Veronica: Thank you for having me here today. I appreciate that introduction and I am happy to be with you today to talk about task oriented training. I am going to present evidence for task oriented training from my dissertation, which was entitled Task Oriented Training and Evaluation at Home. My background is related to this topic specifically. It has morphed into this through my work at Emory with Dr. Wolf in constraint induced movement therapy and also at the University of Southern California with Dr. Winstein in the ICARE randomized clinical trial, looking at a task oriented training intervention. From that, my dissertation was developed and I continued to use contemporary approaches in task oriented training. Today, I want to emphasize how to deliver a task oriented training program to clients with hemiparesis after stroke. It is focused on the upper extremity in hemiparesis, however, I think you will find components of task oriented training that can be implemented to benefit a variety of deficits that occur due to a stroke. Specifically, the evidence that I am going to present was done using a task oriented training in the home environment, which makes a little bit more novel, and it has a basis of theoretical understanding through motor learning and through the occupational therapy theory of occupational adaptation. It will emphasize the importance of task oriented training going beyond repetition and intensity of functional tasks, but the importance and the emphasis on supporting clients using their own problem-solving abilities ultimately to improve their adaptation and increase their function that will last over time, not just while they are with us as therapists. I am going to identify key components of motor learning and occupational adaptation and how those relate to task oriented training. I am also going to describe that idea of adaptation and how that is really a key part of task oriented training by giving you the evidence to the research I have done through a task oriented training program delivered at home. I will also tell you about some novel outcome measures and some not so novel outcome measures that you may not have thought about using in the past.
Motor Rehabilitation After Stroke
These three pictures were recently on the cover of OT Practice in Figure 1, so they may look familiar to you, but I thought they represented a nice progression of the motor control motor learning theory of where it began and somewhat a representation of where it is today.
Figure 1. Motor rehabilitation progression.
This first one is a representation of Jan Davis doing NDT with a client. You are probably all familiar with that. NDT definitely comes from the motor control theory. It involves a lot of hands-on work from the therapist applying it to the client. It is still used a lot today. Unfortunately, the evidence is not as great to support it. However, there are still aspects of it that are vital and important and still can be used. The nice thing about the motor control motor learning theory is that very little has been completely thrown out. I feel like we have just built upon things that we have done in the past. The theory has moved on from NDT and motor control, which also includes things like Brunnstrom's, PNF, and Rood approaches, to that described by Edward Taub as constraint-induced movement therapy and given evidence with Steve Wolf's randomized clinical trial, ExCITE trial. This looked constraint-induced movement therapy where clients, wearing a mitt or some type of constraint on their unaffected hand, are forced to use their affected hand. This method has been shown to have positive results with improved movement and function of the affected arm and hand. There has been some controversy or some complaints about the protocol that was utilized in the randomized clinical trial, which is justified. However, many other studies have been done looking at altered forms of the protocol. The constraint induced movement therapy components of using the mitt and getting the client to do that intense repetitive practice with their affected arm and hand can still show positive results (middle picture). Finally, this has morphed into what I think this picture on the far right represents. She looks like somebody that is doing something that she enjoys, whether that is rock climbing, ziplining, spelunking, etc. I am not quite sure what it is, but she is happy and doing something that is salient and meaningful to her, which is really the key component of motor learning; doing activities that are important to us. You can just look at the smile on her face compared to the expression on this gentleman's face in the middle. It looks like she is having a lot more fun.
Today, we are going to focus on these more current principles of motor rehab, specific to task oriented training for the treatment of upper extremity hemiparesis. I do not by any means say that we are not going to use any of these others. I want to emphasize instead that we have built upon this progression to come up to our current level of contemporary current practice.
TOTE Home Intervention
TOTE home stands for task oriented training and evaluation at home. This is a principle based intervention. It is not a protocol, nor something you can be certified in. It is something anybody can do, and it can be morphed, changed, and adapted. It is based on principles rooted in motor learning theory and occupational adaptation within the home environment.
