CONTEMPORARY TASK ORIENTED APPROACH

 

Introduction

Task oriented training is a restorative, therapeutic approach based on the system theory of motor control.This was given by Bernstein in 1967 to retrain the patients with movement disorders. This approach utilizes a training program that focuses on specific functional tasks to promote and restore optimal functional capacity.

 

Goals

• To achieve control in various different functional activities and postures.

• To attain active movements after a phase of active assisted activity.

  • Minimize hands-on therapy.

  • Maximize role as training coach.

• To transit the patient away from using assistive devices toward independent function as soon as the patient is able.

• To effectively counteract the effects of immobility and the development of indirect impairments such as muscle weakness or loss of flexibility.

• To promote use-dependent cortical plasticity.

• To prevent learned non-use of the involved segments while stimulating CNS recovery.

 

Goal of the task practice

• To involve the patient in goal setting and decision making, thereby enhancing motivation and promoting active commitment to recovery.

• Task analysis include an understanding of

  1. The nature of task;

  2. The essential elements within the task;

  3. The context or environment in which the task occurs.

 

Determination of the Activities to be Practiced

• Consider the patient’s past history, health status, age, interests, and experience.

• Consider the patient’s abilities/strengths, level of recovery, learning style, impairments, and activity limitations.

• Determine a set of activities to be practiced for each training goal.

• Tasks are selected to ensure patient success and motivation like grasp and release of a cup for feeding, forward reach for UE dressing.

• Involved segments are targeted for training (e.g. CIMT).

• Prevent or limit compensatory strategies.

• The therapist selects activities and modifies task demands based on analysis to determine an appropriate plan of care (POC).

• Tasks are modified continually to

  1. Increase the level of difficulty;

  2. Promote adaptation of skills;

  3. Promote independence.

E.g. progressively lowering the seat height during sit-stand training increases the difficulty of the task until the patient is able to stand up from a normal seat height.

• Tasks targeted during Early rehabilitation include:

  1. Basic activities of daily living (BADL) like feeding, dressing, hygiene etc.

  2. Functional mobility skills (FMS) like bed mobility, transfers and locomotion.

  3. Early training include use of assistive devices to assist function (e.g. for transfers training, gait, and locomotion, dressing).

• Tasks targeted during Late rehabilitation depend on the patient’s level of recovery and discharge placement. This include:

  1. Instrumental activities of daily living (IADL) like home chores, shopping etc.

  2. Community mobility;

  3. Work activities.

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Determine Parameters of Practice

• Manage fatigue, determine rest and practice times.

• Model for ideal performance.

• Establish requirements for intensity, minimal number of repetitions.

• Establish practice schedule of tasks; shift to variable practice to enhance retention.

• Determine the practice order of tasks; shift to random order to enhance retention.

• Control use of instructions and augmented feedback to promote learning.

• Control use of assisted movements to promote initial learning.

 

Role of the Therapist

• Training coach.

• Structuring practice.

• Provide appropriate challenge and feedback while encouraging the patient.

• Use sensitive, valid, and reliable functional outcome measures to monitor recovery closely and document progress.

 

Exclusion Criteria

• Lack of voluntary control or cognitive function.

• Vision or hearing not sufficient to participate in self-rating scales.

• Lack of basic head stability during upright positioning.

 

Structure of the Environment

• Promote initial practice in a supportive environment, free of distractors- closed environment.

• Progress to variable practice in real-world environments- open environment.

• Environment should be safe, where the patient can learn without the risk of injury or outright failure.

• Simulated environments are found in many rehabilitation centers (e.g. Easy Street Environment).

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Behaviour Shaping

• Gradually modify the task to increase the challenge and make it progressively more difficult as patient performance improves.

• Provide immediate and explicit feedback; recognize and acknowledge small improvements in task performance.

• Emphasize positive aspects of performance.

• Avoid excessive effort because it degrades performance and dampens motivation.

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Safety Awareness Training

• Safety awareness training is required during self-care activities, postural control, balance activities and functional mobility.

• Identifying fall risk and developing strategies to reduce fall risk are important elements of functional mobility training.

• Instructions in the use of assistive devices and equipment should also be given.

• Provide home exercise program with adequate training for patient/ family/ caregivers.

 

Role of Patient

• The patient must evaluate performance, identify obstacles, generate potential solutions, choose a solution, and evaluate outcome.

• Relate successes to overall goals.

 

References

• Ivey FM, Hafer-Macko CE, Macko RF (2008) Task-oriented treadmill exercise training in chronic hemiparetic stroke. J Rehabil Res Dev 45: 249-259.

• Jang SH, Kim YH, Cho SH, Lee JH, Park JW, et al. (2003) Cortical reorganization induced by task-oriented training in chronic hemiplegic stroke patients. Neuroreport 14: 137-141.

• Outermans JC, van Peppen RP, Wittink H, Takken T, Kwakkel G (2010) Effects of a high-intensity task-oriented training on gait performance early after stroke: a pilot study. ClinRehabil 24: 979-987.

• Schaechter JD (2004) Motor rehabilitation and brain plasticity after hemiparetic stroke. ProgNeurobiol 73: 61-72.

• Gerald V. Smith, Kenneth H. C. Silver, Andrew P. Goldberg, Richard F. Macko (1999) Task-Oriented Exercise Improves Hamstring Strength and Spastic Reflexes in Chronic Stroke Patients. Stroke 30:2112-2118.

• Physical Rehabilitation by Susan Sullivan, Thomas J. Schmitz, George D. Fulk 6th Edition