To investigate the therapeutic interventions reported in the research literature and synthesize their effectiveness in improving upper limb (UL) function in the first 4 weeks poststroke.
If you’ve been through stroke rehabilitation, chances are that you’re familiar with the phrase, “use it or lose it”. Your therapist likely told you this while explaining the principle of neuroplasticity, the brain’s potential to reorganize after damage to regain lost functions. Hopefully “use it or lose it” has helped you remember to engage your weaker arm throughout the day in order for it to make progress!
Here’s another catchy rehab phrase for your repertoire: “you gain what you train”. Research shows that practicing arm movements related to daily living goals may be more effective at improving arm function than standard, non-goal-directed arm exercise. Basically, if you want to be able to hold eating utensils or write with your affected arm, you’re better served by putting a fork or a pen to use than you are by lifting a dumbbell or pinching putty.
“You gain what you train” seems obvious, right? So, why belabor the point? Because many stroke survivors are not practicing real-world skills with their affected arm on their own time. Learning a new skill requires hours of practice and thousands of repetitions. Stroke survivors must ensure they are dedicating sufficient time at home to addressing their specific arm use goals in order to improve.
Think about your current post-stroke home exercise program. Does it go beyond basic stretching and strengthening? If not, consider incorporating task-specific training into your routine to maximize arm and hand function.
Task-specific training is a therapy technique focusing on improving function of a hemiplegic (weakened) arm through repeated activity practice. Just like how you learned to tie your shoes or ride a bike, TST requires consistent performance of the component steps of a task to help the brain re-learn the big-picture skill.
Task-specific training activities for the post-stroke hemiplegic arm incorporate a real-world object and involve the following four steps:
Ideally, a participant will repeat this sequence many times over multiple sessions to show skill improvement. Research studies generally indicate that more repetitions and a greater frequency of training are better.
Stroke survivors with sufficient movement to repeatedly reach for an object, hold on to it, and release it using their affected arm are good candidates for TST.
Anyone with activity restrictions on their affected side, or those who experience pain when using their affected side should consult with their medical team before attempting TST.
First, think about what you would like to be able to do better using your affected arm and hand. Ideally, TST goal activities should be centered around a task that has clear and consistent steps and also involves an object. Although that might sound complicated, there are countless TST possibilities available in your home using your everyday belongings! Any of the following ideas make for great TST goals:
TST skills can also involve your other hand. Consider using your affected hand in the dominant role of a two-handed task, while letting your stronger hand play the role of helper or stabilizer.
Because TST involves repeating the steps of an activity using your affected arm, we need to think about how to measure performance. Completing a reach/grasp/manipulate/release sequence is considered one repetition of a task. The goal of TST is to complete as many repetitions as possible. View the examples of measuring one repetition from the TST tasks on our list above:
Note: The affected arm starts and ends in the same position relative to the task object/s (e.g. on the tabletop next to the object)
Using a spoon: Pick up the spoon from the tabletop, bring it up to your mouth, put it back on the tabletop, return hand to starting position
Writing your signature: Pick up the pen from the tabletop, bring it to paper to write your full name, put the pen back on the tabletop, return hand to starting position
Note: For a two-handed task, you may choose to repeatedly pick up the stabilized object using your unaffected hand, or hold it throughout the task
Putting credit cards into a wallet: One repetition = pick up credit card from tabletop, insert and remove credit card from wallet (held by unaffected hand), place credit card on tabletop, return hand to starting position
After you have defined your activity and what a repetition looks like, you’re ready to go. You may choose to practice one activity in a TST session, or, for a longer session, you may pick two or three goal areas.
Studies show that between one and five repetitions of a task per minute may be ideal to promote improved arm function. Gauge your performance by performing a 15-minute TST test. Have a helper time the number of repetitions you can do during this period. If you have achieved between 15 and 100 repetitions, you’re in the TST sweet spot: continue practicing the skill! If you are over 100 repetitions, it is time to make the task more difficult by add more complex elements (e.g. using heavier objects, attempting the task from standing as opposed to sitting). If that is not possible, try practicing a different, harder skill.
Research has also demonstrated that completing 60 minutes of task-specific training four times per week can produce significant arm function improvements. This is an amount that you may have to build up to. If one hour seems daunting, try to ease into TST practice by attempting increasingly longer intervals (e.g. aim for 5 more minutes of TST each time).
Survivors who have some but not all required arm functions to perform TST may choose to perform a modified version incorporating the elements within their capabilities. For instance, TST might consist of repeatedly reaching to tap an object with the hand as opposed to grasping and releasing it.
If you have minimal to no movement in your affected arm, you will not be able to perform TST. However, your affected side can and should still play a role in your daily living tasks. Use your stronger side to place your affected arm within your field of vision during tabletop tasks. If you are doing a two-handed task, use the stronger arm to place the weaker arm to hold or stabilize objects. Even though doing this is not TST, you are still promoting function of your affected side while preventing learned non-use.
TST is just one tool in your upper extremity stroke rehab toolbox. There are several other evidence-supported activities that may improve arm and hand function. Some people may not be able to perform TST without the guidance of a therapist, while others may not be motivated by the intervention. If you have questions on how to perform TST at home or whether it is the right option for you, consult with your therapy team.
We’ll conclude with one final catchy rehab phrase: “practice means progress”. Needless to say, improving weakened arm function after a stroke can be a long and sometimes frustrating ordeal. However, additional keys to success are right in front of you in the forms of your daily tasks and personal belongings. With practice and repetition, your goals are within reach!
French B, Thomas LH, Coupe J, McMahon NE, Connell L, Harrison J, et al.. Repetitive task training for improving functional ability after stroke.Cochrane Database Syst Rev. 2016; 2016:CD006073. doi: 10.1002/14651858.CD006073.pub3.
Hatem SM, Saussez G, Della Faille M, et al. Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery. Front Hum Neurosci. 2016;10:442. Published 2016 Sep 13. doi:10.3389/fnhum.2016.00442
Lang, Catherine E. PT, PhD; MacDonald, Jillian R.; Gnip, Christopher DPT Counting Repetitions: An Observational Study of Outpatient Therapy for People with Hemiparesis Post-Stroke, Journal of Neurologic Physical Therapy: March 2007 – Volume 31 – Issue 1 – p 3-10 doi: 10.1097/01.NPT.0000260568.31746.34
Waddell, K. J., Strube, M. J., Bailey, R. R., Klaesner, J. W., Birkenmeier, R. L., Dromerick, A. W., & Lang, C. E. (2017). Does Task-Specific Training Improve Upper Limb Performance in Daily Life Poststroke? Neurorehabilitation and Neural Repair, 31(3), 290–300. https://doi.org/10.1177/1545968316680493
Waddell KJ, Birkenmeier RL, Moore JL, Hornby TG, Lang CE. Feasibility of high-repetition, task-specific training for individuals with upper-extremity paresis. Am J Occup Ther. 2014;68(4):444-453. doi:10.5014/ajot.2014.011619
To explore research relating to the use of Augmented Reality (AR) technology for rehabilitation after stroke in order to better understand the current, and potential future application of this technology to enhance stroke rehabilitation.
Database searches and reference list screening were conducted to identify studies relating to the use of AR for stroke rehabilitation. These studies were then reviewed and summarised.
Eighteen studies were identified where AR was used for upper or lower limb rehabilitation following stroke. The findings of these studies indicate the technology is in the early stages of development and application. No clear definition of AR was established, with some confusion between virtual and augmented reality identified. Most AR systems engaged users in rote exercises which lacked an occupational focus and contextual relevance. User experience was mostly positive, however the poor quality of the studies limits generalisability of these findings to the greater stroke survivor population.
AR systems are currently being used for stroke rehabilitation in a variety of ways however the technology is in its infancy and warrants further investigation. A consistent definition of AR must be developed and further research is required to determine the possibilities of using AR to promote practice of occupations in a more contextually relevant environment to enhance motor learning and generalisation to other tasks. This could include using AR to bring the home environment into the hospital setting to enhance practice of prioritised occupations before returning home.
There is a developing body of evidence evaluating the use of various forms of AR technology for stroke rehabilitation.
User motivation and engagement in rehabilitation may improve with the use of AR.
A clear and consistent definition for AR must be developed.
Ongoing work could explore how AR systems support engagement in, and promote motor learning that links to, meaningful occupations.
CHAPTER 40: Optimizing motor performance and sensation after brain impairment
This chapter provides a framework for optimizing motor performance and sensation in adults with brain impairment. Conditions such as stroke and traumatic brain injury are the main focus, however, the chapter content can apply to adults with other neurological conditions. The tasks of eating and drinking are used as examples throughout the chapter. Skills and knowledge required by graduates are identified, including knowledge of motor behaviour, the essential components of reaching to grasp and reaching in sitting, and how to identify compensatory strategies, develop and test movement hypotheses. Factors that enhance skill acquisition are discussed, including task specificity, practice intensity and timely feedback, with implications for therapists’ teaching skills. Finally, a summary is provided of evidence-based interventions to improve motor performance and sensation, including high intensity, task-specific training, mirror therapy, mental practice, electrical stimulation and constraint therapy.
Abnormal motor performance can be observed during a task such as reaching for a cup, and compared with expected performance. Hypotheses about the cause(s) of observed movement differences can then be made and tested.
Paralysis, weakness and loss of co-ordination affect upper limb motor performance. To improve performance after brain impairment, therapists should primarily focus on improving strength and co-ordination.
Many people with brain impairment have difficulty understanding instructions, goals and feedback, and consequently may not practice well. To teach people to practice well and learn skills, therapists need to be good coaches.
Motor performance and sensation can be improved using low-cost evidence-based strategies such as high intensity, repetitive, task-specific training, mirror therapy, mental practice, electrical stimulation and constraint-induced movement therapy.
Upper motor neuron lesions typically cause impairments such as paralysis, muscle weakness and loss of sensation. These impairments can limit participation in everyday tasks such as eating a meal. Motor control is a term commonly used in rehabilitation (Shumway-Cook, 2012; van Vliet et al 2013) and refers to control of movements such as reaching to grasp a cup and standing up. Occupational therapists and physiotherapists retrain motor and sensory impairments that interfere with tasks such as grasping a cup and sitting safely on the toilet.
The aim of this chapter is to provide a framework that helps therapists to systematically observe, analyse and measure motor and sensory impairments. Targeted evidence-based interventions will be described that can drive neuroplasticity. Therapists need to proactively seek muscle activity and sensation. It is not enough to teach a person how to compensate using one-handed techniques, or to wait for recovery to possibly occur.[…]
Motor function may be enhanced if aerobic exercise is paired with motor training. One potential mechanism is that aerobic exercise increases levels of brain-derived neurotrophic factor (BDNF), which is important in neuroplasticity and involved in motor learning and motor memory consolidation. This study will examine the feasibility of a parallel-group assessor-blinded randomised controlled trial investigating whether task-specific training preceded by aerobic exercise improves upper limb function more than task-specific training alone, and determine the effect size of changes in primary outcome measures. People with upper limb motor dysfunction after stroke will be allocated to either task-specific training or aerobic exercise and consecutive task-specific training. Both groups will perform 60 hours of task-specific training over 10 weeks, comprised of 3 × 1 hour sessions per week with a therapist and 3 × 1 hours of home-based self-practice per week. The combined intervention group will also perform 30 minutes of aerobic exercise (70–85%HRmax) immediately prior to the 1 hour of task-specific training with the therapist. Recruitment, adherence, retention, participant acceptability, and adverse events will be recorded. Clinical outcome measures will be performed pre-randomisation at baseline, at completion of the training program, and at 1 and 6 months follow-up. Primary clinical outcome measures will be the Action Research Arm Test (ARAT) and the Wolf Motor Function Test (WMFT). If aerobic exercise prior to task-specific training is acceptable, and a future phase 3 randomised controlled trial seems feasible, it should be pursued to determine the efficacy of this combined intervention for people after stroke.
Currently 440,000 persons after stroke live in community settings in Australia . Many with stroke experience chronic disability and although two-thirds receive care each day , the majority still have unmet needs . Upper limb dysfunction is a persistent and disabling problem present in 69% of persons after stroke in Australia . Upper limb dysfunction is a major contributor to poor well-being and quality-of-life ; ;  ; . Unsurprisingly, advancing treatments for upper limb recovery is a top ten research priority for persons after stroke and their carers .
In Australia, 87% of persons with stroke-attributable upper limb impairments receive task-specific training . Task-specific training is a progressive training strategy that utilises practice of goal-directed, real-world, context-specific tasks that are intrinsically and/or extrinsically meaningful to the person, to enable them to undertake activities of daily living  and may improve upper limb motor function after stroke ;  ; .
Improvements in motor function coincide with structural and functional reorganisation of the brain ; ;  ; . The brain’s ability to undergo these changes is denoted as neuroplasticity. Capitalisation and enhancement of neuroplasticity in peri-infarct and non-primary motor regions may promote recovery via an increased response to motor training and other neurorehabilitative interventions ;  ; .
Many studies show that aerobic exercise (prolonged, rhythmical activity using large muscle groups to increase heart rate) enhances neuroplasticity , grey matter volume, white matter integrity ;  ;  and brain activation ;  ; . Furthermore increasing evidence indicates that lower limb aerobic exercise increases upper limb motor function. A single bout of aerobic cycling exercise can improve long-term retention of a motor skill in healthy individuals , regardless of whether performed immediately before or after motor training .
Aerobic exercise increases BDNF . Improvements in motor skill learning and memory induced by aerobic exercise have been associated with increased peripheral blood concentrations of BDNF . BDNF is involved with neurogenesis  and neuroprotection  in the human brain , thereby playing an important role in stroke recovery, including facilitating functional upper limb motor rehabilitation .
In chronic stroke, an 8-week programme of lower extremity endurance cycling enhanced upper extremity fine motor control . Also, a single bout of aerobic treadmill exercise improved grasp function of the hemiparetic hand . As aerobic exercise alone can enhance motor function after stroke, motor learning in stroke rehabilitation may be facilitated if aerobic exercise is paired with motor training  ; .
The aims of this study are to 1) assess the feasibility of conducting a randomised controlled trial to compare the effects of task-specific training preceded by aerobic exercise to task-specific training alone on upper limb motor function after stroke; and 2) calculate the effect size of changes in primary clinical outcome measures to evaluate proof-of-concept and inform calculation of sample size for a future phase III trial. This includes investigating potential neural correlates of exercise-induced motor function changes using peripheral blood serum BDNF measurement and multi-modal MRI.
This is a parallel-group assessor-blinded randomised controlled pilot study (Fig. 1). One group will undertake task-specific training alone and the other group will undertake 30 minutes of aerobic cycling exercise prior to their task-specific training. The interventions will be delivered by a therapist 3 days per week for 10 weeks. Both groups will be provided with an individually-prescribed task-specific training programme to practice at home for 60 minutes, 3 times per week. Assessments will be conducted at baseline, within 1 week from the end of intervention, and 1 and 6 months following the end of the intervention period. Ethics approval has been obtained from the Hunter New England Human Research Ethics Committee (14/12/10/4.07) and registered with the University of Newcastle Human Research Ethics Committee (H-2015-0105). The study is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12616000848404).
Background and Purpose: This case study describes a task-specific training program for gait walking and functional recovery in a young man with severe chronic traumatic brain injury.
Case Description: The individual was a 26-year-old man 4 years post–traumatic brain injury with severe motor impairments who had not walked outside of therapy since his injury. He had received extensive gait training prior to initiation of services. His goal was to recover the ability to walk.
Intervention: The primary focus of the interventions was the restoration of walking. A variety of interventions were used, including locomotor treadmill training, electrical stimulation, orthoses, and specialized assistive devices. A total of 79 treatments were delivered over a period of 62 weeks.
Outcomes: At the conclusion of therapy, the client was able to walk independently with a gait trainer for approximately 1km (over 3000 ft) and walked in the community with the assistance of his mother using a rocker bottom crutch for distances of 100m (330 ft).
Discussion: Specific interventions were intentionally selected in the development of the treatment plan. The program emphasized structured practice of the salient task, that is, walking, with adequate intensity and frequency. Given the chronicity of this individual’s injury, the magnitude of his functional improvements was unexpected.
Video Abstract available for additional insights from the Authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A175).
Each year at least 1.7 million traumatic brain injuries (TBIs) occur in the United States, which cost an estimated $76.5 billion.1 In addition, 43% of persons discharged home after hospitalization develop long-term disability.1 The sequelae of a TBI can include motor, cognitive, behavioral, and emotional dysfunctions.2 The resulting motor impairments can impact a person’s independence and participation in his or her life roles.3
Independent gait is a common therapy goal for most individuals post–brain injury. In one study, 73.3% of persons achieved independent gait by 5 months postinjury.4 It is interesting that gait recovery occurred early, suggesting that recovery of independent gait more than 3 to 4 months after injury is much less likely.4 Impairments of gait after TBI are common, including decreased velocity, step length, altered stance and swing times, and varied kinematics.5 The inability of a person post-TBI to traverse his environment using upright mobility can limit performance of basic care skills. One study estimated that approximately 33% of individuals post-TBI required assistance with at least 2 activities of daily living (ADLs).6 This high level of dependence places an extraordinary burden on caregivers.7
There is not a consensus on best practice for gait recovery after TBI.8 Although it is generally understood that early intervention creates the best environment for promoting neuroplasticity,9 addressing gait recovery after TBI is often complicated and delayed by musculoskeletal and internal injuries and by altered levels of consciousness.4,10 There is limited and conflicting literature to support the use of locomotor treadmill training (LTT) as a gait training method. There have been 2 randomized controlled trials comparing LTT with conventional gait training and neither found LTT to be superior.11,12 A third study compared manually assisted LTT with robotic-assisted LTT and found gait improvements in persons with chronic TBI with both interventions.13 In addition to these 3 research articles, there have been 3 case series/studies, Seif-Naraghi and Herman14 reported on 2 individuals in which LTT improved ambulatory independence. Likewise, Wilson and Swaboda15 found improvements in gait using LTT with 2 individuals. Scherer16 used LTT with an individual 7 months post-TBI and saw improvements in gait.
Beyond LTT, there is limited evidence to support the use of other interventions for improving gait in persons with TBI. One study found functional electrical stimulation (FES) to be successful for gait recovery with a patient with a chronic TBI when many other interventions had failed.17 There is, however, stronger evidence for the use of FES in other populations. A systematic review found a modest benefit of FES for strengthening in persons with stroke.18 Functional electrical stimulation–assisted gait has been studied in the spinal cord injury population with good outcomes.19–21
Considering the prevalence of TBI and the associated costs, it is critical to explore viable treatment options for recovery of function, especially gait. It is particularly critical to consider treatment options for the growing number of individuals with chronic TBI, many of whom have poor gait prognosis.4 Despite the limited TBI-specific evidence available to guide treatment planning, there is a substantial body of motor learning research available to guide the development of effective treatment plans.9,22–26 Critical to these plans are elements such as salience, intensity, repetition, and task specificity. This case study details a comprehensive outpatient treatment program, which included LTT and FES, as well as other interventions, for a 26-year-old man with a severe chronic TBI after a motor vehicle accident. […]
OBJECTIVE. To determine the impact of transcranial direct current stimulation (tDCS) combined with repetitive, task-specific training (RTP) on upper-extremity (UE) impairment in a chronic stroke survivor with moderate impairment.
METHOD. The participant was a 54-yr-old woman with chronic, moderate UE hemiparesis after a single stroke that had occurred 10 yr before study enrollment. She participated in 45-min RTP sessions 3 days/wk for 8 wk. tDCS was administered concurrent to the first 20 min of each RTP session.
RESULTS. Immediately after intervention, the participant demonstrated marked score increases on the UE section of the Fugl–Meyer Scale and the Motor Activity Log (on both the Amount of Use and the Quality of Movement subscales).
CONCLUSION. These data support the use of tDCS combined with RTP to decrease impairment and increase UE use in chronic stroke patients with moderate impairment. This finding is crucial, given the paucity of efficacious treatment approaches in this impairment level.
Background. A common assumption is that changes in upper limb (UL) capacity, or what an individual is capable of doing, translates to improved UL performance in daily life, or what an individual actually does. This assumption should be explicitly tested for individuals with UL paresis poststroke.
Objective. To examine changes in UL performance after an intensive, individualized, progressive, task-specific UL intervention for individuals at least 6 months poststroke.
Methods. Secondary analysis on 78 individuals with UL paresis who participated in a phase II, single-blind, randomized parallel dose-response trial. Participants were enrolled in a task-specific intervention for 8 weeks. Participants were randomized into 1 of 4 treatment groups with each group completing different amounts of UL movement practice. UL performance was assessed with bilateral, wrist-worn accelerometers once a week for 24 hours throughout the duration of the study. The 6 accelerometer variables were tested for change and the influence of potential modifiers using hierarchical linear modeling.
Results. No changes in UL performance were found on any of the 6 accelerometer variables used to quantify UL performance. Neither changes in UL capacity nor the overall amount of movement practice influenced changes in UL performance. Stroke chronicity, baseline UL capacity, concordance, and ADL status significantly increased the baseline starting points but did not influence the rate of change (slopes) for participants.
Conclusions. Improved motor capacity resulting from an intensive outpatient UL intervention does not appear to translate to increased UL performance outside the clinic.
An unsettled question in the use of robotics for post-stroke gait rehabilitation is whether task-specific locomotor training is more effective than targeting individual joint impairments to improve walking function. The paretic ankle is implicated in gait instability and fall risk, but is difficult to therapeutically isolate and refractory to recovery. We hypothesize that in chronic stroke, treadmill-integrated ankle robotics training is more effective to improve gait function than robotics focused on paretic ankle impairments.
Participants with chronic hemiparetic gait were randomized to either six weeks of treadmill-integrated ankle robotics (n = 14) or dose-matched seated ankle robotics (n = 12) videogame training. Selected gait measures were collected at baseline, post-training, and six-week retention. Friedman, and Wilcoxon Sign Rank and Fisher’s exact tests evaluated within and between group differences across time, respectively. Six weeks post-training, treadmill robotics proved more effective than seated robotics to increase walking velocity, paretic single support, paretic push-off impulse, and active dorsiflexion range of motion. Treadmill robotics durably improved gait dorsiflexion swing angle leading 6/7 initially requiring ankle braces to self-discarded them, while their unassisted paretic heel-first contacts increased from 44 % to 99.6 %, versus no change in assistive device usage (0/9) following seated robotics.
Treadmill-integrated, but not seated ankle robotics training, durably improves gait biomechanics, reversing foot drop, restoring walking propulsion, and establishing safer foot landing in chronic stroke that may reduce reliance on assistive devices. These findings support a task-specific approach integrating adaptive ankle robotics with locomotor training to optimize mobility recovery.