1. Task oriented training
Nisrin Alqatarneh
Thanks to Dr. Hassan Sarsak

2. 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)

3. 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 3

4. 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

5. 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

6. 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

7. 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.

8. 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
Role performance
Occupational performance tasks: performance areas
Task selection and analysis
Person: performance components
Environment: performance context
Interventions are guided by the therapist’s understanding of motor learning principles 8

9. 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

10. 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???

11. 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

12. The rehabilitation environment
Environmental factors play a critical role in the effectiveness of interventions
Include:
Therapeutic relationship between therapist and client
Therapists effectiveness in focusing the client’s attention on the most important features of motor performance
The type and amount of ongoing practice

13. Therapist as coach:
The therapeutic relationship in task-oriented training is an active, collaborative mentorship with regard to motor performance
Therapists goals as coach:
To encourage performance of the most important mechanical features within a given category of motor tasks
To discourage behavioural adaptations that have limited effectiveness

14. 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

15. 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

16. 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

17. Stages of Motor Learning
Acquisition
Retention
Transfer
(O’Sullivan & Schmitz, 2007)

18. 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.

19. 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)

20. 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
Random practice: variable, serial practice
Massed practice: high levels of practice
Mental practice: reduces anxiety; passive relaxation techniques…

21. 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)

22. 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.)

23. 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?

24. 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

25. 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

26. 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

27. Thank you…Questions?