Feasibility of high-repetition, task-specific training for individuals with upper-extremity paresis

Article Reviews
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Read Full Text: Feasibility of high-repetition, task-specific training for individuals with upper-extremity paresis (Free to access)
Journal: American Journal of Occupational Therapy (5-year impact factor of 2.322)
Year Published: 2014
Ranked 31st on our 2014-2019 list of the 50 most influential articles

Although this article is specific to a particular treatment for stroke, this is a conversation that all therapists should be tuning into.

Stroke rehab is one of the most frequently studied topics in the rehab scope, so this research, specifically around high-repetition task-oriented training, is seeking to answer questions that will have a ripple effect extending to almost all therapists.

Questions like:

  • How much therapy is needed to show changes at the brain level?
  • What type of therapy speeds these changes?
  • Does the rehab we are doing actually translate to functional gains?
  • Does it have a lasting impact on function?

Honestly, there is so much research happening right now on high-repetition and task-specific training (with mixed outcomes) that I will need your help in the conversation catching up. But I’ll do my best to lay the groundwork for our discussion.

What is task-specific rehab, and how was it carried out in this article?

If you’re not familiar with task-specific training, I really like the definition from Stroke Engine:

Task-specific training (also called 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.

There appear to be several protocols out there, but for this study they used one from Birkenmeier that involved identifying three meaningful activities to practice via the occupational profile.

What is high-repetition rehab, and how was carried out in this article?

High-repetition rehab is exactly what it sounds like. The goal is to shoot for numbers of repetitions that are staggeringly higher than in a typical therapy session. I usually see talk of numbers ranging from 300-600 repetitions.

In this particular study, the goal was to achieve 100 repetitions of each selected activity per session (300 total repetitions), using the principles of massed practice and shaping.

At this inpatient rehab facility (IRF), patients received six days of occupational therapy per week. For this study, four days per week—with one-hour sessions—were dedicated to high-repetition, task-specific training, while the other two were dedicated to ADLs.

Why is feasibility important? And, what are the implications from this article?

Now, it’s important to drive home that this was a feasibility study.

It was not a study of whether task-oriented, high-intensity rehab rehab is effective.

Instead, this was simply intended to be a study of whether it is even possible to deliver this type of treatment, specifically in an inpatient rehabilitation setting.

The conclusion was that it is possible for patients to achieve almost 300 repetitions on average, without unreasonably increasing pain and fatigue.

Assessments

The authors did track outcomes using assessments that should be familiar to most OTs. And, patients did show improvement on all outcome measures that were tracked.

However, we need to take this with a grain of salt, as this was a feasibility study and there was no control or comparison. This means there was no way to assess whether the improvements were greater than would be seen from usual care—or perhaps even the result of the natural course of healing.

Here are the assessments they used as outcome measures:

Accelerometers were also used to take objective measurements of UE use. Accelerometers, which resemble wristwatches, measure the amount of movement of each arm. In this case, accelerometers were worn for 24 hours on both wrists at the beginning and end of the study.

Takeaways for OT Practitioners

(These are my personal takeaways, and were not mentioned in the article.)

The research on high-repetition, task-specific training is still in the early stages. And we’ve seen mixed messages about this type of training in our journal club this year.

The fact that we are just seeing feasibility studies (which are step one of clinical research) performed within the last five years means that we are still in the very early stages of researching this type of training.

Earlier this year, we looked at a 2016 systematic review of UE motor rehab post stroke, which recommended interventions based on the available evidence. Task-specific training was not recommended based on current evidence, although it was discussed in the article.

We also looked at two randomized control trials, one with a task-oriented UE rehab program and another with a virtual reality task-oriented system, both of which did not show clinically significant outcomes over controls.

All that being said, we are only looking at a fraction of the research available on this topic. From my perspective, it seems like there is probably a sweet spot of intensity for UE rehab treatment; we just don’t know what it is yet, and to complicate that even more it is probably different for different people.

Shifting from an exercise-based approach to a task-based approach is also the direction things are heading; we just don’t know exactly what type of task-based approach is most effective. Should the tasks be delivered in massed practice or a naturalistic setting—or is there some type of technology that is coming to market that will prove to be the most effective of all? Or maybe some kind of cognitive learning strategy or other motor learning research will completely shift our thinking on this?

Technologies are going to be heavily influencing this conversation about best practices for UE stroke.

Previous articles we’ve looked at have shown that several technologies are quickly evolving—and these technologies have the potential to heavily influence this conversation.

We’ve talked here and here about the use of biomarkers, which could provide new data on how well our interventions are working.

We’ve also talked about virtual reality, and will have another article on it next week.

We’ve even heard mention of brain-interface technologies, which would combine brain tracking and robotics to create biofeedback loops. So stay tuned!

These trends are all good news for OTs

I believe that these trends are all good news for OTs:

First, figuring out what motivates people is our jam—and motivation is an essential component of trying to figure out how to help patients engage in high-intensity rehab.

Second, task-oriented approaches are totally in our function-based wheelhouse. We are accustomed to task/activity analysis and also good at thinking through the importance of generalizing task improvement to functional improvement in the home setting.

And lastly, we’ve all been trained in thinking about how to use technology to help patients engage with their environments, and I think our training uniquely prepares us to integrate new technologies when they are proven to be effective.

Listen to my takeaways in podcast form:

Find other platforms for listening to the OT Potential Podcast here.

Discussion-starter questions:

Have you had personal experience with high-repetition, task-specific UE rehab?

How do you see this conversation about levels of intensity and task-specific training potentially influencing your work in your particular setting?

In your opinion, does high-intensity, task oriented training align with how you see people making progress in your practice, or align with your general understanding of skill acquisition/motor learning?

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Great article with very encouraging results which corroborates some of what we know such as the constraint-induced movement therapy. I am a big proponent of CMIT and have seen encouraging results even in acute care with continuous practice of the affected extremity while restraining the uninvolved extremity.
Yes, Sarah, agree with you that these new trends are very good for OT because this is exactly what we do- find out what our clients need to do and what satisfies them (COPM/occ. profile), and task-oriented approaches via function. As far as technology goes, Saeboflex is an approach which focuses on task-specific training introduced by two OT brothers in Charlotte, NC. Check out their research.
"Task-specific training improves upper extremity function in individuals suffering from neurological injuries. However, treatment options are limited for neurological clients who cannot effectively incorporate their hand for functional grasp and release/prehension activities. The vast majority of stroke survivors, head injury and incomplete spinal cord injury patients do not exhibit sufficient active wrist and/or finger extension to allow the hand to be functional. The SaeboFlex has the biomechanical advantage in allowing prehension /grasp and release activities for individuals with moderate to severe hemiparesis.
[Download Saebo Research.](http://Saeboflex)
Another one is the Bioness H200 for UE function which is a functional electrical stimulation (FES) used commonly in inpatient rehab for restoring function in stroke.(www.Bionessmobility.com)
The outcome measures used in this study are well known to OTs which makes it easier to relate to. I did not know about accelerometers to measure the number of reps of the task. It would serve as a good motivator and provide feedback to a client instead of the OT counting the reps.
This feasibility study would appeal even to administrators since it could be done within the patient’s 3 hrs of routine therapy and it did not replace the inpatient priority of ADL retraining and showed improvement in FIMs which is the bread and butter of inpatient settings. Also, though fatigue and pain reported were higher, it is encouraging to see that it did not limit overall participation.
Though there was no control group and the target of 300 repetitions does seem arbitrary ( I had read that more than that is beneficial), the results show that this approach is very doable in inpatient and outpatient settings.
I found an article in the Brain Recovery Project which states as follows;
"Animal studies in neuroplasticity have shown that 400 to 600 repetitions per day of a challenging functional task, such as fine motor grasping, are required before the brain reorganizes to accomplish the new task. Gait evidence in animal studies show that approximately 1,000 – 2,000 steps per session are required to improve hind-limb stepping and step quality.
https://www.brainrecoveryproject.org/parents/therapies-and-development/how-much-therapy-is-enough/
Studies have shown that in a typical session, a patient performs only 40-60 reps of a task which is far less than what is needed to cause a change in the neural connections. Being aware of this, OTs can try to focus on massed practice of a single task rather than combining several different tasks in one session.
Thank you for another thought provoking and exciting article.

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Hey Sanchala! I’m so glad that you linked to some of the products that are on the market for this!!! If massed practice really is the wave of the future, I think technology will be part of making it happen.

That being said, even though the early research animal research shows promise, I have yet to see any studies that show large gains for patients. Am I missing something or is the research not there yet?

My thinking on this topic this week is heavily influenced by this book that I’m reading called “Range: Why generalists triumph in a specialized world”. It explores science-based learning principles (which albeit might be different than motor learning.) But, I would love to hear if others have read it and find it relevant.

For example here are some gems from it:

“Repetition, it turned out, was less important than struggle.”

“Breadth of training predicts breadth of transfer.”

“When your intuition says blocked (practice), you should probably interleave” (mix different types of challenges together)

All of this seems to contradict massed practice, so I really hope someone else has read this book and can weigh in!!!

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Feasibility from the level of the therapist and client interest and engagement would be interesting to explore to. I’ve not done this kind of treatment, but I can imagine conducting hundreds of repetitions of the same or similar task would be mind-numbingly boring for everyone involved which will be a barrier that will have to be overcome with some creativity. How do you make it fresh and entertaining but get the reps in? That will be an interesting challenge to sort out. Technological solutions will probably be necessary to accomplish the kinds of repetition we’re aiming for, since a robot won’t get bored…but a therapist (or OTA) certainly would.

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Ha! Yes- this does seem to have the potential to be super boring :slight_smile: Also, It is hard to imagine keeping that numbered of massed repetitions at the “just-right-challenge” or as the book I’m reading calls it- the level of “desirable difficulty.”

Of course this is where the idea of using virtual reality is stemming from (that it would help get repetition in in a more engaging way), but again, I just haven’t seen the study that supports the use of it for acute stroke care.

I’ve been watching my kids with new eyes this week, as my youngest is busy acquiring the skill of using scissors. He definitely has gotten LOTS of practice in. But it is spaced throughout the day and over weeks. It is also heavily influenced by watching his brother do it and just the satisfaction of cutting out little characters from his coloring book!

I’m hoping that some more people weigh in with more back-ground in motor learning theory! @lauren5

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Although my population is different, I am still keenly interested in research-based ways to facilitate mass practice of functional skills since I personally see an increase in benefit if reps per session are increased.

One way I’m able to achieve mass reps is through playing different games that all involve the same grasp pattern on a tool used to play the game (Thin Ice, BBQ Party, Giggle Wiggle Caterpillar, Baby Bear Sort etc.). That way the child’s interest is renewed during each game, but their rep count keeps going up for use of a tri-pod grasp on tweezers.

Another way, and here comes a link for some research, is through Interactive Metronome, which motivates mass practice that would otherwise be “mind-numbingly boring” like @DevonCochrane said, using instant feedback video games where in order to achieve the goal of, for examples, helping a monkey climb a tree to get bananas or make a soccer goal, you have to keep performing the task to the beat. I have had amazing success achieving mass reps using IM, but only for kids with enough cognitive awareness to be engaged by the video game. Have any of the club members used IM for adults? because when I was certified in its use, we learned about its applicability for adults as well.

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Maggie,
I use some of the techniques you mentioned to make it more interesting for patients. I try to include different activities which use the same function/movements to make it less boring but I don’t think I have come anywhere close to the number of repetitions that are mentioned in research. Nevertheless, I have seen good results with massed practice in adults with a stroke.
I am glad you mentioned the IM. I had attended a workshop on the use of the IM but am not certified in its use. I have used a similar approach with apps on the phone to assist patients to do increased reps while keeping up with the beat. It did seem more engaging for the clients.
Sarah, interesting concept against massed practice in the book read. I have not read it but wonder if it would be different when you are trying to relearn something which is lost versus improving what you already have.
I was trained in Saeboflex but did not have an opportunity to use it much since our facility preferred the Bioness. But check out their research on “massed practice” They appeared to have a lot of articles on the use of Saeboflex.

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It’s great that we have this study to look into feasibility! When I was clinically treating full time it was often when I presented treatment ideas the a usual response was… is this doable and productive prior to implementing. Specifically I think of Wii video games. The Wii games were and are still a big hit for high repetition. We often would bring in multiple patients and have a competition with the different sports. (It got competitive with all of us clinicians as well :smile: ) It made for a very fun and buzzing work environment for our patients and staff. I have never worked with virtual reality games or treatments, but it is something I hope to both learn and utilize in the future. I’m also looking forward to new technology/robotics that will be a great addition to tracking functional gains!

I also got my OT Potential Club Sticker!! It’s great!! Thank YOU!!

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I would love to read this book. Thanks

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Agree. While repetition is necessary to learn a skill, an intelligent brain likes new stuff to learn more and better. However, I guess clinical cognitive constraints may require high reps to achieve progress in basic skills.
Would love to hear back from others regarding this.

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Thanks for all the info re the gadgets and the feedback from your clinical experiences.

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@kerri, @maggie and @sanchala, your conversation is helping me think through all of the ways OTs already work to achieve higher repetitons like the IM (which I didn’t realize there was a training for!) and technology like the Wii. I would love to dig deeper into the long lasting effects of these interventions.

Sorry to keep bringing up this book I’m reading, but per what I’m reading, in education (which might be totally different to re-learning) high repetition seems to work really well in the short term, but doesn’t translate to long term gains. Varied, spaced, and difficult practice does not show the same fruits in the short term but is associated with more long term gains.

@sridevi, let me know if you read the book! I’m so eager to talk to someone about it!! (Obvisously :slight_smile: )

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Also, @kerri, so glad you received your sticker!! I am having so much fun sending them out!!

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Sarah,
I would love to read that book too. And , yes, I received my founder sticker too, thanks.

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@SarahLyon if you’re interested, here’s the link to the list of locations that offer the certification training. Now that I have almost a year of experience with IM I’m planning to get my pediatric specialty certification. Once you get the initial certification training in person the subsequent training is self-study online, which is convenient.

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