Task-Oriented Approach to Stroke Rehabilitation

Key Terms

In the past 30 to 35 years, new models of motor control have evolved from the ecological approach to perception and action^31,87 and from the study of complex, dynamical systems in mathematics and the sciences.³⁵ The new models emphasize the interaction between persons and their environments and suggest that motor behavior emerges from persons' multiple systems interacting with unique tasks and environmental contexts.⁶⁵ “Thus, the systems model of motor control is more interactive or heterarchical and emphasizes the role of the environment more than the earlier reflex-hierarchical model.”⁵⁷

In the systems model, the nervous system is viewed differently from earlier reflex-hierarchical models. Instead of being the primary system controlling movement, the nervous system now is considered only one system among many systems that affects motor behavior. “The nervous system itself is organized heterarchically such that higher centers interact with the lower centers but do not control them. Closed-loop and open-loop systems work cooperatively and both feedback and feedforward control are used to achieve task goals.”⁵⁷ The central nervous system (CNS) interacts with multiple personal and environmental systems as a person attempts to pursue a functional goal.

Systems View of Motor Development

A systems view of motor development suggests that changes over time are caused by multiple factors or systems such as maturation of the nervous system, biomechanical constraints and resources, and the impact of the physical and social environment.^40,54,57 For example, Thelen and Fisher⁸⁴ reported that the disappearance of the stepping reflex at 4 to 5 months old is due to multiple factors internal and external to the child. Internal factors include the strength of the leg muscles, weight of the legs, and arousal level of the child. External factors include the varying effects of gravity in different environments. Thus, maturation of the nervous system alone cannot explain this change in developmental behavior. A systems view also suggests that normal development does not follow a rigid sequence, as the motor milestones would suggest. In fact, children follow variable developmental sequences because of their unique personal characteristics and environmental contexts. If the traditional developmental sequences are no longer sufficient as a guide for working with children, then they are certainly not appropriate as a guide for working with adults after stroke.⁸⁹

In addition, the systems view suggests that behaviors observed after CNS damage result from patients' attempts to use their remaining resources to achieve functional goals. For example, the flexor pattern of spasticity often seen after stroke is due to various factors in addition to spasticity, such as weakness, inability to recruit appropriate muscles, biomechanical principles related to lever arms, or soft-tissue tightness. Thus, when inefficient or ineffective movement patterns are seen after stroke, therapists need to consider multiple factors as potential contributing variables (see Chapter 21).

Contemporary View of Motor Learning

Schmidt⁷⁹ defined motor learning as “a set of processes associated with practice or experience leading to relatively permanent changes in the capabilities of responding.” Thus, recent motor learning theories acknowledge that behavior changes observed during practice may be only temporary. As a result, contemporary motor learning research not only evaluates learning after the acquisition phase (i.e., immediate effects) but also after a retention phase (i.e., short- or long-term effects) or a transfer test (i.e., ability to generalize to new task), and thus new ways of thinking about motor learning have emerged. Motor learning research supports the idea that random practice (i.e., repetitive practice of several tasks in a varied sequence within a practice session) is better than blocked practice (i.e., repetitive practice of the same task within a practice session).⁸⁰ Similarly, practicing variations of the same tasks in varied contexts is better than practicing the same task in the same context. In addition, practicing the whole task rather than parts of a task usually is better, especially if the parts are interdependent or relatively fast.⁷⁷

McNevin and colleagues⁶¹ summarized some additional principles. When persons are learning a new task such as golfing, they should focus on the movement effects (external focus on the golf club head) rather than on their own arm movements (internal focus). Self-controlled practice (i.e., a person being trained decides when and how feedback is given and whether assistive devices are used) is better than instructor-controlled practice. Finally, dyad training, in which a person is able to alternate observing and practicing a task, is beneficial to learning a new task.

Research on the role of feedback in learning demonstrates that physical and verbal guidance enhanced immediate performance but interfered with long-term learning.⁷⁷ Winstein and Schmidt⁹² reported that 50% feedback (i.e., feedback after half of the trials) was better than 100% feedback. Faded or decreasing feedback was better than increasing feedback. Finally, summary feedback after multiple trials is better than immediate feedback after every trial.⁷⁸ In all cases, less feedback was better than more feedback.

Most research on motor learning has been performed on persons without disabilities using a brief, contrived task in laboratory environments. Therefore, therapists need to be cautious about applying these principles to persons with disabilities performing functional tasks in everyday, natural environments.

However, several studies have explored whether motor learning principles can be applied to persons after stroke. Hanlon³⁹ provided some evidence that random practice was better than blocked practice. Merians and colleagues⁶² reported that practice in a condition with reduced augmented feedback was beneficial for performance consistency but not for accuracy for persons with and without stroke. Dean and Shepherd²¹ reported that task-related training using variable practice and varied contexts improved balance ability during seated reaching activities. Finally, Fasoli and colleagues²³ reported that externally focused (task-related) instructions resulted in faster and more forceful movements than internally focused (movement-related) instructions for persons with and without stroke. Chapter 4 provides additional discussion of the application of motor learning principles to stroke rehabilitation.

Systems Model of Motor Behavior

The model in Figure 3-1 has been updated to include terminology from the Occupational Therapy Practice Framework.³ The figure depicts the theoretical basis of the OT task-oriented approach. The model illustrates the interaction between the person (client factors, performance skills, and performance patterns) and his or her environment (context and activity demands). Occupational performance tasks (i.e., activities of daily living [ADLs], instrumental activities of daily living [IADLs], work, education, play or leisure, rest, and sleep) and role performance (social participation) emerge from the interaction between the systems of the person (cognitive, psychosocial, and sensorimotor) and the systems of the environment (physical, socioeconomic, and cultural). Changes in any one of these systems or subsystems can affect occupational performance tasks or role performance. “In some cases, only one primary factor might determine occupational performance. In most cases, occupational performance tasks emerge from the interaction of many systems. The on-going interactions between all components of the model reflect its heterarchical nature.”⁵⁷

In addition, any occupational performance task affects the environment in which it occurs and the person acting. For example, if a patient with hemiplegia becomes independent in driving by using assistive technology and adaptive strategies, the patient's ability to drive would free family members from needing to provide transportation for appointments and social events. The patient would be able to resume the role of driver and the task of driving, which were likely meaningful to the patient's life. Thus, the occupational performance task of driving affects persons and objects in the environment (i.e., assistive technology added to the car). The task also affects the person and the associated components. The ability to be less dependent on the family may affect the patient's self-esteem positively (i.e., psychosocial subsystem). The process of driving “provides the patient the opportunity to solve problems and to discover optimal strategies for performing tasks. This influences a client's cognitive and sensorimotor subsystems and the ability to perform other functional tasks.”⁵⁷

The specific components (subsystems) of the systems, which influence occupational performance tasks, may be framed in OT terminology.^3,4 Components of the cognitive (mental) system include orientation, attention, memory, problem-solving, sequencing, learning, and generalization ability. Components of the psychosocial system include a person's interests, coping skills, self-concept, interpersonal skills, self-expression, time management, emotional regulation, and self-control skills that could affect occupational performance tasks. Strength, endurance, range of motion (ROM), sensory functions and pain, perceptual function, and postural control are components associated with the sensorimotor system. The environment includes physical, socioeconomic, and cultural characteristics of the task itself and the broader environment. Components of the physical environment system include objects, tools, devices, furniture, plants, animals, and the natural and built environments, which could limit or enhance task performance. The social supports provided by the family, friends, caregivers, social groups, community, and financial resources are components of the socioeconomic system, which could influence choice in activities. Finally, components of the cultural system include customs, beliefs, activity patterns, behavioral standards, and societal expectations, which also could affect occupational performance tasks.

The inclusion of role performance in this systems model reflects an OT, not a motor behavior perspective. “Occupational therapists believe the roles that persons want and need to fulfill determine the occupational performance tasks and activities they need to do. Conversely, the tasks and activities persons are able to do determine what roles they are able to fulfill.”⁵⁷ Box 3-1 summarizes the assumptions of the OT task-oriented approach.

Evaluation Framework Using the Occupational Therapy Task-Oriented Approach

The therapist conducts the evaluation using a top-down approach as suggested by Latham.⁵¹ Box 3-2 gives a framework for evaluation. Evaluation efforts focus initially on role performance and occupational performance tasks because they are the goals of motor behavior. A thorough understanding of the roles that a patient wants, needs, or is expected to perform and of the tasks needed to fulfill those roles enables therapists to plan meaningful and motivating treatment programs. After a patient has identified the most important role and occupational performance limitations, therapists use task analysis to identify which subsystem of the person or environment is limiting functional performance. This process may indicate the need for evaluation of selected subsystems of the person or environment.²⁶ The emphasis on role and occupational performance in the OT task-oriented approach is consistent with the idea that OT evaluation should be primarily at the participation and activities level rather than the impairment level, using World Health Organization⁹⁴ terminology. The therapist needs to use qualitative and quantitative measures during the evaluation process.⁹⁰ “Therefore, therapists use interviews, skilled observations, and standardized assessments to evaluate their clients. Although the client is the primary source of information, other sources including the client's records, caregivers, family members, and the client's environment contribute as well.”⁵⁷ A more detailed description of the evaluation framework follows.

The first step in the evaluation process is to assess role performance. “Therapists must determine which roles clients had prior to the onset of disability, and which roles they can and cannot do at this time.”⁵⁷ A discussion of roles that patients want or must do in the future helps determine which roles are most important to them. In addition, therapists need to explore ways that role changes have affected or will affect patients and their families, especially the primary caregivers. Jongbloed and colleagues⁴⁷ recommended that therapists ask questions such as: “How have roles changed since the disability?” “How have family members reacted to these changes?” “Is there role flexibility when needed?” and “How competently do members perform roles?” The therapist may need to adjust these questions to the patient's level of understanding. The patient and significant others must participate in the evaluation of role performance whenever possible.

The therapist may assess role performance using a nonstandardized, semistructured interview. However, a standardized assessment tool such as the Role Checklist^6,67 is suggested. The Role Checklist is a self-report, written inventory designed for adolescent, adult, or geriatric populations. In Part One, patients check the 10 roles (Fig. 3-2) that they have performed in the past, are performing in the present, and plan to perform in the future. In Part Two, patients rate the value of each role to them on a scale from “not at all valuable,” “somewhat valuable,” to “very valuable.” The Role Checklist takes 10 to 15 minutes to complete and has evidence of reliability and validity (Fig. 3-2).

The therapist may use other assessment tools to gather information on role performance. For example, the Occupational Performance History Interview-II (OPHI-II)⁴⁹ is a broad, semi-structured assessment of occupational life history including work, leisure, and daily life activities. One part of it explores life roles, and other parts explore interests, values, organization of daily routines, goals, perceptions of ability, and environmental influences. The complete OPHI-II takes about 50 minutes and has evidence of reliability and validity. The OPHI-II includes information not only on role performance but also on occupational performance tasks, which are the next step of the evaluation process. In conclusion, after patients have identified the roles that they want or need to perform, they can identify more easily the tasks and activities needed to fulfill each role.

The second step in the evaluation process is the assessment of occupational performance tasks: ADL, IADL, work, education, and play or leisure (Box 3-2). “Because roles, tasks, activities, and their contexts are unique to each person, a client-centered assessment tool such as the Canadian Occupational Performance Measure (COPM)⁵² is recommended.”⁵⁷ The COPM uses a semi-structured interview to measure patients' self-perception of occupational performance over time. First, patients identify problem areas in self-care, productivity, and leisure. Second, they rate the importance of each problem area, which assists therapists in setting treatment priorities (Fig. 3-3). Third, patients rate their own performance and their satisfaction with their performance on the five most important problem areas. Therapists may use these performance and satisfaction ratings again as outcome measures, measuring change across time. If therapists are concerned that a patient cannot rate his or her performance accurately because of a cognitive impairment or age, therapists may use direct observation of selected activities or a caregiver interview to verify the information. The information elicited by the COPM is unique to each patient and the individual's environment, which is an essential part of the OT task-oriented approach (Fig. 3-3).

Another recommended measure of occupational performance specific to ADLs and IADLs is the Assessment of Motor and Process Skills (AMPS)²⁵ (http://www.innovativeotsolutions.com/content/amps/). The assessment is client centered because the person chooses two or three ADL or IADL tasks to be performed, which ensures that the task or activity is familiar and relevant to the person being evaluated. The purpose of the AMPS is “to determine whether or not a person has the necessary motor and process skills to effortlessly, efficiently, safely and independently perform the ADL tasks needed for community living.”²⁵ The AMPS is appropriate for persons from diverse backgrounds and with diverse needs and interests because it has been standardized internationally and cross-culturally. “A unique feature of the AMPS is that it can adjust, through Rasch analysis, for the difficulty of tasks performed and the severity of the rater who scores the client's performance. In addition, it allows a therapist to compare the performance of clients who performed one set of tasks on initial evaluation with the results of a re-evaluation on a different set of tasks.”⁵⁷ The primary limitation of the AMPS is that it requires a 5-day training workshop to learn how to administer the assessment in a reliable and valid way. Computer software to score the AMPS is provided as part of the workshop. Finally, the AMPS assists in the next step in the evaluation process because it requires observation of patients performing occupational performance tasks (see Chapter 6).

While evaluating occupational performance tasks, “therapists must observe both the outcome and the process (i.e., the preferred movement patterns, their stability or instability, the flexibility to use other patterns, efficiency of the patterns, and ability to learn new strategies) to understand the motor behaviors used to compensate and to achieve functional goals.”⁵⁷ Determining the stability of the motor behavior is important to determine the feasibility of achieving behavioral change in treatment. “Behaviors that are very stable will require a great amount of time and effort to change. Behaviors that are unstable are in transition, the optimal time for eliciting behavioral change.”⁵⁷ Thus, when behaviors are more stable, a compensatory approach may be most appropriate; when behaviors are unstable, a remediation approach may be more successful. Quantitative and qualitative measures are needed to evaluate the process of task performance.

The third step in the evaluation process involves task selection and analysis. The tasks selected for observation should be ones that patients have identified as important but difficult to do. Task analysis requires therapists to observe their patients performing one or more occupational performance tasks. In most cases, observation of performance happens as part of the second step described previously. Therapists use task or activity analysis to evaluate activity demands, context, patient factors, performance skills, and performance patterns to determine whether a match exists that enables persons to perform occupational tasks within a relevant environment. If the person is unable to perform the task, therapists attempt to determine which person or environment subsystems are interfering with occupational performance. “In dynamical systems theory, these are considered the critical control parameters or the variables that have the potential to shift behavior to a new level of task performance.”⁵⁷ Each person has unique strengths, limitations, and environmental context after a stroke. Therefore, the critical control parameters that support or limit occupational performance tasks are also unique. An effective intervention strategy for one person after stroke may not be effective for the next person. Another concept of dynamical systems theory is that critical control parameters also change as persons and their environments change over time. Therefore, an intervention that worked well early in a patient's rehabilitation might not work well late in the rehabilitation process or vice versa.

The identification of critical control parameters is the most challenging part of the evaluation process. However, evidence in the research literature indicates that some variables or subsystems of the person or environment are potential critical control parameters for persons after stroke. Gresham and colleagues³⁸ reported that psychosocial and environmental factors were significant determinants of functional deficits in persons for the long term after stroke. In a review, Gresham and colleagues³⁷ reported that 11% to 68% of persons experience depression after stroke, with 10% to 27% meeting the criteria for major depression. In the cognitive area, Galski and colleagues³⁰ reported that for persons after stroke, “deficits in cognition, particularly higher-order cognitive abilities (e.g., abstract thinking, judgment, short-term verbal memory, comprehension, orientation) play an important role in determining length of stay and in predicting functional status at the end of hospital stay.” In the sensorimotor area, weakness,⁶⁹ fatigue,⁴⁶ impaired motor function,⁸ and visuospatial deficits⁸⁶ are associated with poorer functional outcomes. For example, Bernspang and colleagues⁸ reported that motor function measured with the Fugl-Meyer Assessment²⁸ was correlated moderately (r = 0.64) with self-care ability.

Practitioners must use the aforementioned literature on potential control parameters with caution. Most of these were correlation studies, indicating relationships between these variables and functional performance, but they do not prove a causal link. In addition, most correlations were moderate or low, which suggests that any one variable explains a relatively small percentage of the variance associated with functional performance. However, Reding and Potes⁷⁴ provided evidence that as the number of impairments increased, functional outcomes decreased. “Thus, multiple variables contribute to functional performance for most persons with central nervous system dysfunction. The challenge is to identify those variables that are most critical to your clients.”⁵⁷

Bobath¹¹ suggested that spasticity is the primary cause of motor deficits in persons after stroke and that weakness and decreased ROM are due to spastic antagonists. However, evidence is increasing that indicates that spasticity is not a critical control parameter.¹³ For example, Sahrmann and Norton⁷⁶ reported electromyography findings that indicated movements were not limited by antagonist stretch reflexes (spasticity) but were limited by delayed initiation and cessation of agonist contraction. Similarly, Fellows and colleagues²⁴ found no relationship between movement impairments and passive muscle hypertonia in the antagonist muscles. O'Dwyer and colleagues⁶⁸ found no relationship between spasticity and either weakness or loss of dexterity. “Thus, research evidence challenges the assumption that spasticity causes the weakness and decreased ROM often seen in persons with central nervous system dysfunction.”⁵⁷ Recently, the Neuro-Developmental Treatment Association acknowledged this change in thinking: “There is not a direct relationship between spasticity and constraints on motor impairments or functional performance, as the Bobaths first proposed.”⁴⁴

After identifying the critical control parameters that support or constrain occupational performance, the therapist must assess the interactions of these systems. Consider two patients who have complete loss of voluntary control of their dominant hand. The role and occupational performance tasks of the patient as a worker may or may not be affected. If the worker were an automobile mechanic, the interaction of this personal limitation with the activity demands of the work environment would likely make the task of repairing a car engine difficult or impossible to perform. However, if the worker were a self-employed writer, the person could learn to use a one-handed keyboard with the nondominant hand and could continue writing because the interaction of performance skills and activity demands would not interfere with role and task performance. This part of the evaluation requires the therapist to use qualitative and quantitative assessments and clinical reasoning to determine how subsystem of the person and the environment might affect occupational performance.

The fourth step in the evaluation process is to perform specific assessments of client factors, performance skills, and performance patterns, which are thought to be critical control parameters. The critical control variables are the only ones that need to be evaluated. “The evaluation of selected variables according to the OT task-oriented approach contrasts with bottom-up approaches that evaluate all component variables. This selective approach eliminates the need to evaluate variables that have little functional implication and saves therapists' time, which is critical for cost containment.”⁵⁷

Occupational therapists use a variety of assessments to evaluate patient factors, performance skills, and performance patterns that support or constrain occupational performance. Some assessments were designed to examine one or more impairments within the context of occupational performance. The Arnadottir OT-ADL Neurobehavioral Evaluation (A-ONE)⁵ facilitates evaluation of perceptual and cognitive systems within the context of ADL (see Chapter 26 for details). From a task-oriented perspective, this is a preferred assessment tool because it links impairments more closely to occupational performance. In contrast, most assessments of impairments are conducted independent of occupational performance.

The fifth step of the evaluation process is evaluation of the environment: context and activity demands. The inclusion of physical, social, and cultural environments in American Occupational Therapy Association⁴ uniform terminology and the current practice framework¹ acknowledges their important impact on occupational³ performance. A number of OT theories^18,53,82 emphasize the importance of assessing environmental context as part of the overall evaluation process (see Chapter 31, Radomski,⁷³ and Cooper and colleagues¹⁹ for specific assessments of environmental contexts).

Many patients are not able to continue some of the roles and tasks that they performed before their strokes. This is a frustrating and sometimes depressing situation for many persons after stroke. Therapists can help by exploring alternative ways of fulfilling roles and of performing the associated tasks. Therapists also can explore potential new roles and new tasks. For example, in the case study presented at the end of this chapter, an important role for G.W. was continuing to help his son on the farm. The therapist helped the patient identify the tasks with which he had helped in the past and which ones would be impossible or difficult to perform in the future. For G.W., heavy or bilateral tasks (e.g., moving bales of hay and repairing heavy equipment) would fit this category. Brainstorming about alternative tasks that he could do unilaterally or relatively light tasks (e.g., record keeping) that he could still perform would enable him to continue his role as an assistant to his son. Inclusion of the son in this discussion was important because he had suggestions that G.W. had not considered. The uses of compensatory strategies (i.e., adapted equipment or techniques) can be an efficient way to address role and task performance limitations.

Practice Functional Tasks or Close Simulations to Find Effective and Efficient Strategies for Performance

In all cases, the therapist must use the functional tasks and activities that have been identified as important and meaningful to their patients. This demonstrates to patients that the therapist has listened to them and respects their choices and priorities. As a result, patients more easily understand the relevance of therapy to their lives.

Use of functional, natural tasks rather than rote exercise in treatment is important. A number of studies have demonstrated that the kinematics of movement are different when one performs a real task instead of rote exercise.^60,95 A meta-analytic review⁵⁵ provided evidence that “engagement in purposeful activity produces better quality of movement than concentration on movement per se.” Nelson and colleagues⁶⁴ demonstrated that after stroke, persons who performed an occupationally embedded exercise had significantly greater supination active ROM than persons who did rote exercises. These studies support the idea that the use of functional tasks has beneficial therapeutic effects.

Higgins⁴¹ suggested that persons need to practice functional, everyday activities to find the most effective and efficient way of doing the activity. Because persons are unique, their performance patterns and levels of skill vary. Therefore, therapists should not expect that one way of performing a task would be the most effective and efficient way of performing a task for all patients. Thus, therapists should encourage patients to experiment to find the most effective and efficient way of performing functional tasks. In one evidence-based review, the authors concluded, “There is strong evidence that patients benefit from exercise programmes in which functional tasks are directly and intensively trained”⁸⁸ (Figure 3-4).

Provide Opportunities for Practice Outside of Therapy Time

Therapists need to recognize that the amount of time they have to work with a patient is short relative to the total time in a day. Therefore, enticing patients to continue therapy on their own time is important. Therapists can provide homework assignments for patients to work on their own (Fig. 3-5). If homework is given, follow-up is important, and therapists should ask their patients how their homework went. What worked for the patients, and what did not work for them? Effective communication with other rehabilitation staff and family members is crucial so that their attempts to be helpful do not reduce the opportunities for patients to practice outside of therapy time. Most important is for therapists to help patients find new ways to use their involved extremity, even if it is only to stabilize objects. A good homework assignment is to challenge the patient to find a new way to use the involved arm each day.²⁷ Ultimately, the goal is to get patients to use their involved arm without thinking about it.

Minimize Ineffective and Inefficient Movement Patterns

As described previously, during observation of a patient performing an occupational performance task, therapists attempt to identify what may be critical personal or environmental factors that are interfering with effective and efficient movement patterns. The following strategies are ways that therapists can intervene to reduce ineffective and inefficient movement.

Remediate a Client Factor (Impairment) if It Is the Critical Control Parameter.

When therapists identify person factors in the cognitive, psychosocial, or sensorimotor systems as possible critical control parameters, then they should attempt to remediate those factors, assuming it is possible. For example, Flinn²⁷ identified decreased strength as one critical control parameter that interfered with occupational performance tasks for a person after stroke. Thus, she attempted to remediate this sensorimotor variable through the use of exercise and increased use of the involved extremity for functional tasks. For this person, the use of exercise was meaningful because she saw a clear connection between her exercise program and her ability to use her involved arm and hand for everyday tasks. The therapist also encouraged her to use her involved extremity whenever possible in therapy and for various homework assignments.

In the case of G.W., decreased strength, impaired sensation, and neglect of the left upper extremity were identified as possible control parameters. Therefore, attempts to remediate these factors were warranted in this case. However, sometimes remediation of a potential control parameter is impossible because of the severity of the disease process or limited time available for therapy. In such cases, a more compensatory approach to treatment is indicated.

Adapt the Environment, Modify the Task, Use Assistive Technology, or Reduce the Effects of Gravity.

For many patients, the quickest and most effective approach to improving occupational performance is to adapt the task or the environment. For example, Gillen³³ described a patient with severe limitations in self-care activities after multiple sclerosis and ataxia. Tremor, impaired postural control, paraparesis, and decreased endurance limited his occupational performance. The patient's priority was to gain access to the community and community resources. He did not have adequate motor control to operate a manual chair or to control a standard power chair. Therefore, a specialized power chair was prescribed that provided optimal head and trunk stability, allowed independent tilting, included a joystick with tremor-dampening electronics, and had a forearm trough to provide maximal stability to the arm controlling the joystick. A volar wrist splint provided additional stability to the wrist. With training in varied environments, the patient improved from total assistance in mobility to minimal supervision. Thus, the use of assistive technology, task modification, and training in varied environments was the most efficient and effective means of improving the mobility independence of this patient.

For G.W., a standard bath chair enabled independent and safe tub transfers. For shoe tying, G.W. preferred the use of Kno-Bows, an adapted device, for fastening his shoes rather than learning one-handed shoe tying. For cutting meat, an enlarged-handled fork was tried to encourage use of the left hand. However, this was not feasible at the time, so a rocker knife was prescribed. Thus, a variety of adapted devices increased the ADL independence of G.W.

For patients unable to raise their arms up against gravity (i.e., grade 2 shoulder flexion and shoulder abduction muscles), the use of technology that minimizes the effects of gravity on their arms may help strengthen those weak muscles and enable increased functional performance. The use of body weight support during treadmill training has resulted in increased lower extremity strength and increased ambulation ability of persons after stroke.⁸⁸ Unfortunately, there has been limited application of this concept to the upper extremity. Devices such as mobile arm supports with elevation assist (Fig. 3-6; e.g., Jaeco Multilink Elevation Assist or SaeboMAS dynamic mobile arm support system) or deltoid aide counterbalanced slings (e.g., Swedish Help Arm or Mobility Arm) minimize the effects of gravity on a patient's arm and can be graded to provide less assistance as the person increases in strength. When these patients have some hand function, these devices can be used effectively for task-specific training. When these patients have limited hand function, the Armeo or T-WREX (http://www.hocoma.com) may be effective devices. They enable patients with upper extremity weakness and limited grasp and release to exercise their arm while using virtual reality simulated functional activities such as grocery shopping and cleaning a stovetop. These task-specific activities can be adjusted to each patient's ability, and they motivate patients to use the available function in their arms and hands.⁴³ These devices that minimize the effects of gravity on a patient's arm have the potential to increase upper extremity strength and to improve functional performance. However, more research is needed to evaluate their effectiveness (see Chapter 22).

For Persons with Poor Control of Movement, Constrain the Degrees of Freedom.

Persons learning a new task initially restrict the degrees of freedom at their joints by self-imposing some form of freezing of body segments.⁴¹ As a result, their performance appears stiff and uncoordinated. With practice, the performance becomes smoother and more coordinated as the restrictions on the degrees of freedom decrease. Unfortunately, some persons with CNS damage are not able to constrain the degrees of freedom at their joints. For example, Gillen³⁴ identified poor postural stability and tremor as interfering with the functional performance of a person with multiple sclerosis and ataxia. He speculated “that performance would be improved by increasing postural stability and decreasing the number of joints (decreasing the degrees of freedom) required to participate in chosen tasks.”³⁴ Therefore, he used orthotic devices, assistive technology, and adaptive positioning of the trunk and upper extremity to help his patient constrain the degrees of freedom and to increase stability, which enabled improved ADL performance. Thus, the occupational performance of a patient with tremor was enhanced by strategies to decrease the degrees of freedom at those joints.

For Persons Who Do Not Use Returned Function in Their Involved Extremities, Use Constraint-Induced Therapy.

A growing body of literature supports the beneficial effects of constraint-induced movement therapy (CIMT) for persons after stroke with active wrist extension and active finger extension.^12,63,93 The original CIMT involves intensive therapy (i.e., about 6 hours per day for 10 days in a 2-week period) while the less-involved arm is constrained by a sling or glove. As a result, participants are forced to use their involved extremity to complete functional tasks, and thus CIMT counteracts the learned nonuse seen in many persons after stroke. CIMT is consistent with two assumptions of the OT task-oriented approach: “functional tasks help organize behavior and experimentation with various strategies leads to optimal solutions to motor problems”⁵⁷ (see Chapters 17 and 21).

In most clinical settings, CIMT as originally proposed would not fit into the current structure of inpatient rehabilitation programs and current reimbursement practices. However, there is growing evidence that a less intense (i.e., less times per day) and more distributed (i.e., spread out longer than 2 weeks) form of CIMT is also effective.^22,70,71,96 Thus, modified constraint-induced therapy (mCIT) can be used within current rehabilitation programs. However, after stroke, many persons do not meet the minimal eligibility requirements during their initial rehabilitation, so most mCIT or CIMT programs are conducted on an outpatient basis for persons who are 6 months or more post-stroke and who have sufficient return of function to benefit from CIMT. No evidence indicates that CIMT is effective for persons without some active wrist and finger extension. In the case of G.W., with the neglect of his involved extremity, he would not be a good candidate for CIMT now because he does not have sufficient active wrist and finger extension to benefit. At a later time, when that function does return, a trial of mCIT or CIMT would be indicated. Chapters 17 and 21 contain more detailed discussions of CIMT. For a more detailed discussion of the OT task-oriented approach treatment, see Bass-Haugen and colleagues⁷ and Almhdawi.¹

Evidence Supporting the OT Task-Oriented Approach

There is strong evidence supporting elements of the theoretical basis and treatment principles or assumptions of the OT task-oriented approach as described earlier.⁸¹ A recent systematic literature review of interventions to improve occupational performance of persons post-stroke suggested that the characteristics of “effective interventions include the use of goal-directed, indi­vidualized tasks that promote frequent repetitions of task-related or task-specific movements.”⁶⁶ These characteristics are consistent with the OT task-oriented approach. However, there is limited evidence regarding the clinical efficacy of the approach as described in this chapter. Four clinical case studies provide descriptive evidence in support of the approach. Flinn²⁷ described the successful application of the approach to a person post-stroke without cognitive deficits. Preissner effectively applied this approach to a person post-stroke with significant cognitive limitations.⁷² Gillen^33,34 reported the positive results of applying the approach to two different persons with multiple sclerosis and ataxia. These case studies are good examples of the practical application of the OT task-oriented approach to specific clients.

The strongest evidence in support of the OT task-oriented approach is the randomized controlled trial conducted by Almhdawi.¹ This study aimed to evaluate the functional and the impairment effects of this approach and to refine its treatment protocol. Twenty participants with stroke of 3 months or more fulfilled the minimal affected upper extremity active movements of at least 10 degrees of shoulder flexion and abduction and elbow flexion-extension. Participants were randomized into two order groups. The immediate group got 3 hours of OT task-oriented treatment per week for 6 weeks and then got 6 weeks of no treatment control; the delayed intervention group underwent the reversed order. Participants were evaluated before the first phase, at the cross over, and after the second phase by trained, blinded evaluators. The treatment change scores from both groups were compared with those of the control. The results supported the OT task-oriented approach's functional superiority as indicated by significant and clinically meaningful changes in the COPM, the Motor Activity Log, and the time scale of the Wolf Motor Function Test. The result failed to support hypothesis of the impairment effects superiority of the OT task-oriented approach. He was able to get comparable effect sizes as the large Extremity Constraint Induced Therapy Evaluation (EXCITE) trial⁹³ on CIMT even though his participants were more severely involved and longer after the onset of their strokes. They also received a lower intensity of therapy (i.e., 18 hours vs. 40–60 hours for CIMT participants). He concluded that the OT task-oriented approach is an effective upper extremity post-stroke rehabilitation approach in improving upper extremity functional abilities. More studies are needed to provide more evidence for this approach compared with other approaches and to illuminate more of its therapeutic abilities with different stroke severity and chronicity levels.

Summary

This chapter describes an OT task-oriented approach for persons after stroke and describes the theoretical basis for and assumptions of the approach, based on contemporary motor control, motor learning, and motor development literature. The chapter also provides a top-down evaluation framework that emphasizes the importance of evaluating role and occupational performance tasks first and then the selective assessment of personal and environmental factors. In addition, the chapter describes the application of treatment principles to various patient problems and, finally, includes a case study describing the application of the OT task-oriented approach to a specific person after stroke.

G.W. is a 69-year-old retired farmer who sustained a right cerebrovascular accident with resultant left hemiparesis 5 days ago. He was admitted to the acute care hospital and was then transferred to the rehabilitation unit today.

From the chart, it was learned that he is now medically stable. He is taking angiotensin-converting enzyme inhibitors for high blood pressure and Coumadin for prevention of a second stroke. He has been living in a small town with his wife since moving from their farm 3 years ago. His son, daughter-in-law, and their three children are farming in the local community.