Task-Oriented Training – Upper Extremity

Evidence Reviewed as of before: 13-07-2014
Author(s)*: Annabel McDermott, BOccThy; Adam Kagan, BSc BA; Carole Richards, Ph. D PT; Nicol Korner-Bitensky, Ph. D OT
Table of contents

Introduction

Task-oriented training involves practicing real-life tasks (such as walking or answering a telephone), with the intention of acquiring or reacquiring a skill (defined by consistency, flexibility and efficiency). The tasks should be challenging and progressively adapted and should involve active participation (Wolf & Winstein, 2009). It is important to note that it differs from repetitive training, where a task is usually divided into component parts and then reassembled into an overall task once each component is learned. Repetitive training is usually considered a bottom-up approach, and is missing the end-goal of acquiring a skill. Task-oriented training can involve the use of a technological aid as long as the technology allows the patient to be actively involved. Task-oriented training is also sometimes called task-specific training, goal-directed training, and functional task practice. This particular module focuses on task-oriented training intended specifically to improve upper extremity function.

Note: Studies were excluded if the intervention did not involve: 1) practicing a salient, real-life task, 2) progressively adapting the task to the patient’s progress over time, or 3) active participation by the patient. As well, studies that mixed task-oriented training with other types of exercise (e.g. aerobic, strength), or that compared one type of task-oriented training to another type of task-oriented training (e.g. different types of feedback, or different types of gait training) were excluded. To date 10 high quality RCTs, 1 of fair quality and 1 pre-post single group design that meet the above inclusion criteria have investigated this topic. Please note that the Cochrane Review by French et al. (2010) used different inclusion criteria and classification of outcomes, thus the findings differ somewhat from ours.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

*Studies may not have been sufficiently powered to find between-group differences, while important within-group differences indicated a possible effect of treatment.

Results Table

View results table

Outcomes

Acute Phase

Activities of daily living (ADLs)
Not effective
1A

Two high quality RCTs (Langhammer et al., 2000; Van Vliet et al., 2005) examined the effect of upper extremity task-oriented training on ADLs in patients with acute stroke.

The first high quality RCT (Langhammer et al., 2000) found no significant difference in ADLs (measured by the Barthel Index) at either 2 weeks or 3 months, between a group of patients who received a 3-month full-body motor relearning program based on a task-oriented training approach (based on the approach described by Carr & Sheppard, 1987), compared to a group that received Bobath-based treatment for 3 months.

The second high quality RCT (Van Vliet et al., 2005) found no significant difference at 1, 3 and 6 months in ADLs (measured by the Barthel Index and the Extended Activities of Daily Living Scale) between a group who received a whole body motor relearning program based on a task-specific repetitive approach (based on the approach described by Carr & Sheppard, 1987), compared to a group who received Bobath treatment.
Note: Treatment did not have a specific ‘end-point’ and continued as long as needed.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that task-oriented training for the upper extremity is not more effective in improving ADLs compared to Bobath treatment in patients with acute stroke.

Arm strength
Not effective
1B

One high quality RCT (Winstein et al., 2004) examined the effect of upper extremity task-oriented training on arm strength in patients with acute stroke. This high quality RCT firstly stratified patients according to stroke severity based on the Orpington Prognostic Scale as more severe or less severe. Patients were then randomized within these strata to receive one of three interventions: task-oriented training + standard care, strength training + standard care, or standard care alone. There was no significant between-group difference in arm strength (measured by isometric torque) at 4-6 weeks (post-treatment). There was a significant between-group difference in arm strength only at 9-month follow-up among patients with less severe stroke only, in favour of task-oriented training compared to strength training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that task-oriented training is not more effective than comparison interventions (strength training, standard care) for improving arm strength among patients with acute stroke.
Note: However, task-oriented training was seen to be more effective than strength training at 9-month follow-up among patients with less severe stroke.

Dressing
Effective
2B

One non-randomized study (Christie et al., 2011) examined the effect of upper extremity task-oriented training on dressing in patients with acute stroke. This non-randomized study provided patients to a group-based task-specific dressing retraining program during admission in a stroke unit. There was a significant improvement in upper limb dressing skills (Functional Independence Measure) at discharge (average 4 sessions).

Conclusion: There is limited evidence (level 2b) from one non-randomized study that a task-specific dressing program is effective for improving dressing skills in patients with acute stroke.

Grip strength
Not Effective
1B

One high quality RCT (Winstein et al., 2004) examined the effect of upper extremity task-oriented training on grip strength in patients with acute stroke. This high quality RCT ) firstly stratified patients according to stroke severity based on the Orpington Prognostic Scale as more severe or less severe. Patients were then randomized within these strata to receive one of three interventions: task-oriented training + standard care, strength training + standard care, or standard care alone. There was no significant between-group difference in grip strength (measured by handheld dynamometer) at 4-6 weeks (post-treatment) or follow-up (9 months).

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that task-oriented training for the upper extremity is not more effective than comparison interventions (strength training, standard care) for improving grip strength among patients with acute stroke.

Hand dexterity
Hand dexterity
1b

One high quality RCTs (Van Vliet et al., 2005) examined the effect of upper extremity task-oriented training on hand dexterity in patients with acute stroke. This high quality RCT randomized patients to receive a full-body task-specific repetitive approach (based on the approach described by Carr & Sheppard, 1987) or a control group that received Bobath treatment. There was no significant between-group difference in hand dexterity (measured by the Ten Hole Peg Test) at 1, 3 or 6 months.
Note: Treatment did not have a specific ‘end-point’ and continued as long as needed.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity task-oriented training is not more effective than a comparison intervention (Bobath treatment) for improving hand dexterity among patients with acute stroke.

Pain
Not effective
1B

One high quality RCT (Winstein et al., 2004) examined the effect of upper extremity task-oriented training on pain in patients with acute stroke. This high quality RCT firstly stratified patients according to stroke severity based on the Orpington Prognostic Scale as more severe or less severe. Patients were then randomized within these strata to receive one of three interventions: task-oriented training + standard care, strength training + standard care, or standard care alone. There was no significant between-group difference in pain (measured by the Fugl-Meyer Assessment pain subscale) at 4-6 weeks (post-treatment) or follow-up (9 months).

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity task-oriented training is not more effective than comparison interventions (strength training, standard care) for reducing pain among patients with acute stroke.

Perceived task performance
Not effective
1B

One high quality RCT (Liu et al., 2004) examined the effect of upper extremity task-oriented training on perceived task performance in patients with acute stroke. This high quality RCT randomized patients to receive functional task training or mental imagery for 3 weeks. There were significant between-group differences in patients’ perceived performance of trained tasks (measured by 7 point Likert scale) at 2 weeks (mid-treatment), 3 weeks (post-treatment) and 1-month follow-up, and untrained tasks at post-treatment (3 weeks), in favour of mental imagery compared to functional task training.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that functional task training is not more effective than a comparison intervention (mental imagery) for improving perceived task performance among patients with acute stroke. In fact, mental imagery was found to be more effective than functional task training.

Pinch force
Not effective
1B

One high quality RCT (Winstein et al., 2004) examined the effect of upper extremity task-oriented training on pinch force in patients with acute stroke. This high quality RCT firstly stratified patients according to stroke severity based on the Orpington Prognostic Scale as more severe or less severe. Patients were then randomized within these strata to receive one of three interventions: task-oriented training + standard care, strength training + standard care, or standard care alone. There was no significant between-group difference in palmar pinch force at 4-6 weeks (post-treatment). There was a significant between-group difference in palmar pinch force at 9-month follow-up among patients with less severe stroke, in favour of task-oriented training compared to standard care, but not between task-oriented training and strength training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity task-oriented training is not more effective than comparison interventions (strength training, standard care) for improving palmar pinch force among patients with acute stroke.
Note: However, task-oriented training was more effective than standard care for improving palmar pinch force among patients with less severe stroke in the long term.

Range of motion
Not effective
1B

One high quality RCT (Winstein et al., 2004) examined the effect of upper extremity task-oriented training on range of motion in patients with acute stroke. This high quality RCT firstly stratified patients with acute stroke according to stroke severity based on the Orpington Prognostic Scale as more severe or less severe. Patients were then randomized within these strata to receive one of three interventions: task-oriented training + standard care, strength training + standard care, or standard care alone. There was no significant between-group difference in range of motion (measured by the Fugl-Meyer Assessment) at 4-6 weeks (post-treatment) or follow-up (9 months).

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity task-oriented training is not more effective than comparison interventions (strength training, standard care) for improving range of motion among patients with acute stroke.

Sensation
Not effective
1a

Two high quality RCTs (Liu et al., 2004; Winstein et al., 2004) investigated the effect of upper extremity task-oriented training on sensation among patients with acute stroke.

The first high quality RCT (Liu et al., 2004) randomized patients to receive functional task training or mental imagery for 3 weeks. There was no significant between-group difference in sensation (measured by the Fugl-Meyer Assessment sensation subscale) at 1 week (mid-treatment), 2 weeks (mid-treatment), 3 weeks (post-treatment) or 1-month follow-up.

The second high quality RCT (Winstein et al., 2004) firstly stratified patients according to stroke severity based on the Orpington Prognostic Scale as more severe or less severe. Patients were then randomized within these strata to receive one of three interventions: task-oriented training + standard care, strength training + standard care, or standard care alone. There was no significant between-group difference in sensation (measured by the Fugl-Meyer Assessment sensation subscale) at 4-6 weeks (post-treatment) or follow-up (9 months).

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that task-oriented training is not more effective than comparison interventions (mental imagery, strength training, standard care) for improving sensation among patients with acute stroke.

Upper extremity motor function
Not effective
1A

Four high quality RCTs (Langhammer et al., 2000; Liu et al., 2004; Winstein et al., 2004; Van Vliet et al., 2005) investigated the effect of upper extremity task-oriented training on upper extremity motor function in patients with acute stroke.

The first high quality RCT (Langhammer et al., 2000) randomized patients to receive a full-body relearning program based on a task-oriented training approach by Carr & Sheppard (1987) or Bobath treatment. Between-group differences in upper extremity motor function (Sødring Motor Evaluation Scale –upper extremity subtest) and overall motor function (Motor Assessment Scale) approached significance after 2 weeks of intervention (10 sessions), in favour of task-oriented training compared to Bobath treatment. There were no significant between-group differences in either outcome at 3 months.

The second high quality RCT (Liu et al., 2004) randomized patients to receive functional task training or mental imagery for 3 weeks. There was no significant between-group difference in upper extremity motor function (Fugl-Meyer Assessment (FMA) upper extremity motor function subscale) at 1 week (mid-treatment), 2 weeks (mid-treatment), 3 weeks (post-treatment) or 1-month follow-up.

The third high quality RCT (Winstein et al., 2004) firstly stratified patients according to stroke severity based on the Orpington Prognostic Scale as more severe or less severe. Patients were then randomized within these strata to receive one of three interventions: task-oriented training + standard care, strength training + standard care, or standard care alone. There was a significant between-group difference in upper extremity motor function (measured by the FMA) at 4-6 weeks (post-treatment) among patients with less severe stroke only, in favour of task-oriented training compared to standard care. A significant between-group difference was also seen at this time point in favour of strength training compared to standard care. Results did not remain significant at follow-up (9 months). There was no significant difference in upper extremity motor function between task-oriented training and strength training at either time point.

The fourth high quality RCT (Van Vliet et al., 2005) randomised patients to receive a full-body task-specific repetitive approach based on Carr & Sheppard (1987), or Bobath treatment. There was no significant between-group difference in upper extremity motor function (Rivermead Motor Assessment, Motor Assessment Scale) at 1, 3 and 6 months.
Note: Treatment did not have a specific ‘end-point’ and continued as long as needed.

Conclusion: There is strong evidence (level 1a) from four high quality RCTs that task-oriented training is not more effective than comparison interventions (Bobath treatment, mental imagery, strength training or standard care alone) for improving upper extremity motor function among patients with acute stroke.
Note: However, one of the high quality RCTs found that task-oriented training was more effective than standard care alone only among patients with less severe stroke. Results were significant at post-treatment but did not remain significant at long-term follow-up.

Upper extremity spasticity
Not effective
1B

One high quality RCTs (Van Vliet et al., 2005) examined the effect of upper extremity task-oriented training on upper extremity spasticity in patients with acute stroke. This high quality RCT found no significant difference at 1,3 and 6 months for upper extremity spasticity (measured by the Modified Ashworth Scale) between a group who received a whole body motor relearning program based on a task-specific repetitive approach (Carr & Sheppard, 1987), compared to a group who received Bobath treatment. It should be noted that treatment did not have a specific ‘end-point’ and continued as long as was needed.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that task-oriented training for the upper extremity is not more effective than a comparison intervention (Bobath treatment) in reducing upper extremity spasticityamong patients with acute stroke.

Subacute phase

Activities of daily living (ADLs)
Not effective
1A

Two high quality RCTs (Baskett et al., 1999; Widén Holmqvist et al., 1998) investigated the effect of upper extremity task-oriented training on ADLs among patients with subacute stroke.

The first high quality RCT (Baskett et al., 1999) randomized patients to receive functional self-directed home-based therapy or conventional outpatient physical and occupational therapy. There were no significant between group differences in activities of daily living (measured by the modified Barthel Index) at 6 weeks or 3 months.

The second high quality RCT (Widén Holmqvist et al., 1998) randomized patients to receive task-oriented home rehabilitation or conventional outpatient rehabilitation. There were no significant between-group differences in ADLs (measured by the Katz Index of Independence in Activities of Daily Living personal and instrumental scores, Barthel Index and Frenchay Activities Index) at 3 months (approaching end of treatment).
Note: The study had a small sample size and may not have been adequately powered to detect between-group differences.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that task-oriented training is not more effective than conventional rehabilitation for improving activities of daily living among patients with subacute stroke.

Emotional wellbeing
Not effective
1b

One high quality RCTs (Baskett et al., 1999) investigated the effect of upper extremity task-oriented training on emotional wellbeing among patients with subacute stroke. This high quality RCT randomized patients to receive functional self-directed home-based therapy or conventional outpatient physical and occupational therapy. There were no significant between-group differences in emotional wellbeing (measured using the Hospital Anxiety and Depression Scale and the General Health Questionnaire – GHQ-28) at 6 weeks or 3 months.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that task-oriented training is not more effective than conventional rehabilitation for improving emotional wellbeing among patients with subacute stroke.

Grip strength
Not effective
1B

One high quality RCTs (Baskett et al., 1999) investigated the effect of upper extremity task-oriented training on grip strength among patients with subacute stroke. This high quality RCT randomized patients to receive functional self-directed home-based therapy or conventional outpatient physical and occupational therapy. There were no significant between group differences in grip strength (measured using the Jamar Dynamometer) at 6 weeks or 3 months.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that task-oriented training is not more effective than conventional rehabilitation for improving grip strength among patients with subacute stroke.

Hand function and dexterity
Not effective
1A

Three high quality RCTs (Blennerhassett & Dite, 2004; Baskett et al., 1999; Widén Holmqvist et al., 1998) investigated the effect of upper extremity task-oriented training on hand function and dexterity among patients with subacute stroke.

The first high quality RCT (Blennerhassett & Dite, 2004) randomized patients to receive upper extremity task-oriented training and conventional rehabilitation or lower-limb task-oriented mobility training and conventional rehabilitation. There were no significant between-group differences in hand function and dexterity (measured by the Jebsen Taylor Hand Function Test) at 4 weeks (post-treatment) or 6 months (follow-up).

The second high quality RCT (Baskett et al., 1999) randomized patients to receive functional self-directed home-based therapy or conventional outpatient physical and occupational therapy. There were no significant between group differences in manual dexterity (measured by the Nine Hole Peg Test) at 6 weeks or 3 months.

The third high quality RCT (Widén Holmqvist et al., 1998) randomized patients to receive task-oriented home rehabilitation or conventional outpatient rehabilitation. There were no significant between-group differences in manual dexterity (Nine Hole Peg Test) at 3 months (approaching end of treatment).
Note: The study had a small sample size and may not have been adequately powered to detect between-group differences.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs that task-oriented training is not more effective than comparison interventions (lower-limb task-oriented mobility training or conventional rehabilitation) for improving hand function and dexterity in patients with subacute stroke.

Upper extremity motor activity
Insufficient evidence
5

One high quality RCTs (Arya et al., 2012) investigated the effect of upper extremity task-oriented training on upper extremity motor activity among patients with subacute stroke. This high quality RCT randomized patients to receive meaningful task-specific training (MTST) or standard training based on Brunnstrom movement therapy and Bobath neurodevelopmental therapy. There was a significant between-group difference in change scores on measures of upper extremity motor activity (Motor Activity Log amount of use and quality of movement scores) at 8-week follow-up, in favour of MTST compared to standard training.
Note: Results depict change scores at 8-week follow-up. Statistical data for between-group differences in scores at 4 weeks (post-treatment) and 8 weeks (follow-up) was not provided. This study cannot therefore be used to determine the level of evidence in the conclusion below.

Conclusion: There is insufficient evidence (level 5) regarding the effectiveness of task-oriented training compared to other interventions on upper extremity motor activity among patients with subacute stroke. However, one high quality RCT reported a significant difference in follow-up change scores, in favour of task-specific training compared to standard training.

Upper extremity motor function
Not effective
1a

Four high quality RCTs (Arya et al., 2012; Blennerhassett & Dite, 2004; Baskett et al., 1999; Widén Holmqvist et al., 1998) investigated the effect of upper extremity task-oriented training on upper extremity motor function among patients with subacute stroke.

The first high quality RCT (Arya et al., 2012) randomized patients to receive meaningful task-specific training (MTST) or standard training based on Brunnstrom movement therapy and Bobath neurodevelopmental therapy. There was a significant between-group difference in change scores on measures of upper extremity motor function (Fugl-Meyer Assessment FMA upper extremity, upper arm and wrist and hand scores, Action Research Arm Test overall, grasp, grip, pinch and gross arm movement scores, Graded Wolf Motor Function Test time and quality of movement scores) at 8-week follow-up, in favour of MTST compared to standard training.
Note: Results depict change scores at 8-week follow-up. Statistical data for between-group differences in scores at 4 weeks (post-treatment) and 8 weeks (follow-up) was not provided. This study cannot therefore be used to determine the level of evidence in the conclusion below.

The second high quality RCT (Blennerhassett & Dite, 2004) randomized patients to receive upper limb task-oriented training combined with standard rehabilitation or lower limb task-oriented mobility training combined with standard rehabilitation (control). There were no significant between-group differences in upper extremity motor function (measured using the Motor Assessment Scale) at 4 weeks (post-treatment) or 6 months (follow-up).
Note: The study may not have been adequately powered (n=30) to find significant between-group differences. A significant within-group difference on the MAS was found for the upper limb group but not the mobility group. Significance was set to p=0.008 to account for multiple comparisons.

The third high quality RCT (Baskett et al., 1999) randomized patients to receive functional self-directed home-based therapy or conventional outpatient physical and occupational therapy. There were no significant between group differences in upper extremity motor function (measured by the Motor Assessment Scale and Frenchay Arm Test) at 6 weeks or 3 months.

The fourth high quality RCT (Widén Holmqvist et al., 1998) randomized patients to receive task-oriented home rehabilitation or conventional outpatient rehabilitation. There were no significant between-group differences in upper extremity motor function (Fugl-Meyer assessment arm score) at 3 months (approaching end of treatment).
Note: The study had a small sample size and may not have been adequately powered to detect between-group differences.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs that upper extremity task-oriented training is not more effective than comparison interventions (lower limb task-oriented mobility training, conventional rehabilitation) for improving upper extremity motor function among patients with subacute stroke.
Note: However, two of the high quality RCTs may not have been sufficiently powered to detect significant change. Further, one high quality RCT reported follow-up change scores only.

Chronic phase

Activities of daily living (ADL)
Not effective
1A

Two high quality RCTs (Corti et al., 2012; Higgins et al., 2006) examined the effect of upper extremity task-oriented training on ADLs in patients with chronic stroke.

The first high quality crossover RCT (Corti et al., 2012) randomized patients to receive functional task practice or dynamic high-intensity resistance (power) training. There were no significant between-group differences in functional activity (measured by the Chedoke McMaster Hand and Arm Inventory) at post-treatment (10 weeks, 20 weeks).

The second high quality RCT (Higgins et al., 2006) randomized patients to receive upper extremity task-oriented training or task-oriented mobility training. There were no significant between-group differences in ADLs (measured by the Barthel Index and the Older Americans Resources and Services Scale – Instrumental Activities of Daily Living) at post-treatment (6 weeks).

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that upper extremity task-oriented training is not more effective than comparison interventions (power training, task-oriented mobility training) for improving ADLs in patients with chronic stroke.

Grip strength
Not effective
1B

One high quality RCT (Higgins et al. 2006) investigated the effect of task-oriented training on grip strength in patients with chronic stroke. This high quality RCT found no difference in grip strength as measured by a hand-held dynamometer immediately post-intervention (at 6 weeks), between a group that received upper-extremity task-oriented training compared to a group that received a task-oriented mobility training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity task-oriented training is not more effective than a comparison intervention (task-oriented mobility training) for improving grip strength among patients with chronic stroke.

Hand function and dexterity
Not effective
1b

One high quality RCT (Higgins et al., 2006) investigated the effect of upper extremity task-oriented training on hand function and dexterity in patients with chronic stroke. The study found no significant differences immediately post-treatment (at 6 weeks) in hand function and dexterity as measured by the Box & Block Test and the Nine-Hole Peg Test, between a group that received upper extremity task-oriented training compared to a group that received task-oriented mobility training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity task-oriented training is not more effective than a comparison intervention (task-oriented mobility training) for improving hand function and dexterity among patients with chronic stroke.

Participation
Not effective
1B

One high quality RCT (Corti et al., 2012) investigated the effect of upper extremity task-oriented training on participation in patients with chronic stroke. This high quality crossover RCT randomized patients to receive functional task practice or dynamic high-intensity resistance (power) training. There were no significant between-group differences in participation (measured by the Reintegration to Normal Living Index) at post-treatment (10 weeks, 20 weeks).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that task-oriented training is not more effective than power training for improving participation among patients with chronic stroke.

Quality of life
Not effective
1B

One high quality RCT (Higgins et al., 2006) investigated the effect of upper extremity task-oriented training on quality of life in patients with chronic stroke. At 6 weeks (immediately post-intervention) the study found no significant differences in quality of life as measured by 2 upper-extremity questions from the Medical Outcomes Short Form-36, and the Geriatric Depression Scale, between a group that received upper extremity task-oriented training compared to a group that received task-oriented mobility training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity task-oriented training is not more effective than a comparison intervention (task-oriented mobility training) for improving quality of life among patients with chronic stroke.

Range of motion
Not effective
1B

One high quality RCT (Thielman et al., 2008) investigated the effect of upper-extremity task-oriented training on elbow and shoulder range of motion in patients with chronic stroke. At 4 weeks, there was no significant difference between a group that received upper-extremity task-oriented training with trunk restraint compared to a group that received progressive resistance exercises with trunk restraint.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity task-oriented training is not more effective than a comparison intervention (progressive resistance exercises) for improving range of motion among patients with chronic stroke.
Note: This study may not have been adequately powered (n=11) to find significant between-group differences.

Spasticity
Not effective
1B

One high quality RCT (Corti et al., 2012) investigated the effect of upper extremity task-oriented training on spasticity in patients with chronic stroke. This high quality crossover RCT randomized patients to receive functional task practice or dynamic high-intensity resistance (power) training. There was no significant between-group difference in upper extremity spasticity (measured by the Modified Ashworth Scale) at post-treatment (10 weeks, 20 weeks).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that task-oriented training is not more effective than a comparison intervention (power training) for reducing spasticity among patients with chronic stroke.

Stroke Impairment
Not effective
1B

One high quality RCT (Corti et al., 2012) investigated the effect of upper extremity task-oriented training on stroke impairment in patients with chronic stroke. This high quality crossover RCT randomized patients to receive task-oriented training or dynamic high-intensity resistance (power) training. There were no significant between-group differences in stroke impairment (measured by the European Stroke Scale) at post-treatment (10 weeks, 20 weeks).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that task oriented training is not more effective than a comparison intervention (power training) for improving stroke impairment among patients with chronic stroke.

Trunk compensation
Not effective
1a

Two high quality RCTs (Corti et al., 2012; Thielman et al., 2008) and one fair quality RCT (Thielman et al. 2004) investigated the effect of upper extremity task-oriented training on trunk compensation in patients with chronic stroke.

The first high quality crossover RCT (Corti et al., 2012) randomized patients to receive functional task practice or dynamic high-intensity resistance (power) training. There was a significant between-group difference in kinematic measures of trunk displacement at 10 weeks and 20 weeks, in favour of power training compared to functional task practice.

The second high quality RCT (Thielman et al., 2008) found no significant differences at 4 weeks (immediately post-treatment) in trunk compensation, measured by kinematics, between a group that received upper-extremity task-oriented training with trunk restraint compared to a group that received progressive resistance exercises with trunk restraint.
Note: This study may not have been adequately powered (n=11) to find significant between-group differences,

The fair quality RCT (Thielman et al. 2004) found no significant differences at 4 weeks (immediately post-treatment) in trunk compensation, measured by kinematics, between a group that received task-oriented training compared to a group that received progressive resistive training.
Note: This study may not have been adequately powered (n=12) to find significant between-group differences.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs and one fair quality RCT that upper extremity task-oriented training is not more effective than comparison intervention (resistance training) for improving trunk compensation among patients with chronic stroke. In fact, one high quality RCT found that power training was more effective than task-oriented training for improving trunk displacement.
Note: Some studies may not have been adequately powered to find significant between-group differences.

Upper extremity kinematics
Not effective
1A

Two high quality RCTs (Corti et al., 2012; Thielman et al., 2008) and one fair quality RCT (Thielman et al. 2004) investigated the effect of upper extremity task-oriented training on upper extremity kinematics in patients with chronic stroke.

The first high quality crossover RCT (Corti et al., 2012) randomized patients to receive functional task practice or dynamic high-intensity resistance (power) training. There were significant between-group differences in kinematic measures of elbow extension ROM at 10 weeks, in favour of power training compared to functional task practice. There was a significant between-group difference in movement speed (measured as mean velocity) at 20 weeks, in favour of functional task practice compared to power training. There were no significant between-group differences at either time point for other kinematic measures of movement accuracy (measured as reach-path ratio and submovements), motor coordination (time to peak hand velocity, time to maximum shoulder flexion, time to maximum elbow extension), and shoulder flexion ROM.

The second high quality RCT (Thielman et al., 2008) randomized patients to receive upper-extremity task-oriented training with trunk restraint or a control group that received progressive resistance exercises with trunk restraint. There were found no significant difference in kinematic measures of arm trajectory at 4 weeks (post-treatment).
Note: This study may not have been adequately powered to find significant between-group differences (n=11); further, the intervention group, but not the control group, showed a significant pre-post improvement in arm trajectory (reaching hand path, deceleration time and upper arm flexion).

The fair quality RCT (Thielman et al., 2004) randomized patients to receive upper-extremity task-oriented training or a control group that received progressive resistance exercises. There were no significant differences in kinematic measures of arm trajectory at 4 weeks (post-treatment).
Note: This study may not have been adequately powered to find significant between-group differences (n=12). Further analysis revealed that within the intervention group, patients with initial low-level function (based on a reaching pre-test) had improved significantly more at 4 weeks than patients with initial high-level function across all kinematic variables for arm movement. Furthermore, within the low-level subgroup of the intervention group there was a significant pre-post improvement in hand path (suggesting better coordination of elbow and shoulder motion) while there were no significant improvements for any kinematic measures in the control group.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs and one fair quality RCTthat task-oriented training is not more effective than comparison interventions (power training, progressive resistance exercises with trunk restraint) for improving upper extremity kinematics among patients with chronic stroke.
Note: One high quality RCT found that task-oriented training was more effective than power training for improving movement speed; the same high quality RCT found that power training was more effective than task-oriented training for improving elbow extension ROM and trunk displacement.

Upper extremity motor function
Not effective
1A

Three high quality RCTs (Corti et al., 2012; Higgins et al., 2006 ; Thielman et al., 2008) and one fair quality RCT (Thielman et al. 2004) investigated the effect of upper extremity task-oriented training on upper extremity motor function in patients with chronic stroke.

The first high quality crossover RCT (Corti et al., 2012) randomized patients with chronic stroke to receive functional task practice or dynamic high-intensity resistance (power) training. There was no significant between-group difference in upper extremity function (measured by the Fugl-Meyer Assessment of Upper Extremity Motor Score and shoulder/elbow score) at post-treatment (10 weeks, 20 weeks).

The second high quality RCT (Higgins et al., 2006) found no significant difference at post-treatment (6 weeks) in upper extremity motor function as measured by the upper extremity subscale of the Stroke Rehabilitation Assessment of Movement (STREAM) and the Upper Extremity Performance Test for the Elderly, between a group that received upper extremity task-oriented training compared to a group that received lower extremity task-oriented training.

The third high quality RCT (Thielman et al. 2008) found no significant difference in motor function (measured by the Fugl-Meyer Assessment –upper limb score and the Wolf Motor Arm Test) at 4 weeks (immediately post-treatment), between a group that received task-oriented training with trunk restraint compared to the group that received progressive resistance training with trunk restraint.
Note: This study may not have been adequately powered (n=11) to find significant between-group differences.

The fair quality RCT (Thielman et al., 2004) reported no significant differences in upper extremity motor function immediately post-intervention (at 4 weeks), measured by 2 upper extremity subscales from the Motor Assessment Scale and the arm section of the Rivermead Motor Assessment, between a group that received upper-extremity task-oriented training compared to a group that received progressive resistance exercises.
Note: The study may not have been adequately powered (n=12) to find significant between-group differences.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs and one fair quality RCT that upper extremity task-oriented training is not more effective than comparison interventions (power training, resistance training, lower extremity task-oriented training) for improving upper extremity motor function among patients with chronic stroke.

References

Arya, K.N., Verma, R., Garg, R.K., Sharma, V.P., Agarwal, M., & Aggarwal, G.G. (2012). Meaningful task-specific training (MTST) for stroke rehabilitation: A randomized controlled trial. Topics in Stroke Rehabilitation, 19(3), 193-211.

Baskett, J.J., Broad, J.B., Reekie, G., Hocking, C., & Green, G. (1999). Shared responsibility for ongoing rehabilitation: a new approach to home-based therapy after stroke. Clinical Rehabilitation, 13, 23-33.

Blennerhassett J, Dite W. (2004). Additional task-related practice improves mobility and upper limb function early after stroke: a randomised controlled trial. Aust J Physiother. 50, 219-224.

Christie, L., Bedford, R., & McCluskey, A. (2011). Task-specific practice of dressing tasks in a hospital setting improved dressing performance post-stroke: a feasibility study. Australian Occupational Therapy Journal, 58, 364-9.

Corti, M., McGuirk, T.E., Wu, S.S., & Patten, C. (2012). Differential effects of power training versus functional task practice on compensation and restoration of arm function after stroke. Neurorehabilitation and Neural Repair, 26(7), 842-54.

Higgins J, Salbach NM, Wood-Dauphinee S, Richards CL, Cote R, Mayo NE. (2006). The effect of a task-oriented intervention on arm function in people with stroke: a randomized controlled trial. Clin Rehabil, 20(4), 296-310.

Langhammer B, Stanghelle JK. (2000). Bobath or motor relearning programme? A comparison of two different approaches of physiotherapy in stroke rehabilitation: a randomized controlled study. Clin Rehabil, 14, 361-69.

Liu, K.P., Chan, C.C., Lee, T.M., Hui-Chan, C.W. (2004). Mental imagery for promoting relearning for people after stroke: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 85, 1403-8.

Thielman G, Kaminski T, & Gentile A. (2008). Rehabilitation of Reaching After Stroke: Comparing 2 Training Protocols Utilizing Trunk Restraint. Neurorehabilitation and Neural Repair, 22(6), 697.

Thielman GT, Dean CM, Gentile AM. (2004). Rehabilitation of reaching after stroke: task-related training versus progressive resistive exercise. Arch Phys Med Rehabil, 85, 1613-1618.

Van Vliet PM, Lincoln NB, Foxall A. (2005). Comparison of Bobath based and movement science based treatment for stroke: a randomised controlled trial. J Neurol Neurosurg Psychiatry, 76, 503–08.

Widén Holmqvist, L., von Koch, L., Kostulas, V., Holm, M., Widsell, G., Tegler, H., Johansson, K., Almazan, J., & de Pedro-Cuesta, J. (1998). A randomized controlled trial of rehabilitation at home after stroke in southwest Stockholm. Stroke, 29, 591-7.

Winstein CJ, Rose DK, Tan SM, Lewthwaite R, Chui HC, Azen SP. (2004). A randomized controlled comparison of upper-extremity rehabilitation strategies in acute stroke: A pilot study of immediate and long-term outcomes. Arch Phys Med Rehabil, 85(4), 620-628.

Excluded Studies

Bourbonnais D, Bilodeau S, Lepage Y, Beaudoin Nm Gravel D, Forget R. (2002). Effect of force-feedback treatments in patients with chronic motor deficits after a stroke. Am J Phys Med Rehabil, 81, 890 – 897.
Reason for exclusion: Did not involve a functional salient, real-life task.

Cauraugh J, & Kim S. (2003). Stroke motor recovery: active neuromuscular stimulation and repetitive practice schedules. Journal of Neurology, Neurosurgery & Psychiatry, 74(11), 1562.
Reason for exclusion: The intervention involved a mixed therapy of task-oriented training + muscular stimulation, and muscular stimulation was not controlled for.

Chan D, Chan C & Au D. (2006). Motor relearning programme for stroke patients: a randomized controlled trial. Clinical Rehabilitation, 20(3), 191.
Reason for exclusion: Both groups may have received a type of task-oriented training.

Cirstea MC & Levin MF. (2007). Improvement of Arm Movement Patterns and Endpoint Control Depends on Type of Feedback During Practice in Stroke Survivors. Neurorehabil Neural Repair, 21:1-14.
Reason for exclusion: 1) The main purpose of the study was to determine the effect of different types of feedback between two groups that received task oriented training, which was considered outside the scope of this review, and 2) the intervention was not progressively adapted to patient’s progress.

Cirstea MC, Ptito A, Levin MF. Arm reaching improvements with short-term practice depend on the severity of the motor deficit in stroke. Experimental Brain Research 2003;152(4):476–88.
Reason for exclusion: 1) The main purpose of the study was to determine the effect of different types of feedback between two groups that received task oriented training, which was considered outside the scope of this review, and 2) the intervention was not progressively adapted to patient’s progress.

Desrosiers J, Bourbonnais D, Corriveau H, Gosselin S, Bravo G. (2005). Effectiveness of unilateral and symmetrical bilateral task training for arm during the subacute phase after stroke: a randomized controlled trial. Clin Rehabil, 19, 581-593.
Reason for exclusion: Both groups may have received a type of task-oriented training.

Dickstein R, Heffes Y, Laufer Y, Abulaffio N, Shabtai EL. (1997). Repetitive practice of a single joint movement for enhancing elbow function in hemiparetic patients. Percept Mot Skills, 85, 771-778.
Reason for exclusion: 1) Did not involve a salient, functional real-life task, and 2) intervention was not progressively adapted to patient’s progress.

Duncan, P., Studenski, S., Richards, L., Gollub, S., Lai, S.M., Reker, D., Perera, S., Yates, J., Koch, V., Rigler, S., & Johnson, D. (2003). Randomized clinical trial of therapeutic exercise in subacute stroke. Stroke, 34, 2173-80.
Reason for exclusion: Intervention comprised task-oriented training in addition to other therapeutic interventions including stretching, strengthening and endurance training.

Sackley, C., Wade, D.T., Mant, D., Atkinson, J., Yudkin, P., Cardoso, K., Levin, S., Lee, V., & Reel, K. (2006). Cluster randomized pilot controlled trial of an occupational therapy intervention for residents with stroke in UK care homes. Stroke, 37, 2336-41.
Reason for exclusion: Intervention comprised task-oriented training in addition to mobility training and treatment of specific impairment (e.g. stretching contractures).

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