OCCUPATIONAL THERAPY INTERNATIONAL Occup. Ther. Int.

16(34): 175189 (2009) Published online 5 June 2009 in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/oti.275

Task-specic training: evidence for and translation to clinical practice

ISOBEL J. HUBBARD, MARK W. PARSONS, Acute Stroke Unit, John Hunter Hospital, Hunter New England Area Health Service, Newcastle, and the University of Newcastle, Newcastle, Australia CHERYL NEILSON, Mt Alexander Hospital, Castlemaine Australia LEEANNE M. CAREY, National Stroke Research Institute, Florey Neuroscience Institutes, Melbourne, and School of Occupational Therapy, LaTrobe University, Bundoora, Australia ABSTRACT: There is mounting evidence of the value of task-specic training as a neuromotor intervention in neurological rehabilitation. The evidence is founded in the psychology of motor skill learning and in the neuroscience of experiencedependent and learning-dependent neural plastic changes in the brain in animals and humans. Further, there is growing empirical evidence for the effectiveness of taskspecic training in rehabilitation and for neural plastic changes following taskoriented training. In this paper, we position the evidence for task-specic training in the context of rehabilitation; review its relevance for occupation-based neurological rehabilitation, particularly in relation to upper limb function and everyday activities; and recommend evidence-driven strategies for its application. We recommend that task-specic training be routinely applied by occupational therapists as a component of their neuromotor interventions, particularly in management related to post-stroke upper limb recovery. Specically, we propose ve implementation strategies based on review of the evidence. These are: task-specic training should be relevant to the patient/client and to the context; be randomly assigned; be repetitive and involve massed practice; aim towards reconstruction of the whole task; and be reinforced with positive and timely feedback. Copyright 2009 John Wiley & Sons, Ltd. Key words: motor rehabilitation, stroke, task specic training

Introduction: task-specic training There is mounting evidence that therapists treating people affected by a neurological disorder should be prescribing task-specic training in their therapy (National Stroke Foundation, 2005; Winstein et al., 2006; French et al., 2008).
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Task-specic training is a term that has evolved from the movement science and motor skill learning literature (Schmidt and Lee, 2005) and is dened as training or therapy where patients practice context-specic motor tasks and receive some form of feedback (Teasell et al., 2008, p. 576). In the eld of skill learning, it may be associated with different practice conditions, feedback and conditions of transfer (Schmidt and Lee, 2005; Winstein et al., 2006). Taskspecic training in rehabilitation focuses on improvement of performance in functional tasks through goal-directed practice and repetition. The focus is on training of functional tasks rather than impairment, such as with muscle strengthening. Other terms used that reect these elements are repetitive functional task practice, repetitive task practice (French et al., 2008), task-related training (Carr and Shepherd, 1982) and task-orientated therapy (Bayona et al., 2005). A strength of the task-specic training approach is in its scientic origins. The evidence informing task-specic training is based on animal (basic science) research (Knapp et al., 1963; Nudo and Milliken, 1996; Nudo et al., 1996), has been developed within the psychology literature of motor control and learning (Schmidt and Lee, 2005), and has since been applied in human studies with healthy participants (Schmidt and Lee, 2005) and following injury (Nelson et al., 1996; Winstein et al., 2004; Michaelsen et al., 2006). Further, there is increasing evidence of neural plastic changes associated with training (Richards et al., 2008). Learning is reported to be maximal for the specic task trained (Schmidt, 1991; Goldstone, 1998). Importantly, repetitive use alone may not be sufcient to effect changes in cortical representation. Rather, changes are associated with specic skill learning, consistent with a learning-dependent model of neural plasticity (Karni et al., 1995; Plautz et al., 2000). Neurophysiological evidence also supports the value of the object used or task undertaken in the organization of movement (Lemon et al., 1991; Turton et al., 1993). The evidence indicates that cortico-motor neuron pools are organized relative to specic tasks rather than specic muscles. Importantly, evidence suggests that motor skill learning capability may be retained in stroke survivors under similar conditions to healthy volunteers (Platz, 2004; Winstein et al., 2006).

Neural plasticity and task-specic training A major contributor to the theoretical framework informing neuromotor rehabilitation is the evidence concerning brain plasticity. Neuroplasticity refers to the brains ability to reorganize itself in response to changes in behavioural demands (Rossini et al., 2003). It is important to remember that this is a capacity of both the healthy and injured brain, and is therefore always active. Noninvasive technology, such as functional magnetic resonance imaging, provides an opportunity to better understand how the brains circuits interact with one another, and to explore the reorganization that occurs when one or more areas
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of the brain are either partially or completely shut down following injury. Researchers have suggested that in time, therapists should be able to decide on the most optimal intervention for an individual based on evidence of residual brain circuits (Guadagno et al., 2003; Dobkin and Carmichael, 2005; Johansson, 2005; Teasell et al., 2005; Duffau, 2006; Carey, 2007; Carey and Seitz, 2007; Stinear et al., 2007). Animal studies have demonstrated that task-specic training (e.g. skilled reaching task) can restore function by using spared (non-affected) parts of the brain which are generally adjacent to the lesion (Nudo et al., 1996) and/or recruiting supplementary parts of the brain (Nudo et al., 2000). Many authors, including Rossi et al. (2007), have detailed the neurobiological changes underlying the brains reorganization in response to task-specic training, concluding: Regardless of concomitant interventions, the extent of functional improvement is strongly dependent on the specic external stimulation that the rewiring circuits experience. Adaptive cortical reorganization in both intact and injured CNS is not induced by generic use or activation, but requires the application of task-specic training protocols. (Rossi et al., 2007, p. 19) Neural plastic changes have also been demonstrated in the human brain (Calautti et al., 2001; Carey and Seitz, 2007; Richards et al., 2008) following an ischaemic stroke and neuromotor interventions. For example, the effect of taskoriented arm training on motor function and brain reorganization has been investigated in randomized controlled trials with a small number of patients (Nelles et al., 2001; Carey et al., 2002). Using a task-oriented training regime of intensive nger movement tracking, improvement in nger control was found in association with evidence of brain reorganization in chronic stroke patients (Carey et al., 2002). There are now an increasing number of such studies measuring changes in brain activation patterns following task-specic training which, although still relatively small in participant numbers, provided enough data for meta-analysis (Richards et al., 2008). Findings from this analysis suggest that task-specic training can inuence functional outcomes and brain activation patterns. As summarized by Bayona et al. (2005): Task-oriented therapy is important. It makes intuitive sense that the best way to relearn a given task is to train specically for that task. In animals, functional reorganization is greater for tasks that are meaningful to the animal. Repetition alone, without usefulness or meaning in terms of function, is not enough to produce increased motor cortical representations. In humans, less intense but task-specic training regimens with the more affected limb can produce cortical reorganization and associated, meaningful functional improvements. (p. 58)
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Evidence for task-specic training in rehabilitation Evidence indicates that task-specic training could have relevance for people affected by a traumatic brain injury (Canning et al., 2003; Chua et al., 2007), Parkinsons disease (Mak and Hui-Chan, 2008), a total hip replacement (Drabsch et al., 1998), a work-related injury (McCannon et al., 2005) and/or a spinal cord injury (Betker et al., 2007; Kubasak et al., 2008). However, most of the taskspecic training evidence relates to post-stroke recovery. It has been found to be effective in cognitive neurorehabilitation (Calvanio et al., 1993), sensory retraining (Carey et al., 1993), gait retraining (Hesse, 1999; Peurala et al., 2004; Sullivan et al., 2007), sit-to-stand retraining (Canning et al., 2003) and motor training of the upper limb (Feys et al., 1998; Byl et al., 2003; Blennerhassett and Dite, 2004; Page et al., 2004, 2005; Hakkennes and Keating, 2005; WoodDauphinee and Kwakkel, 2005; Michaelsen et al., 2006; Wolf et al., 2006). Task-specic training is a core element of a number of interventions, as discussed below. It may be augmented by strategies to enhance learning, as used in the motor relearning/movement sciences approaches, or to force use of the limb in daily activities, as in the constraint-induced movement therapy (CIMT) approaches (Winstein et al., 2006). Equipment or virtual environments may also be used to facilitate the movement or learning environment. A recent systematic review of repetitive functional task practice in stroke rehabilitation included 31 trials with 1078 participants (French et al., 2008). Overall, it was found that some form of task-specic training resulted in improvement in global motor function, and in both arm and lower limb function, although the evidence for upper limb interventions was less clear because of insufcient good-quality evidence. Nineteen trials, with 634 participants, measured arm or hand function. The pooled effects for the impact of repetitive functional task training across all trials showed small effect sizes, which were statistically signicant for arm function and marginally non-signicant for the hand. There was little or no evidence for modication of treatment effects because of time post-stroke or dosage of task practice. However, for the upper limb, the type of intervention did impact on treatment effects, with ndings from the CIMT studies showing a large, statistically signicant effect. Improvement in activities of daily living was also reported, and it was recommended that adverse effects should be monitored with this therapy. Retention effects persisted for up to 6 months, with retention beyond this time unclear. Economic modelling suggested that taskspecic training was cost-effective. Post-stroke, there is evidence that task-specic, upper limb training not only impacts functional recovery, but also brain activation patterns. This evidence includes a meta-analysis by Richards et al. (2008) and a review by Carey and Seitz (2007). Examples of upper limb, task-specic training used included: taskoriented motor training (Nelles et al., 2001); CIMT and household tasks such as eating, opening and closing jars and spring-loaded clothespins (Hamzei et al., 2006, p. 712); CIMT and gross and ne motor skills, such as grasping and
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using a spoon and picking up an object with a specied grasp (Schaechter et al., 2002, p. 328); and CIMT and gross motor activities such as throwing a ball and simulating hockey, and ne motor activities using pegs and putty, and general activities related to daily living (ADL) (Kim et al., 2004, p. 242). It is worth noting that much of this task-specic training was supervised by physiotherapists, and the rationale for this is not discussed.

Task-specic training: how does it relate to current interventions? It will be increasingly obvious to the reader that rstly, the term task-specic training is part of a broad range of interventions, and secondly, it is difcult to differentiate it from routinely used neuromotor interventions in current occupational therapy practice. For occupational therapists, neuromotor interventions have been historically driven by three primary approaches: neurodevelopmental, sensorimotor and motor relearning approaches (Trombly, 1995; Umphred, 1995). The Bobath (1980) approach, sometimes referred to as neurodevelopmental therapy (NDT), is based on the concept of abnormal patterns of movement and stresses the importance of breaking down the abnormal or maladaptive patterns with the use of limb and trunk positioning and/or weight bearing, and is still very much in use today (Langhammer and Stanghelle, 2000). Walker et al. (2000) surveyed therapists in the United Kingdom and found that most reported that they used the Bobath approach when treating stroke patients. While the approach focuses on patterns of movement, it also includes incorporation of these movement strategies in daily activities, once improvements in patterns of movement have been achieved (Davies, 1994), and thus has an element of task-specic practice. It does not, however, recognize that movement is organized according to the object used or the environment. The sensorimotor approach, originating from the research of Ayres (1965) and further developed by others [e.g. Case-Smith (2005)] is based on theories of a childs healthy development through a series of motor skill milestones. Ayress approach, although primarily aimed at paediatric neurorehabilitation, has also been used in adult neurorehabilitation (Moulton, 1997). In the sensorimotor approach, therapists selected tasks and activities which enabled them to modulate the amount of stimulation and were of interest. The sensorimotor approach has some similarities, therefore, with task-specic training in that it is task orientated, uses tasks which are meaningful to the patient and involves repetition and practice. It does not, however, incorporate motor learning principles. The motor relearning approach, as described by Carr and Shepherd (1982, 2000), is derived from the movement science literature and incorporates principles closely aligned with task-specic training. It includes isolated training practice of impaired essential movements, and then immediate practice within the relevant, specic functional task. As such, it emphasizes specic training of
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motor control in everyday activities and represents a shift away from facilitation of movement and exercise therapy. This approach formally identies the task as integral to effective motor relearning. The repetitive task training is combined with techniques to enhance cognitive involvement (e.g. through functional relevance of tasks used and knowledge of performance). Task-specic training is most closely related to the motor relearning approach, but the two are not synonymous. An approach that has gained interest more recently and is supported by evidence from animal studies (Knapp et al., 1958, 1963; Taub et al., 1993; Nudo et al., 1996) and systematic review (Hakkennes and Keating, 2005) is CIMT. CIMT is primarily designed to reverse the conditioning that leads to learned non-use and aims to promote spontaneous use of the hand through using of shaping procedures (Taub et al., 1993, 2002). The approach involves a constraint applied to the less affected limb and intensive upper limb training of the more affected limb. The shaping procedure is based on operant conditioning, with the aim of eliciting a behaviour (task goal) and reinforcing it (positive feedback). This involves intensive periods of task practice using shaping and progressive increments in task difculty, feedback and encouragement (Wolf et al., 2002). Although the approach is task based and involves practice of graded activities, the focus is not on the acquisition of a voluntary skill nor the optimization of motor skill learning (Winstein et al., 2006).

Task-specic training and use of everyday activities It is recognized that movement emerges from an interaction between the individual, the task, and the environment in which the task is being carried out (Shumway-Cook and Woollacott, 1995). This model is consistent with the taskoriented, occupation focus of occupational therapy. It has been suggested that the organization of movement of the upper limb for reaching is positively inuenced by the conditions in which it is undertaken (Trombly and Wu, 1999). Further, movement kinematics of the upper limb are different under different conditions, from real-life action to simulated conditions, in healthy volunteers (Ross and Nelson, 2000). Similarly, van Vliet et al. (1995) found that there was a difference in movement kinematics of the upper limb when undertaking a more functional goal of drinking from a glass compared to only moving a glass of water, further highlighting the goal of the task. Wu et al. (2000) concluded that the use of real and functional objects might be an effective way of facilitating efcient, smooth and coordinated movement with the impaired arm after stroke. Task-specic training often uses real-world or everyday tasks as the therapeutic medium in functional recovery. In combination with high levels of massed practice, it aims to achieve optimal function, which in turn allows the patient/client to adequately undertake everyday activities (Dobkin and
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Carmichael, 2005). To review the importance of tasks and everyday activities in neurorehabilitation, and further, to report this to occupational therapists could well be preaching to the converted. However, the authors would suggest that this body of evidence serves to validate the focus of occupations, tasks and activities in neuromotor interventions. Sufce to say that researchers and opinion leaders are in agreement that there is ample evidence to support neuromotor interventions, which are task specic and based in and around everyday activities (Blennerhassett and Dite, 2004; Mathiowetz, 2004; Bayona et al., 2005; Dobkin and Carmichael, 2005; Teasell et al., 2005; Kelly et al., 2006). In this context, we may dene task-specic training as: training or intervention which utilizes, as its principal therapeutic medium, ordinary everyday activities which are intrinsically and/or extrinsically meaningful to the patient or client. Recommendations for application of task-specic training in clinical practice Taking into consideration the limitations and strengths of the evidence available, the authors recommend that: task-specic training be routinely applied by occupational therapists as a component of their neuromotor interventions, particularly in post-stroke upper limb management. Further, authors/researchers should consider using task-specic terminology if reporting on outcomes relating to neuromotor interventions, particularly those based in and around everyday tasks, occupations and/or activities. Following a review of the task-specic evidence, it is also possible to recommend ve strategies to guide application of task-specic training in clinical practice. These are consistent with guidelines put forward by others (e.g. Byl et al., 2003; Mathiowetz, 2004; Bayona et al., 2005; Dobkin and Carmichael, 2005; Carey, 2006; Davis, 2006; Krakauer, 2006). The strategies are presented in practice-ready dialogue with the aim of assisting therapists in translating them into clinical practice. To facilitate recall, they have been formulated as the ve Rs: (i.e. task-specic training should be relevant, randomly ordered, repetitive, aim towards reconstruction of the whole task and positively reinforced). Strategy 1: task-specic training should be relevant to the patient and to the context Firstly, it should involve activities which are intrinsically and/or extrinsically meaningful to the patient (Byl et al., 2003; Bayona et al., 2005; Davis, 2006). A patient-generated index such as the Canadian Occupational Performance Measure (Law et al., 2005) can be used to formally identify these tasks, and this, in turn, can serve as an outcome measure for later reassessment. The evidence infers that to spend large amounts of time and effort on tasks and
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activities which, although appearing important to the therapist and/or institution, have no such value for the patient, could be counterproductive. Secondly, evidence indicates that where possible, the task trained should be real world or context specic (Shumway-Cook and Woollacott, 1995). For example, if a patient/client is relearning to use a knife and fork, then they should be doing this in sitting and if possible, with real food and using ordinary cutlery and crockery. This evidence supports the move in many neurorehabilitation settings to set up the treatment environment to reect the usual home and/or community environment. Some may also refer to this as enriching the environment (Johansson, 2005; Davis, 2006). Strategy 2: task-specic training practice sequences should be randomly ordered Task variability has been identied as important to increasing generalisation of learning to new tasks (Krakauer, 2006, p. 85). Further, evidence indicates that utilizing randomly ordered practice facilitates retention and transfer, thus increasing the tasks generalizability (Schmidt and Lee, 2005). Task-specic therapy, therefore, should be random in its application using differing contexts and settings, and differing occupational demands and sequences (Bayona et al., 2005; Dobkin and Carmichael, 2005; Teasell et al., 2005; Davis, 2006). If taskspecic training is too task or movement specic, and applied in only one context or sequence, then potentially the skills re-learned or learned are not as readily applied across similar tasks and alternate settings. Clearly, there are times when this is neither practical nor feasible (e.g. showering), but for the most part, where possible, therapists should randomly schedule therapy routines and task selection. Strategy 3: task-specic training should be repetitive Task-specic training should be repetitive and involve massed practice (Schmidt and Lee, 2005; Winstein et al., 2006). The old adage of practice makes perfect applies in this context as it is practice which assists the healthy and injured brain alike to master skills and to reorganize to accommodate the new learning. Most researchers (Blennerhassett and Dite, 2004; Mathiowetz, 2004; Bayona et al., 2005) recommend that the more a task is practiced, the better the overall performance. However, Page (2003) suggested that task specicity is clinically more signicant than intensity, and recommends that task-specic training is still worth considering even if patients are not able to manage high-intensity treatment regimes. Bearing in mind that for much of the day, patients in hospital are frequently doing very little (Bernhardt et al., 2007; Hubbard and Parsons, 2007), therapists should assume that more is better and that most patients are not practicing enough. It is recommended that the maximum amount of repetition feasible should be prescribed in task-specic, neuromotor interventions and that the
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task-specic environment should be as occupationally demanding as possible (Johansson, 2005), with every opportunity afforded to patients to practice realworld tasks (Teasell et al., 2005). Strategy 4: task-specic training should aim towards reconstruction of the whole task When formulating a treatment plan, a therapist will: deconstruct a task into its component parts assess the patients performance of the whole task and of its component parts identify which skills and/or component parts are adversely affected and why formulate a treatment plan targeted at the mismatch between can do and need/want to do. Task-specic training should start with skill acquisition and massed practice of the individual component parts (shaping) (Page et al., 2005), moving towards the regrouping and normal sequencing of some, most and, if feasible, eventually all of the component parts. However, in the midst of all the planning, prescribing, goal setting, documenting and discharge planning, the achieving of whole tasks may become lost in the day-to-day activity of the neurorehabilitation setting. Nevertheless, the overriding goal should be the reconstruction of the whole task to maintain focus and motivation. The evidence suggests that it is unwise to simply prescribe a series of selfdirected upper limb exercises, with an increasing dose of practice which, although seemingly advantageous, bears no relationship to the mastering of a task that is important to the patient. If the patients interest and motivation are to be maintained, task-specic interventions should be in the context of eventual mastery of a whole task that has been identied as relevant. Further, interventions should include complex tasks as a means of involving more regions of the brain in the reorganization response (Mathiowetz, 2004; Davis, 2006; Kelly et al., 2006; Krakauer, 2006). Strategy 5: task-specic training should be positively reinforced The evidence indicates that task-specic therapy should include timely and positive feedback, but that all rewards should fade over time to prevent unnecessary dependency (Mathiowetz, 2004; Dobkin and Carmichael, 2005; Seitz, 2005; Davis, 2006). Therapists can enhance the feedback environment by using commentary and positive encouragement; however, this augmented reinforcement or articial feedback should fade over the duration of a task, session and admission as it is potentially maladaptive. Dobkin and Carmichael (2005) recommend that this feedback is always positive.
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The ve strategies arise out of the task-specic evidence and expert commentary. Again, much of this may not be new to readers, but may provide evidence to support practices already applied. However, there is some evidence that the inpatient setting particularly can raise competing agendas for therapists (Danils et al., 2002), and these strategies may serve to refocus the efforts of therapists in their prescription of neuromotor interventions. Implications of task-specic training for occupational therapists and future practice The evidence relating to task-specic training has direct application to occupational therapy practice and resonates with the theory and ideology associated with occupational science (Christiansen and Townsend, 2004) and occupational therapy. The strategies are steeped in long-held, professional values concerning client-centred practice and the importance of involving the patient/client in goal setting and rehabilitation agendas (Armstrong, 2008). However, while the premise of occupation and our approach to learning new motor skills are highly consistent with task-specic training, it is not a term that is commonly used by us. Further, despite the growing evidence for task-specic training, rehabilitation is commonly based instead on accepted practice or custom. The theoretical and empirical foundations for task-specic training, derived from research on brain plasticity and motor learning, provide a strong, evidencebased platform for occupational therapists to condently select neuromotor interventions which involve task-specic training and everyday tasks and activities. References
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Occup. Ther. Int. 16(34): 175189 (2009) Copyright 2009 John Wiley & Sons, Ltd DOI: 10.1002/oti