Task oriented trainingNisrin Alqatarneh Thanks to Dr. Hassan Sarsak

• The origins of assumptions ▫ Systems model of motor control

Motor behavior emerges from persons’ multiple systems interaction with unique task in a specific environment

▫ Dynamical systems theory (reviewed later)

▫ Systems view of motor development

changes over time are due to maturation in CNS, biomechanical changes, social and physical environment

Development doesn’t follow a rigid sequence but may be the interaction between personality characteristics and environment

• OT: Interaction between role performance, occupational tasks, cognition, psychosocial, sensorimotor, (PERSON) and ENVIRONMENT (socioeconomic, culture, physical)

Task-oriented approaches

•View of recovery after CNS lesions

▫ When damage to CNS: compensate for the lesion to achieve functional goals

▫ Recovery : a process of discovering remaining abilities

▫ CNS damage: relative to functional performance

-Example: in stroke, spasticity may lead to a specific pattern which is enhanced by improper positioning, lack of activities, and environmental factors

-Treatment example: Constraint-Induced Movement Therapy (CIMT)

▫ Control is NOT simply over muscle actions, but over the interactions of kinematic variables

Dynamical systems theory

•Principles:▫Organisms demonstrate an inherent

tendency to self-organize throughout life▫Plasticity; is a system’s capacity to

reorganize after distribution and to adapt to functional demands

Cont’d•Environmental opportunities are seen as

critical to CNS plasticity •Environmental challenges encourages

dynamic reorganization of an injured CNS•Therapeutic challenges has the potential to

influence how a person’s neuromuscular system will reorganize itself after injury

•Functional task demands are used instead of exercise to provide graded motor challenges

Attractor state• Are the preferred movement patterns for various

categories of motor performance.• Ranging from handwriting to a golf swing• Attractor state is characterized by the depth of its

well:▫Movement patterns with shallow wells are extremely

unstable, they vary each time the task is performed▫Movement patterns with deep wells are extremely

stable; makes difficult for the person to achieve variety in task performance

• In a functioning CNS the attractor wells are deep enough to be stable but shallow enough to allow flexibility

Control parameters• Are variables that when changed, influence

changes in motor behaviour• External control parameters: such as task

requirements or features in the environment, elicit variations in performance▫Handwriting: pen, writing surface

• Internal control parameters: such as body alignment, muscle length

• During intervention: Early in the intervention; therapist should identify internal control parameters as obstacles for efficient movement.

Task-oriented approaches •Evaluation

▫ Top-down approach (roles, tasks, needs)

▫ This will determine components to work on

▫ Activity and participation level NOT impairment level

▫ Use of standardized, non-standardized, interviews, observations

1. Role performance

2. Occupational performance tasks: performance areas

3. Task selection and analysis

4. Person: performance components

5. Environment: performance context

▫ Interventions are guided by the therapist’s understanding of motor learning principles

Principles of Carr and Shepherd’s Motor Relearning Program (MRP)

• The person is an active participant whose goal is to relearn effective strategies for performing functional movement

• Successful task relearning has occurred when activities are performed automatically and efficiently

• The learning of skills does NOT follow a developmental sequence

• Intervention is NOT focused on learning specific movements but instead on learning general strategies for solving motor problems

Principles of Carr and Shepherd’s Motor Relearning Program (MRP) –

Cont’d• Obstacles to efficient movement include

muscle weakness, balance loss, fixation patterns due to postural insecurity, and loss of soft tissue extensibility

• Abnormal movement patterns are attributed to the repeated practice of compensatory movement strategies that become overlearned ▫ Continued practice of compensatory strategies limits

functional recovery…. Is that true??? Elaborate???

Impairments related to rehabilitation

• Positive features of the CNS after injury; which are exaggerations of normal phenomena due to release of spinal or brainstem reflexes from hierarchical inhibitory control; such as spasticity, hyperreflexia

• Negative features; are due to impairments in recruitment and firing rate modulation of motor neurons; include weakness, fatigability, slowness, and impaired dexterity

• Secondary impairments (adaptive features); physiological, mechanical, and functional changes muscles and other soft tissues; such as shortening or stiffness of muscles and joints

The rehabilitation environment

•Environmental factors play a critical role in the effectiveness of interventions

•Include:1. Therapeutic relationship between

therapist and client2. Therapists effectiveness in focusing the

client’s attention on the most important features of motor performance

3. The type and amount of ongoing practice

Therapist as coach:

•The therapeutic relationship in task-oriented training is an active, collaborative mentorship with regard to motor performance

•Therapists goals as coach:1. To encourage performance of the most

important mechanical features within a given category of motor tasks

2. To discourage behavioural adaptations that have limited effectiveness

Focused attention

• Early in the intervention the therapist focuses the attention of the patient on features of the task that are most important and obvious for learning

• Therapist and patient identify the key components of the task

• Therapist uses demonstration and instructions to focus on one or two important components of the task

• Patient needs to have a clear idea of the motor goal and which strategies are appropriate or inappropriate for reaching these goals

• Routinely ask patient to describe or demonstrate the specific movement required to achieve the task, sometimes with another body segment

Focused attention

• Later in intervention, move from details of the action to external goals of the current activity

• Use the task goal and different control parameters to shape the movement sequence

• Less focus on abstract movements such as weight shifting, range of motion exercise, and more focus on the individualized, organization of control parameters to focus on intended sequence of movements

• Use of temporary adaptive aids instead of the physical support from the therapist to do a task

Practice

• Move away from physical exercises and repetitions• Teach patient more problem solving techniques to

overcome difficulties and changes in tasks• Use variations of task within ADL and patient’s own

environment• Whole task performance rather than practicing

components of the task only• Design a program that includes therapeutic movements

within his/her daily routine• Use family and friends to support patient within home as

part of the program• The ultimate goal is the acquisition of functional skills that

can be generalized to multiple situations and environments

Stages of Motor Learning

Acquisition Transfer

(O’Sullivan & Schmitz, 2007)

Retention

-Skill acquisition stage (cognitive stage) occurs during initial instruction and practice of a skill

-Skill retention stage (associated stage) which is defined as “carry-over” as individuals are asked to demonstrate their newly acquired skill after initial practice

-Skill transfer stage (autonomous stage) which involves the individual demonstrating the skill in a new context/environment.

• Automatic processing: the activity is done without conscious awareness (highly familiar and practiced situations. Examples: driving a familiar route, walking

• Controlled processing: unfamiliar new tasks/experiences. Examples: driving on unfamiliar road on a rainy day while trying to locate an address, walking with a broken leg and using crutches.

• Selective attention: to select important and relevant information and block what is not needed (information filtering). Example: during a lecture, you may miss important notes because you are daydreaming or distracted by conversations in the hallway!

• Divided attention: to engage in more than one task at a time (multi-tasking). Example: to talk on the cellphone while driving.

• Vigilance: the ability to sustain attention over time (attention span)

Practice • Random practice involves practice of several tasks presented in a

random order encouraging reformulation of the solution to the presented motor problem

• Blocked practice involves repeated performance of the same motor skill

• Distributed practice provides adequate rest periods if task is complex, long, or energy costly or if learner fatigues easily, has short attention span and poor concentration

• Variable conditions involve practice of skills in various contexts to improve transfer of learning and retention of skills

Feedback

Intrinsic feedback:-Information received by the learner as a result of performing the task-Information is received from tactile, vestibular, and visual systems during and after the task

Extrinsic feedback: -Feedback provided from an outside source (i.e. the therapist or a mechanical device)-Verbal feedback about the process or performance itself (knowledge of performance)-Results of the motor action/end product/outcome (knowledge of results)

Factors “Conditions” that promote generalization of motor learning

• Capacity to generate intrinsic feedback• High extrinsic feedback regarding knowledge of

performance• Low extrinsic feedback regarding knowledge of results • Practice conditions that are variable and random• Whole task performance and breaking task into smaller

parts• High contextual interference utilizes environmental

conditions that increase the difficulty of learning such as noise distractions, crowded environment

• Practice in naturalistic settings (where the skill will be actually performed; home, simulated clinic, etc.)

Lab Exercise •Split into groups•In your own words, based on what you

have learned, and with a concentration in Occupational Therapy, translate into practice, formulate, and help develop 5 training methods/techniques/strategies for each motor learning stage?

Tips/Cues Sample:Training Strategies “Cognitive Stage”

• Highlight purpose of task in functionally relevant terms • Have patients verbalize task components and

requirements • High dependence on vision: have patients watch

movement (visual feedback)• Blocked repeated practice? Random variable practice?

Distributed practice?• Feedback; intrinsic? Extrinsic? Continuous?

Occasional? • Reinforcement type?• Environment characteristics? • Others? Please specify

Tips/Cues Sample:Training Strategies “Associated Stage”

• High dependence on visual? or proprioceptive feedback “feel of movement”?

• Blocked repeated practice? Random variable practice? Distributed practice?

• Feedback; intrinsic? Extrinsic? Continuous? Occasional?

• Environment characteristics? • Others? Please specify

Tips/Cues Sample:Training Strategies “Autonomous Stage”

• High dependence on visual? or proprioceptive feedback “feel of movement”?

• Blocked repeated practice? Random variable practice? Distributed practice?

• Feedback; intrinsic? Extrinsic? Continuous? Occasional?

• Environment characteristics? • Others? Please specify

Thank you…Questions?