyasMom’sﬁngersmovefromkeyto key.“Thisisanewrecordwhenitcomestotummytime”,thePTsays.

However,therapeutichandlingwasnotalwaysbeneﬁcial.OnsomeoccasionsthePTsinterruptedtheinfants’playor inducedsuddenshiftsofpositionthatstartledtheinfants.Iftheseinterruptionswerenotsuccessfullyrepaired,theycould leadtobreakdownsininteractionthatweredetrimentaltothetherapeuticprocess.Asanexample,welookatasequence withVanessaat3monthsCA:

Layinginsupine,Vanessaisputtingherrighthandintohermouth.“Thereyoufoundyourhand”,saysthePT,before shegrabsVanessa’sfeetandmovesthemuptowardhermouth.“Oh,that’ssogood”,shesaysandputsVanessaright footandthentheleftintohermouth.AsthePTmovesthefeetaway,Vanessaputsherlefthandintohermouth.The PTmakesadditionalattemptsatputtingVanessa’sfeettohermouth,butVanessaiseagerlychewingherﬁngersand gruntswithdiscontentatthedisturbanceofherfeet.Forabriefmoment,however,Vanessalooksatherfeet,removes herlefthandfromhermouthandtriestoreachforherfeetwithbotharms.ThePToverlooksthisinitiativefrom VanessaandonceagainbringsVanessa’sfeettohermouth.Asaconsequence,Vanessa’scomplaintsincreaseandshe isonthevergeofcrying.ThePTdiscontinuestheactivityandpicksVanessaup.

4. Discussion

Ourﬁndingsdemonstratethatsuccessfulsensory-motorplayinteractions duringtherapy arefoundedonmutuality betweenthePTandtheinfant.ThePTsstrivetoconnectwithandupholdtheinfant’sengagement,andsimultaneously proceedwiththeirtargetedtherapeuticactions.Inthisprocess,thePTshavetoattunethemselvestotheinfant’ssignalsand actinconcurrencetothem.Theyarrangethetherapeuticstage,incorporaterelevanttherapeuticmeasuresintoplayactivities

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R.B.Håkstadetal./InfantBehavior&Development46(2017)115–123 121 andadjusttheirstrategyinaccordancewiththeinfant’ssignalsofinitiativeandinterest;andonsignsofdisengagementand distress.Successfulattunementandinteraction,includingrepairsofinteractionalmismatches,facilitateprolongedtraining sessionsandprovidetheinfantswithnovelmotorchallengesthatpromotetheemergenceofnewskills.

4.1. Themeetingofintentionsintherapeuticplayinteractions

Interactivesensory-motorplayisinfants’waytodevelopnewskillsandlearnabouttheirworld(Adolph,2008;Lifter, Foster-Sandaetal.,2011;Loboetal.,2013;Sheets-Johnstone,2011).Theinfantsinourmaterial,asexempliﬁedbyJohn, Hannah,Annaand Vanessa;alldemonstratethisurgetoexplore theirownmotorabilitiesand possibilitiesofferedby thesurroundings.WhereasHannah’sandJohn’splayengagementwasreinforcedbytheirPTs,Anna’sandVanessa’splay initiativesweredisrupted.ThisdemonstratestheencounteringofintentionsthatoccurwithinthePT-infantinteractions.

WhilethePTswanttoacknowledgeandscaffoldthepreterminfants’inherentdrivetoplay,theyalsohaveanotherintention;

theyaretheretoworkoncertaintherapeuticgoalstogetherwiththeinfantandparents(Campbelletal.,2012).Amidthese differentintentions,cooperationmustproceedandcontinuouslygovernthetherapeuticprocess.Atthecoreofsuccessful cooperationliestheestablishmentandmaintenanceofasharedintention.ThisiswhatAnnaandVanessadidnotachieve withtheirPT;whatHannahandherPTquicklyestablishedandwereabletomaintain;andwhatJohnandhisPTworked towardandaccomplishedattheendoftheirkeyboardplay.

AccordingtoPacherie(2012),intentionscanbeatdifferentlevels.Theinfants’intentionsarepre-reflective;theyare actionorientedandformedinthemoment,intermsofengagingsensory-motorplayactivities.ThePTs’intentionsextend beyondthesemomentaryactions,ontoareflectiveleveloftherapeuticmeasuresandgoalsthatareconsideredbeneficialfor theinfant.Thiscanexplaincooperativebreakdownsduringthetherapysessions;theinfantscannotcooperateinactivities thatcomeintoconflictwiththeirownintentions.However,itcanalsoexplainsuccessesininteraction,inspiteofdiverging intentions.WhenthePTisabletolinktherapeuticintentionsandactionswiththeinfant’splayintentionsandengagement, cooperativeopportunitiesbecomeavailable.Therefore,therapeuticinteractionsneedtoco-developinamutualitythat maintainsboththeinfant’sintentiontoplayandthePT’stargetedtherapeuticactions.Bythis,therapeuticmeasuressuch asmotorchallenges,positioning,handlingandalterationsoftaskscanbeacceptedbytheinfant,andmayevenbecomepart ofthegame,e.g.whenthePT’shandlingscaffoldsandextendsJohn’sengagedkeyboardplaywithMom.

4.2. Let’splay!

Thus,successfulcooperationisachievedwhenthePTisabletodetectandactincompliancewiththeinfant’sintentions.

IntheexampleswithAnnaandVanessa,thePTdetectedtheinfant’ssignalsofintentionandinterest(althoughVanessa’s reachinginitiativetowardherfeetwasoverlooked).Inspiteoftheirgoodintentions,however,bothPTsdisplayedalack ofsensitivityandproceededwithactionsthatdisruptedtheinfants’playengagement.Asaresult,Annawasnolonger interestedinchasingthetoy,andVanessaneededsoothingbeforetheycouldproceedwiththerapy.Incomparison,John’s PTsuccessfullydetectedandcompliedwithhisintentionsthroughouttheirkeyboardplay.ShecomplementedJohn’splay, viaasensitivecoordinationwithhim.InaccordancewiththedescriptionsofØbergetal.(2014),thissensitivityininteraction enabledthePT’scomprehensionofJohn’sobjectionstobeingpositioned,andhisconcurrencewiththesameadjustments ashebecamemoreengagedinthekeyboardplaywithMom.Theirdyadicbodilycoordinationfacilitatedtheircooperation towardthetherapeuticgoalofplayinginanalignedproneposition.ForJohn,thiscooperationalsomadehimdiscovernew movementstrategies,whichinturnimprovedandextendedhisabilitytoplaywithMomandthePT.Thismergingofplayand therapyentailsanacknowledgementoftheinfantasacooperativepartnerandcontributorofmeaningandintentionduring interaction.Bythis,withassociationtothefundamentalroleofcooperationininfantdevelopment(Fantasiaetal.,2014);

sensory-motorplaycanbecomebothaframeworkforandeventsofinteractionalsensory-motorlearninganddevelopment duringphysicaltherapy.

Viasuchsuccessfulcooperation,theinfant’smotivationincreasesandgivesmomentumtotheinteraction;amomentum whichcaninturninﬂuenceandguidethetherapeuticprocess(Fantasiaetal.,2014).John’sengagementwiththekeyboard providedsuchamomentumtotheirrecord-breakingtherapeuticworkinprone.Hismotivationtoplaygraduallybrought theactivitytoanewlevel;Johnforgotabouthisobjectionsanddiscoveredthebeneﬁtsofamorealignedposition.Inthis way,John’ssubmissiontothemomentumoftheinteractionenabledhimtomakenewmotorachievements.ThePTwas alsoledbythesamemomentum.AssherealizedandcontinuedtoactuponJohn’surgetoplay,shewasabletobringJohn’s motorperformancebeyondpreviouslimits.Inaself-reinforcingprocess,thePT’shandlingandadjustmentsgaveJohna bettermotorfunction,whichinturnenabledJohn’sprolongedinteractiveplayengagementinprone.Thisdemonstrates thatinfants’playcanbemorethanjustacontextforintervention.Interactivesensory-motorplayprovidesapowerful momentumthatneedstobeutilizedinPTs’worktopromoteinfants’discoveryandlearningofmotorskills.

4.3. Enactivetherapeuticsensory-motorplay

Aswehaveshown,cooperativesensory-motorplayinteractionsevolveviatheemergenceofsharedintentions;incoor- dinationwitheachother;byamutualsubmittingtothemomentumoftheinteraction.PTshaveaprofessional,decisiverole regardingthecontentanddevelopmentoftheseinteractions(Lifter,Foster-Sandaetal.,2011;Loboetal.,2013).Ashigh-

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lightedintheliterature(Childress,2011;Cressetal.,2007;Fantasiaetal.,2014;Lifter,Foster-Sandaetal.,2011),scaffolding ofsensory-motorplayisimportantforthepreterminfantsinourmaterial.Therefore,theirsolitaryplayisnotsufﬁcient.

Tosupportdevelopmentandlearning,PTsneedtoengageinplaytogetherwiththeinfantandbesensitivetotheinfant’s responsestotheirhandlingandalterationsoftheongoingplayactivities.Inaccordancewithourfindings,wesuggestthat PTs’targetedtherapeuticactionscanbesuccessfullymergedwithinfants’intentiontoplay;withinwhatwedenoteas anenactive,therapeuticsensory-motorplayapproach.Saidapproachentailsanestablishmentandworktowardtherapeutic goals,insuccessfulcooperationwiththeinfant.AsourexampleswithJohn,Hannah,AnnaandVanessademonstrate;this successfulcooperationreliesonseveralrequirementsthatallneedtobefulfilled.ThePTneedstobecompetentatrec- ognizingandpursuingtheinfant’ssignsofintention,attentionandmotivation.Simultaneously,thePTmustplanandput atherapeuticstrategyintoactionandfindwaystomergetheseprocessesintoengaging,interactivesensory-motorplay activitieswiththeinfant.Toupholdtheinfant’sengagement,therapeuticactionsandhandling,choicesoftoysandchanges tothetaskorenvironmentallneedtobepartofthegame,notadisturbancetoit.Astheplayinteractionsproceed,thePT needstocontinuouslyaddresstheinfant’sspecificmotorimpairmentsandfacilitateimprovementstotheinfant’smotor performance.Bythis,thePTcanestablishatherapeuticplayarenaofcooperativeandinteractivelearning,inwhichthe infantcandevelopappropriatemotorstrategiesandextendtheirmovementandsensory-motorplayrepertoire.

4.4. Studylimitationsandfuturedirections

InthisstudywehaveinvestigatedPTs’scaffoldinganduseofplayinphysicaltherapywithpreterminfants.Basedona smallsampleofpreterminfantswithvariablemedicalconditionsandmotorimpairments,wehaveidentiﬁedprinciplesof whatwedenoteasenactivetherapeuticsensory-motorplay.Weconsiderthisconcepttocontainelementsthatmighttransfer toPTs’workwithinfantsandyoungchildreningeneral.However,enactivetheoryprimarilydescribestypicaldevelopment, andinvestigationsofitsapplicationintherapeuticsettingswithchildrenwithdevelopmentalimpairmentsarelimited.

Therefore,ourstudyisaninitialexplorationoftheutilizationofplayasatherapeutictool,basedontheenactivetheoret- icalperspective.Moreinvestigationsareneededtoexplorethecontent,variationsandapplicationofenactivetherapeutic sensory-motorplayacrossdifferenttherapeuticsettings.Moreover,studiestoinvestigatethepotentialeffectsofanenactive therapeuticsensory-motorplayapproachoninfantlearninganddevelopmentshouldbedeveloped.

5. Conclusions

Sensory-motorplayisunequivocallytiedwithinfants’attentionandmotivation,motorandsocialcompetencies,learning anddevelopment.ThisstudydemonstratesthatPTsmustbeawareoftheserelationshipsanddeveloptheirtherapeutic approachaccordingly,astheyengageintherapeuticinteractionswithpreterminfants.Wesuggestthatthiscanbeachieved viaanenactivetherapeuticsensory-motorplayapproach,bywhichthePTcooperateswiththeinfantandincorporatesnew motorchallengesintheinfant’smovementlearningandunderstandingoftheworld.

Funding

ThisworkwassupportedbygrantfromTheNorwegianFundforPost-GraduateTraininginPhysiotherapy(grant1/370- 00/10-A).

Acknowledgements

WeextendourgratitudetothePTswhoassistedintherecruitmentprocess,andtotheparticipatingPTsandparents withtheirinfants.

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