Name: Date:

Evidence-Based
Stroke Rehabilitation  

2014  
 
 

Pre-Reading and
Homework Tasks
 
                               
                                                                                         Prepared  by  presenters:  
 
               Annie  McCluskey  PhD  MA  DipCOT  
                                                           Occupational  Therapist  
                                                                                                                               
                                                                                                                               &    
                                   Karl  Schurr  MAppSc  BAppSc  MAPA  
                                                                       Physiotherapist  
 
 
Address  for  correspondence:  
PO  Box  141,  Regents  Park  NSW  2143,  AUSTRALIA  
 
Website:  www.strokeEd.com                                                                                    StrokeEd  
 
 
 
Tel  +61  2  9644  8217  /    0419  447738  
Email:  annie.mccluskey@sydney.edu.au  
Email:  kschurr@bigpond.net.au  
 
Annie McCluskey PhD MA DipCOT PO Box 141,
Occupational Therapist Regents Park,
NSW 2143 Australia
Karl Schurr BAppSc MAppSc (Physiotherapy)
Physiotherapist Ph 02 9644 8217/ 0419 447738
_______________________________________________________________________________________________________________
Dear participant,

Evidence-Based Stroke Rehabilitation

1. Homework: Recommended Pre-Reading
A book chapter is provided as pre-reading for the 3-day upper limb retraining workshop (and for
those attending the ‘masterclass’ on postural adjustments in sitting). The chapter discusses analysis
of reach to grasp, postural adjustments when reaching in sitting, common compensations, and best-
practice teaching of motor skills. Research on the effectiveness of therapy interventions is also
summarised, particularly randomised controlled trials and systematic reviews (up to 2010, when the
chapter was published). That research, and more recent studies will be discussed during the
workshop and masterclass.

A journal article is also provided about translating stroke evidence into practice, and common
barriers to practice change. This article is recommended as pre-reading for the session about
translating evidence into practice.
We suggest that you take time to read and re-read the pre-reading, in order to gain maximum benefit
from the events. If English is your first language, allow 2-4 hours. If English is not your first
language, allow 4-8 hours for the pre-reading. The more prepared you, the more likely you are to
apply the information in practice. By early afternoon on Day 2 of the upper limb workshop, groups
of therapists who are attending the full 3-day workshop will assess and train a patient whom they
have not seen before. The more preparation, the easier you will find the first clinical session.

2. Homework: Upper Limb Task Analysis and Anatomy Revision

Four task analysis worksheets are attached, to complete before Day 1 of the upper limb workshop.
We will review these analyses early on Day 1. Previous participants have also suggested that
therapists revise their upper limb anatomy before coming to the workshop.

3. Upper Limb Kit [to bring to the full 3-day upper limb workshop]
If attending the full 3-day workshop, including the afternoon clinical sessions, we recommend that
you bring your own personal upper limb kit to use during the workshop. You can add to the kit after
you return to work. If you cannot bring any items, don’t worry, as equipment will be available at the
workshop. Items that you may need/ want to bring include: knife, fork, flexible straws, Micropore
tape, ruler, stopwatch/timer, large whiteboard marker pens, wooden tongue depressor, plastic picnic
cup(s), plastic tweezers from wound dressing trays, clicker/counter for recording repetitions. These
items may be required when you are working with patients at the workshop. Please label your kit.
If you have access to an electrical stimulation machine, and (portable) mirror box, bring them also
unless they are awkward to transport. Also bring electrodes, fresh batteries, adhesive pads or gel.

We both look forward to meeting you soon. Please note the workshop starts at 8.00am both days.

Annie McCluskey Karl Schurr

annie.mccluskey@sydney.edu.au kschurr@bigpond.net.au
 PRE-READING

* Distributed and copied for teaching and learning purposes.

Not to be copied for any other purpose nor for financial gain *

Pre-reading for the 3-day upper limb retraining workshop and the
masterclass on postural adjustments when reaching in sitting:

McCluskey, A., Lannin, N.A., & Schurr, K. (2010). Optimising motor performance following
brain impairment. In M. Curtin, M. Molineux & J. Supyk-Mellson (Eds). Occupational therapy
and physical dysfunction: Enabling occupation (pp.579-606, 6th ed). Edinburgh: Churchill
Livingston.

(This chapter uses the tasks of eating and drinking to highlight features of reaching to grasp, and postural
adjustments required during seated reaching. Common movement compensations are explained, and photographic
examples provided. Secondary musculoskeletal complications such as contractures are discussed, along with factors
which enhance motor learning and skill acquisition (for example, goals and feedback). Evidence is reviewed for
interventions aimed at improving strength in paralysed or weak muscles (eg electrical stimulation, ES), postural
control in sitting, control of force generation, contracture management as well as interventions such as constraint
induced movement therapy (CIMT), mental practice, and dexterity training. Although the chapter was completed a
few years ago, and the evidence is no longer up-to-date, evidence for each intervention can updated using free
databases such as PEDro and OTseeker. An update will be provided at the workshop and in the reference list.

Pre-reading for the session on translational research

McCluskey, A., Vratsistas, A., & Schurr, K. (2013). Barriers and enablers to implementing multiple stroke
guideline recommendations: A qualitative study. BMC Health Services Research, 13: 323.

Background: Translating evidence into practice is an important final step in the process of evidence-based practice.
Medical record audits can be used to examine how well practice compares with published evidence, and identify
evidence-practice gaps. After providing audit feedback to professionals, local barriers to practice change can be
identified and targetted with focussed behaviour change interventions. This study aimed to identify barriers and
enablers to implementing multiple stroke guideline recommendations at one Australian stroke unit. Methods: A
qualitative methodology was used. A sample of 28 allied health, nursing and medical professionals participated in a
group or individual interview. These interviews occurred after staff had received audit feedback and identified
areas for practice change. Questions focused on barriers and enablers to implementing guideline recommendations
about management of: upper limb sensory impairments, mobility including sitting balance; vision; anxiety and
depression; neglect; swallowing; communication; education for stroke survivors and carers; advice about return to
work and driving. Qualitative data were analysed for themes using theoretical domains described by Michie and
colleagues (2005). Results: Six group and two individual interviews were conducted, involving six disciplines.
Barriers were different across disciplines. The six key barriers identified were: (1) Beliefs about capabilities of
individual professionals and their discipline, and about patient capabilities (2) Beliefs about the consequences,
positive and negative, of implementing the recommendations (3) Memory of, and attention to, best practices (4)
Knowledge and skills required to implement best practice; (5) Intention and motivation to implement best practice,
and (6) Resources. Some barriers were also enablers to change. For example, occupational therapists required new
knowledge and skills (a barrier), to better manage sensation and neglect impairments while physiotherapists
generally knew how to implement best-practice mobility rehabilitation (an enabler). Conclusions: Findings add to
current knowledge about barriers to change and implementation of multiple guideline recommendations. Major
challenges included sexuality education and depression screening. Limited knowledge and skills was a common
barrier. Knowledge about specific interventions was needed before implementation could commence, and to
maintain treatment fidelity. The provision of detailed online intervention protocols and manuals may help clinicians
to overcome the knowledge barrier.
 Citation: McCluskey, A., Lannin, N.A., &
Schurr, K. (2010). Optimising motor performance
following brain impairment (Chapter 37). In
Chapter M.Curtin, M. Molineux & J. Supyk (Eds.).
Thirty-Seven
37
Occupational therapy and physical dysfunction:
Enhancing occupation (pp 580-606, 6thed.).
Edinburgh: Churchill Livingstone.

Optimising motor performance

following brain impairment
Annie McCluskey, Natasha Lannin and Karl Schurr

CHAPTER CONTENTS Preventing and managing contractures . . . 599

Introduction . . . . . . . . . . . . . . . . . . 580 Improving reaching and postural control
in sitting . . . . . . . . . . . . . . . . . . . 601
Essential skills, knowledge and attitudes
for improving motor performance . . . . . . 580 Future directions . . . . . . . . . . . . . . . 602

Analysing movement . . . . . . . . . . . . . 580 Conclusion. . . . . . . . . . . . . . . . . . . 603

Normal reaching to grasp . . . . . . . . . . 580 SUMMARY

Postural adjustments in sitting . . . . . . . 583
Focus on ‘positive’ versus ‘negative’
impairments . . . . . . . . . . . . . . . . . 585
Recognising contractures . . . . . . . . . . 585
Recognising compensatory strategies . . . 587
Hypothesising about compensatory
strategies . . . . . . . . . . . . . . . . . . 588
Teaching motor skills . . . . . . . . . . . . . 589
The stages of motor learning . . . . . . . . 589
Making training task-specific . . . . . . . . 590
Maximising practise . . . . . . . . . . . . . 590
Giving feedback . . . . . . . . . . . . . . . 591
Evaluating change in motor
performance . . . . . . . . . . . . . . . . . . 591
Evidence-based intervention to improve
upper-limb motor performance . . . . . . . . 593
Strength training for weak or paralysed
muscles . . . . . . . . . . . . . . . . . . . 594
Electrical stimulation. . . . . . . . . . . . . 594
Constraint-induced movement therapy . . . 594
Mental practice . . . . . . . . . . . . . . . 595
Reducing muscle force during grasp . . . . 595
Dexterity training. . . . . . . . . . . . . . . 598
This chapter provides a framework for optimising
the motor performance of children and adults
with brain impairment. Conditions such as stroke,
traumatic brain injury, and cerebral palsy are
mainly focused upon; however, the content can
be applied to people with other progressive
neurological conditions, such as multiple
sclerosis. The occupations of eating and drinking
are used as examples throughout the chapter.
Skills and knowledge required by graduates are
identified, including knowledge of motor
behaviour, the features of reaching to grasp and
postural adjustments required when reaching in
sitting. Common movement compensations are
explained, followed by secondary musculoskeletal
complications such as contracture, which need
to be anticipated and managed. Factors which
enhance motor learning, skill acquisition and
engagement are discussed, with implications for
therapists’ teaching skills. Finally, a summary is
provided of interventions to improve motor
performance after brain impairment. The best
currently available evidence is provided, from
systematic reviews and randomised trials.
KEY POINTS
} Essential knowledge in neurological
rehabilitation includes an understanding of

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 SECTION FIVE Working with the individual
normal motor behaviour, muscle biology, and
skill acquisition.
} Abnormal motor performance can be observed
during a task such as reaching for a cup, and
compared with expected performance.
Hypotheses about the cause(s) of observed
movement differences can be made and
tested.
} Paralysis, weakness, and loss of dexterity
negatively affect upper-limb motor
performance and occupational engagement.
These impairments should be the focus of
the therapists’ attention rather than spasticity,
which is not correlated with reduced
performance.
} Many people with brain impairment have
difficulty understanding instructions and
feedback, and do not practise well. To help
people learn, each therapist needs to become
an effective coach.
} Motor performance should be remediated
using evidence-based strategies including
task-specific training (as opposed to
generalised, non-specific training).
Introduction
Some people are born with cerebral palsy; others
may sustain a stroke or brain injury later in life.
These types of brain impairment can lead to paral-
ysis and muscle weakness, and disrupt occupa-
tional engagement. Motor control is a term
commonly used in rehabilitation (Dickson 2002)
and refers to the complex neural mechanisms
responsible for movements such as reaching-
to-grasp, and sitting-to-standing. Occupational
therapists and physiotherapists retrain motor
impairments which interfere with tasks such as
sitting safely on the toilet or picking up a cup. The
aim in this chapter is to encourage therapists to
systematically observe, analyse and measure motor
impairments and use targeted evidence-based
interventions.
Participation in rehabilitation, and later in com-
munity occupations such as eating in a restaurant,
may be restricted by paralysis or contractures. These
impairments need to be actively managed. It is not
enough to teach a person how to compensate using
one-handed techniques, or wait for recovery.
Instead, therapists need to proactively seek muscle
activity and anticipate secondary problems such as
contractures.
580
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Essential skills, knowledge
and attitudes for improving
motor performance
To improve motor performance, therapists should
think of themselves as ‘movement scientists’ (Carr
et al 1987, Refshauge et al 2005). Just as occupa-
tional science refers to the science of occupation,
movement science refers to the science of
movement.
A movement scientist uses specialist knowledge
from basic science (e.g. neuroplasticity, muscle
biology), applied science (e.g. normal movement or
motor control), education and adult learning (e.g.
coaching strategies, feedback, and practise). This
knowledge is combined with critical appraisal of
systematic reviews and randomised controlled trials
to inform intervention decisions. Valid and reliable
instruments are used to measure motor perfor-
mance, and determine the effectiveness of those
intervention decisions. Systematic reviews and ran-
domised controlled trials are critically appraised and
implications of those reviews and trials are used to
inform treatment decisions. Movement scientists
use this background knowledge to observe and
analyse movement, plan intervention, and evaluate
the success (or failure) of intervention. The first step
in this process involves analysing movement.
Analysing movement
Movement analysis involves watching a person as
they attempt a task, then comparing the details of
that attempt with ‘normal’ movement. Therefore,
therapists need to understand the biomechanics of
normal movement, including kinematics and kinet-
ics. The biomechanics of reaching to grasp a cup in
sitting will be described, to illustrate the process of
movement analysis. Reaching to grasp for a cup has
been chosen because drinking is an everyday
occupation.
Normal reaching to grasp
The kinematics and kinetics of reaching to grasp
have been described elsewhere (e.g. Jeannerod
1984, 1986, Martenuik et al 1987, 1990, Wing et al
1986). Kinematics refers to the observable features
of a movement (i.e. the angular displacements, the
trajectory that body parts take during movement,
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 Optimising motor performance following brain impairment CHAPTER 37

velocity and acceleration). Kinematics are what we
see. For example, we see increasing shoulder flexion
and thumb abduction when a person reaches for a
cup (Figures 37.1A–C). While kinematics can be
seen, the kinetics (or forces) that cause these dis-
placements cannot be directly observed.
When reaching for a cup, our brain automatically
selects the most appropriate hand trajectory (the
‘path’ our arm will take as it moves through space),
decides when to begin forming the appropriate
shape and how much grip force to use, based on
experience and visual input. In addition, adaptations
are made to disturbances and inertial forces on the
cup when it is grasped. Also, selection is made of
the appropriate arm trajectory to transport the cup
to an end point, and control the release of the cup.
This process of reaching occurs with little or no
conscious thought. Final grasp is based on the intrin-
sic properties of the cup, such as the shape, size and
perceived fragility (e.g. a plastic cup versus a wine
glass) as well as extrinsic factors, such as distance
from the object, and whether the person is sitting
or standing. Hand shape and grasp position are
selected early in reach. Normally, we produce a
smooth trajectory, control forces at all joints
involved, and resist disturbances to our grasp.

A B

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Transport and pre-shaping of the hand during reaching to grasp a glass
These illustrations present the kinematics of reaching (i.e. what we see).
Figures 37.1A and 37.1B show the trajectory of the arm (the transport phase), and pre-shaping of the fingers and thumb.
As the hand is transported forwards, the shoulder moves into forward flexion, external rotation (enabling the hand and
thumb to reach the glass), elbow flexion then elbow extension.
Figure 37.1C shows wrist extension, and the forearm held midway between pronation and supination. As pre-shaping
occurs, the fingers are slightly flexed and rotated (at the metacarpal joints), producing pad-to-pad opposition in preparation
for contact with the glass. The thumb is abducted to make a space for the glass, but also rotated at the base of the
thumb, allowing pad-to-pad opposition.

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 SECTION FIVE Working with the individual

The timing and synchronisation of reaching

requires careful observation, particularly the timing
of the hand’s pre-shaping and transport, acceleration
and deceleration, and the size of hand aperture, if
abnormalities are to be identified. For example, we
know that in healthy adults, hand pre-shaping and
transport of the arm do not begin at exactly the same
time (van Vliet 1998). Rather, our arm begins to
move (particularly shoulder forward flexion and
external rotation) slightly before the thumb, fingers
and hand open to form the grasp shape.
Reaching to grasp in children has also been inves-
tigated (e.g. Zoia et al 2006). Even when object size A
and distance reached vary, 5-year-old children and
adults show more similarities than differences in
their reach (e.g. grasp formation and timing). The
major differences include longer movement dura-
tion and deceleration times in 5-year-olds compared
to adults, and a larger hand aperture (opening) in
children, particularly when visual feedback is
missing. Zoia and colleagues propose that younger
children may naturally compensate by reaching with
a larger ‘safety margin’ than necessary (hand aper-
ture) while developing reaching skills.
Finally, when adults reach for a cup which is close
(i.e. within 60% of arm’s length), there is minimal
hip flexion and trunk movement (Dean et al 1999a). B
When reaching for a cup or object further away (i.e.
100% or 140% of arm’s length), movement occurs
first at the trunk (via hip flexion). Hip and shoulder
flexion, and elbow extension all contribute to trans-
port the hand forwards. Trunk displacement via hip
flexion, and upper-arm movements are observed
earlier when people reach for objects further away.
The elbow does not fully extend at the end of reach,
except when this is the only way the object can be
reached (Figures 37.2A–C).
Therefore, it is normal, and biomechanically
more efficient, for people to move their trunk for-
wards to assist with arm placement during many
reaching tasks. Similarly, it is abnormal, and biome- C
chanically inefficient, for people to fully extend
their elbow when reaching for a cup which is close 5XVdaT
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}
Transporting the hand forward during
to them, unless that is the only way to accomplish seated reaching (cup within arms length then at 100% of
arms length)
the task.
In Figures 37.2A and 37.2B, there is minimal hip flexion and
In summary, in people without brain impairment, trunk displacement when this lady reaches for a cup which
the hand begins to make an appropriate hand shape is close and within arms length. Note also that her elbow
and aperture shortly after the upper arm begins to remains flexed even when grasping the cup.
move. During near reaching, the elbow remains In Figure 37.2C, the cup has been placed at arms length,
and on her affected side. Hip and shoulder flexion, and
flexed, with minimal hip and trunk movement. When elbow extension all help this lady to successfully transport
reaching for distant objects, the trunk moves first, her hand forward.
via hip flexion. These features are characteristic of

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 Optimising motor performance following brain impairment
many observed reaching tasks, not just reaching for
a cup, and are consequently often called essential
components.
Postural adjustments in sitting
In the next section, we discuss adjustments required
to maintain upright sitting when reaching for a cup,
and what to look for when analysing this task. We
have intentionally chosen the term ‘postural adjust-
ments’ to encourage a shift in thinking (and therapy)
away from muscles of the trunk, to muscles of the
lower limb. It is the leg, not the trunk, muscles that
prevent falling when a person reaches forward or to
the side. In this section, we also discuss environmen-
tal factors such as base of support, reaching distance
and direction. Each of these factors can be manipu-
lated during analysis, to make seated reaching easier
or more challenging.
When reaching for a cup in sitting, we anticipate
the effect that gravity will have on our body prior
to moving. We intuitively know, and can anticipate,
what will happen when we reach forwards, sideways
or towards the floor because of the effect of gravity.
Consequently, we adjust our bodies to maintain
balance and avoid falling. These adjustments are
required during dressing and toiletting. Our base of
support, the direction and speed of reaching all
influence reaching in sitting (Dean et al 1999a,
1999b).
Our base of support comes from our feet and
thighs when we sit with both feet on the floor.
When reaching forwards beyond this base of support,
the leg muscles are critical for maintaining upright
sitting (Chari & Kirby 1986, Dean et al 1999a,
1999b). For example, when reaching for a cup at
140% of arm’s length, tibialis anterior contracts
prior to anterior deltoid in the arm. Soleus and
biceps femoris muscles contract soon after, to
control the forward movement of our body mass
(Dean et al 1999a, Crosbie et al 1995) (Figures
37.3A–F).
If thigh support is reduced when reaching for-
wards, the contribution of the leg muscles increases
to compensate (Dean et al 1999b). If both feet are
off the floor (e.g. when sitting on a high bed or
plinth), our base of support is reduced considerably.
We can no longer push with our feet. We cannot
make postural adjustments using the large muscles
which cross our knees and reach our feet. Instead,
we have to rely on muscles around the hip to keep
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CHAPTER 37
us from falling. Reaching distance is significantly
reduced when both feet are off the ground, and
becomes difficult even for healthy adults.
Reaching direction also influences leg muscle
activity. Reaching for a cup on the right side of the
body results in increased right leg extensor activity
(Chari & Kirby 1986, Dean et al 1999b). Reaching
in front, or to the opposite side, results in increasing
leg extensor activity on the side opposite to the
reaching arm (Dean et al 1999b). Absence of one
leg (e.g. following amputation) also reduces the dis-
tance that can be reached to that side (Chari &
Kirby 1986).
This research on normal reaching in sitting can be
applied when training people who have difficulty
staying upright while reaching. For example, if a
person is unable to generate sufficient leg extensor
force to prevent him/herself from falling forward
while reaching, they will need to learn to activate
their leg extensor muscles in order to be successful
at this task. Reaching forward will be easiest when
there is maximal thigh support, both feet are
on the floor and the chair/bed height is low. A per-
son’s practise will be more successful if they are
asked to reach to a target within arm’s reach, so
they can control their trunk movement before
reaching further forward (i.e. beyond arms
reach).
Less muscle activity is required from the affected
leg extensors if a person reaches to the unaffected
side. Therefore, it is likely to be easier for a person
to practise reaching for a cup on their unaffected
side first. Task difficulty can be progressed by reach-
ing further forward, reaching first to the unaffected
side, then to the front, then to the affected side. As
the person becomes more successful, the amount of
thigh support can be reduced and the seat height
increased to increase the force required from
the legs.
Feedback during training also helps to increase
learning. If a person is unable to push effectively on
their affected leg, they may need specific feedback
about whether their leg muscles are working. Bath-
room scales can be used to give feedback about the
force being generated through the affected leg (e.g.
weight in kilograms). Bathroom scales can also
provide information about timing. For example, are
the leg muscles pushing at the appropriate time (i.e.
anticipating the transfer of weight forward) to
prevent the person falling? Systematic and persis-
tent practise of reaching in this way has been
shown to improve reaching ability and the ability to
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 SECTION FIVE Working with the individual

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Postural
adjustments required to stay
upright in sitting, when reaching
for a cup at distances greater
than arms length
This lady has been asked to reach
for, and pick up a cup on her
unaffected side, beyond arms
length. Her thighs and feet form her
base of support. She looks at the
object, begins to pre-shape her
hand, anticipates the effect that
gravity will have on her base of
support as she lifts her arm, then
transports her arm forwards. To
avoid falling forwards when lifting
her arm, she pushes with her feet
A (Figures 37.3A and 37.3B).
B
In Figure 37.3C, this lady is
reaching for a cup placed beyond
arms length, and on her affected
side. This task is difficult for her,
requiring greater leg extensor
activity from her left leg. If she does
not push through her left leg and
foot, she will fall forwards and to her
left.
Figure 37.3D illustrates her weight
shift forwards and to her left side.
Figure 37.3E shows a training
session which involves practice of
seated reaching. This lady is
practicing reaching for a cup placed
beyond arms length and to her
C D unaffected side. When her skill and
motor control improve, she will
practice placing the cup across to
the left side of the table. Her feet
are on the floor and her thighs well
supported. Electrical tape marks
correct foot position.
In Figure 37.3F, the seat height has
been raised, and this lady’s feet are
now off the floor. She cannot push
with her feet. Consequently, she is
unable to reach as far forward as
when her feet are one the floor. To
optimise successful reaching, the
base of support available to a
person needs to be considered and
E planned.

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 Optimising motor performance following brain impairment
stand-up in people who have had a stroke in both
acute (Dean et al 2007) and chronic settings (Dean
& Shepherd 1997).
Before concluding this section, we want to argue
strongly against the practice of ‘facilitating’ move-
ment. Training postural adjustments and sitting
balance by pushing a person in one direction (exter-
nal perturbations by the therapist) will result in very
different muscle activation patterns compared to
self-generated movement (Forssberg & Hirschfield
1994). The person cannot anticipate what direction
or force of perturbation will be used by the thera-
pist, nor when these disturbances will occur. Train-
ing postural adjustments by pushing a person from
side to side in sitting is unlikely to help them acti-
vate appropriate muscles necessary for self-gener-
ated movement (for example, when cleaning
themself on the toilet). Such ‘training’ strategies
may cause the person to become rigid and fearful of
moving during therapy, and should be avoided. The
anticipatory muscle activity that occurs during
reaching while seating, and the possible intervention
implications and strategies, are presented in Table
37.1.
Training strategies should aim to mimic the
normal sequence of muscle activity specific to the
task for which the person is being trained (see Table
37.1 for some examples). If a person is unable to
sit, the therapist will need to accurately analyse the
reasons why they cannot sit, then develop training
strategies which are specific to those difficulties.
In summary, seated reach can be progressed by
gradually increasing the distance, and changing the
direction of reach (i.e. to the affected side, then
forwards, then to the contralateral or unaffected
side), decreasing the amount of thigh support and
increasing seat height. However, ‘tapping’ or pushing
a person off balance as part of training is unhelpful
and may interfere with their recovery. By systemati-
cally increasing the demands of a reaching task as
suggested previously, people with neurological con-
ditions can learn to engage more successfully in
occupations such as dressing and bathing.
Focus on ‘positive’ versus
‘negative’ impairments
Neurological conditions, such as stroke and cerebral
palsy, lead to impairments which can be classified
as either ‘positive’ or ‘negative’ (Ada et al 2000,
Burke 1988, O’Dwyer et al 1996). ‘Positive’
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CHAPTER 37
impairments include abnormal postures, exagger-
ated proprioceptive reflexes producing spasticity,
and exaggerated cutaneous reflexes of the limbs
producing flexion withdrawal spasms. ‘Negative’
impairments include paralysis, weakness, loss of
coordination and loss of dexterity. In practice, it is
the ‘negative’ impairments or characteristics, such
as paralysis, that most concern people with stroke
and other conditions, not spasticity and abnormal
reflexes.
Therapy textbooks (and many experienced prac-
titioners), focus on the management of spasticity (a
‘negative’ impairment), but provide less guidance to
students and new graduates on strength or dexterity
training. However, research indicates that reducing
spasticity does not automatically improve perfor-
mance (McLellan 1977, Neilson & McCaughey
1982). There appears to be little correlation between
spasticity and function (Ada et al 2006b, O’Dwyer
et al 1996, Sommerfield et al 2003). Thus, while
acknowledging the presence of spasticity, we ques-
tion its emphasis. In this chapter, we provide exam-
ples of strategies which focus on strength and
dexterity (‘positive’ impairments), which therapists
are more likely to be able to influence.
Here is a final note about analysing and labelling
motor impairments. Therapists often use the term
‘spasticity’ or ‘high tone’ to refer to stiff or tight
muscles in the hand or arm, or to stiff joints. The
cause of such stiffness or tightness needs to be
determined so that intervention can be planned
(Boyd & Ada 2001). Often what therapists describe
as spasticity or high tone is a shortening of muscles
or contracture. Therapists need to be able to recog-
nise and diagnose a contracture, because muscle
contractures, unlike spasticity, may be amenable to
therapy.
Recognising contractures
A contracture can be recognised by loss of joint
range and increased resistance to passive movement
at a joint (Ada & Canning 2005). Resistance to
movement is typically due to peripheral changes in
muscle fibres and connective tissue (O’Dwyer et al
1996, Pandyan et al 2003), not to central nervous
system changes or spasticity. Animal studies show
that muscles shorten and lengthen in response to
immobilisation. Animal muscles increase in length
when immobilised in a lengthened position, and
decrease in length when immobilised in a shortened
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Table 37.1 Summary of seated reaching without back support, feet on or off the floor

Reaching Implications for Possible training

forward in Anticipatory muscle activity intervention strategies
sitting without
back support, Leg/trunk Arm
feet on the floor
Within arm’s Back extensors Transport } Begin to train reaching Practice set-up
length Hip extensors Shoulder forward within arm’s length if } Sitting with back support:
flexion and person is unable to activate practise moving forward
external rotation hip extensors from (hip flexors) and back
Pre-shaping } Sit with back supported to to (hip extensors) the back
Wrist and finger minimise initial task support
extension, difficulty } Sit next to wall on the
radial deviation, } Provide trunk support if non-affected side for a
thumb abduction unable to sit without vertical cue
and opposition assistance
Greater than Hip extensors } Practise sitting on a stable Feedback:
arm’s length Knee extensors surface } Provide vertical cue for
Plantarflexors } Specific training of hip and sitting alignment (i.e. if the
knee extensor strength and person is falling towards
endurance on affected side their left, position them
} Maximise thigh support with a wall at their right
} Practise with feet supported side to provide a close
before training with feet vertical cue and feedback
unsupported when they begin to fall)
} Provide visual cue (e.g. line
Ipsilaterally (i.e. Ipsilateral } Train reaching to ipsilateral
on wall for appropriate
to the unaffected or (unaffected) side if person is unable to
shoulder position)
intact side) hip, knee and reach to contralateral side
} Place bathroom scales
ankle extensors } Gradually increase distance
under affected foot for
the person is attempting to
feedback about weight
reach ipsilaterally
bearing
} Gradually introduce
} Sitting on lower surface to
reaching across the midline
decrease extensor force
towards contralateral side
required
Contralaterally Contralateral } Ensure appropriate Progress difficulty by:
(i.e. to affected side) hip, knee and alignment of weight- T increasing time
ankle extensors bearing leg (i.e. knee over T increasing distance
foot, leg not abducted) from wall
} Ensure person begins to T decreasing thigh
use leg extensors in support
anticipation of weight T increasing height of
transference to affected surface
side T increasing distance
reached
T increasing contralateral
distance

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 Optimising motor performance following brain impairment
Table 37.1 Summary of seated reaching without back support, feet on or off the floor—cont’d
Reaching forward Anticipatory
in sitting, without muscle activity
back support,
feet off the floor
Within arm’s length Back extensors
Hip extensors
Greater than arm’s Hip extensors
length Back extensors
Ipsilaterally Ipsilateral hip extensors
Contralaterally Contralateral hip
extensors
position, for example, in a plaster cast, by adding or
losing sarcomeres, respectively (Tabary et al 1972,
Williams & Goldspink 1978). A sarcomere is the
contractile part of a myofibril, within skeletal muscle
(Gossman et al 1982). When immobilised in a short-
ened position, muscles generate tension at a new,
shorter resting length (Herbert & Balnave 1993).
These structural changes lead to disorganisation
of connective tissue within a muscle (Goldspink &
Williams 1990), disrupting the synovial fluid, joint
membrane and articular cartilage (Trudel et al
2003). Changes in the mechanical-elastic properties
of muscles and connective tissue limit joint range of
movement after stroke (Vattanaslip et al 2000), and
probably also after other neurological conditions.
This joint stiffness leads to resistance. Therapists
often (inappropriately) call this resistance to move-
ment ‘high tone’ or ‘spasticity’.
While it remains unknown how long contractures
take to develop after brain impairment, there is no
doubt that they do develop. Contractures are unde-
sirable for many reasons, including their effect on
occupational performance. For example, a person
with contractures of the wrist and finger flexor
muscles will be unable to extend their wrist to
achieve normal grasp and release. Nor will they be
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CHAPTER 37
Implications for intervention Possible training strategies
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Feedback:
purpose is to train reaching. } Provide vertical cue for sitting
alignment (i.e. if the person is
} Specific training of hip extensors if
falling towards their left side
unable to elicit hip extensor activity
position them with a wall at
} Maximise thigh support
their right side to give them
} Gradually and systematically
feedback when they begin to
increase the distance reached
fall)
} Practise with feet supported before
} Bathroom scales under the
training with feet unsupported
affected thigh for weight-
}
0b
PQ^eT
R^]RT]caPcT
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bearing feedback
hip extensors Progress difficulty by:
T increasing distance from wall
}
2^]RT]caPcT
caPX]X]V
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T decreasing thigh support
contralateral hip extensors T increasing distance reached
T increasing contralateral
distance
able to open their hand wide enough to pick up a
cup. Such contractures will need to be reversed
using strategies such as positioning, passive stretch-
ing and plaster casting. There is, however, still
uncertainty about the effectiveness of these inter-
ventions, and how long stretches or positioning
need to be maintained per day to adequately
reverse contracture. Nonetheless, it is unlikely
that short-duration stretch methods such as
passive ranging of joints, will change tissue structure.
Therefore, methods for applying long-duration
stretch are required, and are discussed later in this
chapter.
Recognising compensatory
strategies
When analysing motor and occupational perfor-
mance, therapists need to be able to recognise com-
pensations. Compensatory strategies are movement
solutions that allow a person to compensate for loss
of normal muscle activity (Carr & Shepherd 1989).
Compensations may be caused by a muscle contrac-
ture, muscle weakness or both. For example, a
person who cannot successfully reach forward to
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 SECTION FIVE Working with the individual

grasp a cup may use hip flexion and/or shoulder

abduction to compensate for poor shoulder flexion.
In previous years, these patterns of muscle contrac-
tion were called ‘abnormal synergies’, and believed
to be a normal stage of recovery after stroke or brain
injury. However, there is no neurophysiological
explanation for these synergies. Rather, this combi-
nation of muscle activity appears to be more biome-
chanically advantageous to the person who cannot
activate weak or paralysed muscles (Carr & Shep-
herd 1989).
The problem with compensations is that they
become learned. The more a person practises using
these inappropriate movement solutions, the more A
difficult it becomes to change behaviour. In the long
term, compensatory strategies are inefficient and
inflexible. Therefore, therapists need to help people
to contract their muscles more appropriately when
reaching. When observing a person reach to grasp a
cup, we also need to compare what we see (kine-
matics) with our knowledge of normal movement.
For example, when pre-shaping to reach for a cup
within arm’s reach, we need to determine if a person
is opening their hand and abducting their thumb at
the beginning of reaching. Thumb abduction and
metacarpo-phalangeal extension of the fingers are
essential, and result in a web space large enough to
accommodate the cup. Typically, people who have B
difficulty abducting their thumb, and/or extending
their fingers and wrist will compensate by extending
5XVdaT
"&#
}
Normal pre-shaping while reaching for
their thumb, pronating their forearm and/or abduct- a cup and commonly observed compensations
ing their shoulder (Carr & Shepherd 1987, 2003) Figure 37.4A illustrates normal pre-shaping during reaching,
(Figures 37.4A–B). These strategies may lead to suc- with the thumb abducted and opposed, and the person’s
cessful contact with a cup, but are inefficient and wrist extended ready to grasp the cup.
However, in Figure 37.4B the person is compensating
compensatory.
during reaching for poor control of thumb abduction (a
When a person transports their arm towards a missing essential component). Instead, they are extending
cup which is nearby (i.e. within arm’s reach), we their thumb and pronating their forearm (both are
watch to see if they are using their shoulder flexors compensations) to try to grasp the cup.
and external rotators, without using excessive shoul-
der elevation, internal rotation or abduction. The
latter three compensatory movements may suggest
weakness or paralysis of the person’s shoulder flexion and trunk movement may be compensations
flexors and/or external rotators. Alternatively, these for weak shoulder flexors.
shoulder movements may be helping to compensate
for poor control of forearm, wrist, thumb or finger
muscles. For a full discussion and analysis, see Carr Hypothesising about
and Shepherd (1987). compensatory strategies
When reaching in sitting, it is normal to flex at
the hips to reach distances at arm’s length or greater The final step in the process of analysing movement
(Dean et al 1999a). However, it is not normal to use is developing then testing the movement hypothe-
hip flexion when reaching for an object such as a cup ses. Developing a hypothesis (or hypotheses) about
which is very close to the body. In that case, hip a person’s movement compensations will help us to

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 Optimising motor performance following brain impairment
plan treatment. One hypothesis might be that a
person’s shoulder muscles are paralysed or too weak
to lift the limb up against gravity, to reach for a cup.
This hypothesis can be tested by assessing muscle
strength (i.e. palpating the muscle belly during a
movement attempt). If a person cannot easily reach
forwards, two key muscles to check are anterior
deltoid (a shoulder flexor) and infraspinatus (an
external rotator). If these muscles are weak,
strengthening exercises will be required. In the
absence of a muscle contraction, we might use elec-
trical stimulation (Ada & Foongchomcheay 2002,
Pomeroy et al 2006) and/or mental practise to elicit
muscle contractions (see Bell & Murray 2005, Braun
et al 2006).
A second hypothesis might be that muscles such
as the internal rotators, elbow, wrist and finger
flexors are short and/or stiff due to contractures.
The opposing muscles may be incapable of generat-
ing the necessary force to lift the arm, extend the
wrist or open the hand. This hypothesis can be
tested by manually checking the available range of
external rotation; forward flexion; elbow, wrist and
finger extension; and thumb abduction. Loss of
range at any one of these joints will change the
person’s ability to reach for an object such as a cup.
A third possible hypothesis might be that the
person is using excessive muscle force to achieve the
task (i.e. to pick up the cup). They may be using too
many muscles, too much force, or both. A group of
muscles such as the finger and wrist flexors may be
overactive and contract with excessive force when
movement is attempted. Overactivity may occur
(e.g. all the muscles of the arm switch on with
effort) to help compensate for weakness in other
muscle groups, such as the shoulder flexors. We can
test our hypothesis by setting up the practice task
to minimise effort. For example, the person could
practise reaching with their arm supported on a
table, and a sheet of paper or cloth under their hand
to reduce friction.
A fourth hypothesis might be that the task and/
or environmental set-up are too challenging. The
cup may be positioned too far in front or to the side
for the person to grasp without compensating. Or
the table may be too high. We can test these hypoth-
eses by placing the cup closer or lowering the table.
Another example is changing the person’s position,
allowing muscles to contract more easily (e.g.
moving the person from a sitting to lying position).
This change will lessen the effect of gravity on their
weak shoulder flexors, and decrease the amount of
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CHAPTER 37
muscle force required. Taping a light polystyrene
cup into their hand will also decrease task demands
and eliminate the need to pre-shape the hand. The
person can then concentrate on transporting the cup
rather than worrying about pre-shaping. Each move-
ment hypothesis can be tested in turn.
Assuming we have correctly analysed the person’s
movement problems, identified the missing essential
components and compensations, and tested our
hypotheses, the next step is to design a programme
to improve motor performance.
Teaching motor skills
People with brain impairment often have difficulty
understanding instructions, using feedback, remem-
bering their practice and learning motor skills.
Therefore, therapists need to develop critical teach-
ing skills and become effective coaches. We need to
understand how motor learning progresses, provide
training that is task-specific, ensure learners practise
well and often, and provide useful, timely feedback.
Each of these factors will influence learning.
The stages of motor learning
There is considerable literature on motor learning.
The Fitts and Posner model of motor learning
(1967) is most often used to inform rehabilitation
practice. The three stages described by Fitts and
Posner are: (1) the verbal-cognitive stage; (2) the
motor stage; and (3) the autonomous stage. In the
first stage, learners rely on verbal feedback and
external environmental information to achieve goals
and understand the demands of a task (Haggard
2001, Prinz 1997). In the second stage, the focus is
on the quality of movement, mass practice (Mastos
et al 2007) and decreasing mistakes (McNevin et al
2000). Finally, in the third stage the learner is able
to perform the task with less cognitive effort, cope
more effectively with distractions and draw on their
problem-solving skills when performing the task in
novel situations (Mastos et al 2007, McNevin et al
2000). At each stage, learners need timely feedback
about performance and goal achievement, and
increasing amounts of practise (Lee & White 1990,
McNevin et al 2000, Shea et al 2000).
Using our previous training example of reaching
for a cup in sitting, a goal might be for the person
to sit upright for 30 seconds without falling to the
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 SECTION FIVE Working with the individual
affected side. In the first stage of learning, they may
require continual feedback about pushing with their
affected leg, to avoid falling to their affected side.
In the second stage, they may recognise when they
are beginning to fall, make an attempt to prevent
this but require occasional assistance or prompting.
In the third stage, they can sit without assistance,
conduct a concurrent conversation and reach forward
to pick up a cup of water with their non-affected
hand without falling to the affected side. If practise
tasks are too demanding in the early stages of learn-
ing, the person may be unable to achieve the goal.
For example, asking the person to reach to their
contralateral (affected) side before they can sit
upright for 5 seconds would be unrealistic.
Making training task-specific
The terms ‘task-specific training’, ‘task-related prac-
tise’ and ‘specificity of training’ are used in the lit-
erature (e.g. Blennerhassett & Dite 2004, Dean &
Shepherd 1997, Michaelsen et al 2006, van der Lee
et al 2001). These terms refer to therapy involving
intentional practise of a specific movement, action
or task, versus repetition of non-specific tasks
(Bayona et al 2005) such as lifting your arm up high
for no reason, touching your head or nose (in
response to an instruction by a professional) or
stacking cones instead of practising reaching for a
cup. Examples of task-specific training include prac-
tise of pen or cutlery manipulation to improve
writing and eating respectively, or picking up and
transporting a cup to improve the occupation of
drinking. In the early stages of motor recovery, when
a person cannot hold objects, implements can be
taped into the affected hand (e.g. a fork or cup), or
placed in front to encourage reaching.
Research shows that we learn (or relearn) motor
skills through engagement in tasks and activities. For
example, when people practised reaching to pick up
a pen and write their name, compared to pretending
or imagining themselves picking up a pen to write,
the quality of reach and grasp improved significantly
(Wu et al 1994). Although that writing study
involved healthy adults, the implication is that
people need to practise real-life tasks, not simulate
them. Studies involving adults with brain injury also
demonstrate the importance of using real-life tasks
for motor training (Neistadt 1994, Sietsema et al
1993). For instance, people with a brain injury pro-
duced a greater range of movement when reaching
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out to control a computer game (Sietsema et al
1993), and demonstrated improved dexterity when
engaging in kitchen activities versus table-top
therapy activities (Neistadt 1994).
The bottom line is that people learn what they
practise. If a person wants to learn to drink from a
cup, they should practise reaching for and transport-
ing a cup, not a plastic shape or cone that vaguely
resembles a cup. Early training might involve sliding
or placing a lightweight plastic cup forwards on a
low table, with the cup taped into the person’s hand
if they have no active hand movement. Advanced
dexterity training might involve moving and manipu-
lating objects of interest, such as garments, eye-
glasses, cutlery and writing implements, not beans
or plastic counters. Training should replicate the
skill or task that a person wants to learn. Valuable
time should not be wasted on non-specific
practise.
Maximising practise
More time spent practising leads to improved per-
formance across many skill areas including chess
(Charness 1981), typing (Ericsson 2004), sports
performance (Helsen-Starkes & Hodges 1998) and
playing musical instruments (Ericsson 2004,
Lehmann & Ericsson 1996). In a study involving
20-year-old violinists (Ericsson 2004), the best per-
formers, as judged by conservatory teachers aver-
aged 10,000 hours of practise during their lives. The
second-best performers averaged 7,500 hours, the
next-best, 5,000 hours and so forth.
A similar commitment to practise is required by
learners with acquired brain impairment and their
therapists, if motor performance is to improve. In a
randomised controlled trial evaluating the effect of
seated reaching (Dean & Shepherd 1997), people
with stroke each performed 2,970 reaches beyond
arm’s length during a 2-week training period. Par-
ticipants in the intervention group could reach
further and faster than the control group after task-
specific training, and improved their ability to
stand-up.
Repetition of practise tasks is also integral to
learning. Multiple repetitions of a movement can
significantly improve upper limb strength in people
following stroke. In one study, people with stroke
practised repetitive finger flexion and extension
against resistance, twice daily for 15-minute periods
(Butefisch et al 1995). This task-specific practise led
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 Optimising motor performance following brain impairment
to greater grip strength, improved contraction veloc-
ities and peak acceleration in the extensor muscles,
compared to a control group receiving standard
Bobath therapy. Another study by Feys and col-
leagues (1998, 2004) included adults with minimal
arm function after stroke, who were required to
protract and retract their affected shoulder while
seated in a rocking chair, for 30 minutes daily over
6 weeks. This practise was intended to help improve
forward reaching. The treatment had greatest effect
in people with more severe motor deficits. Improve-
ments in upper-limb motor function were retained
at 5 years’ follow-up.
Mass practise and multiple repetitions are also
features of constraint-induced movement therapy
(CIMT; see Morris et al 1997 for a summary).
CIMT involves restraining the unimpaired arm and
hand to encourage intensive practise of tasks using
the affected arm. Although CIMT studies require
participants to practise for up to 6 hours a day, the
amount of practise required to improve function
remains unknown. However, we do know that a
minimum dose of 16 hours additional practise is
needed to improve motor outcome following stroke,
according to a recent systematic review (Kwakkel
2006).
Finally, practice which involves lots of repetitions
but no transfer of learning may limit skill develop-
ment. For example, using a fork with a built-up
handle to repeatedly pick up pieces of soft bread
will not enable a person to eat a meal successfully
in a restaurant with a normal fork. Motor learning
theory suggests that people improve their perfor-
mance by practising in a variety of situations, and
experiencing errors during learning. In order to
move beyond the first two stages of motor learning,
people need to practise in different settings, with
different movement parameters (for example, forks
with different handles, and different foods). Increas-
ing demands in this way helps learners to problem
solve and fathom the rules underlying task perfor-
mance (Schmidt & Lee 1999).
Giving feedback
Accurate feedback is critical to the teaching and
learning of motor skills. Feedback can be provided
by the task itself (intrinsic feedback), or by an
outside source such as the therapist, biofeedback
device or timer (extrinsic feedback). Extrinsic feed-
back has been further classified into two types:
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CHAPTER 37
knowledge of performance and knowledge of results
(Kilduski & Rice 2003).
Knowledge of performance refers to information
about the movement process or attempt, for example
‘Your wrist was flexed’ or ‘You kept your elbow
close to your body’. Knowledge of results refers to
information about the movement outcome, for
example ‘You picked up the cup’. Knowledge of
results is usually obvious to the person performing
the task; they either achieved the desired outcome
or they did not. The bigger problem is how to change
the next attempt. This is where the therapist as
coach can provide knowledge about performance,
and suggest ways to make the next attempt more
successful.
Extrinsic feedback can be very helpful to learn-
ers, particularly corrections that need to be made,
and features to focus on during subsequent attempts
(Kernodle & Carlton 1992). The timing of feedback
is important, relative to performance. Concurrent
knowledge of results – that is, feedback provided
during performance – appears to impede motor
learning (Annett 1959). Talking during performance
may be distracting (although motivational com-
ments such as ‘Keep going’ or ‘That’s right’ can be
helpful). However, feedback given after task com-
pletion has a positive influence on motor learning
(Adams 1971, Bilodeau 1966, Newell 1976). The
amount and frequency of extrinsic feedback also
affects performance. Intermittent feedback is more
effective than constant feedback (Ho & Shea 1978,
Winstein & Schmidt 1990), whereas too much feed-
back may negatively influence learning (van Vliet &
Wulf 2006). People appear to benefit from watching
others demonstrate a task, and then receive feed-
back about their movement outcome (Reo & Mercer
2004). This form of modelling seems to be most
effective when presented at intervals during skill
acquisition, before practise commences, and at
various intervals thereafter.
Evaluating change in motor
performance
Therapists need to re-evaluate motor (and occupa-
tional) performance at regular intervals. Objective
measures need to be taken before and during train-
ing. Ideally, a review of performance and goals will
occur at every session. Performance can be mea-
sured using complex or simple equipment. For
example, to determine if a person with sitting
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 SECTION FIVE Working with the individual
balance problems is weight-bearing equally through
both legs, a therapist may use bathroom scales.
Other simple measures of performance include the
number of movement repetitions per session, the
number of correctly performed movements versus
those performed with compensations, and distance
reached.
If performance is not changing, the problem may
lie with the therapist rather than the person with
brain impairment. Common reasons for lack of
improvement include unclear instructions, feedback
and goals. If instructions are unclear, off-target, or
too detailed, the person with stroke or brain injury
may not understand the expected goal. Similarly, if
verbal feedback is unclear (or even absent), the
person may not understand how to alter their next
movement attempt to achieve success.
In addition to carefully considering the words we
use to explain and correct movement attempts, the
task chosen to elicit a movement attempt is also
important. If the task is too difficult (or too easy)
progress may not be seen. If our initial movement
hypothesis was wrong, we miss the main cause of a
movement problem, and change in performance
may not be seen. When re-measurement of perfor-
mance shows little or no progress, we need to reas-
sess the person’s abilities before hypothesising again
about the possible causes of their movement prob-
lems. If the movement hypotheses are correct,
therapists can then reflect critically on their teaching
skills. Alternatively, if a different movement hypoth-
esis is made new training strategies and an interven-
tion plan will be needed. Therapists should not
underestimate the importance of re-measuring per-
formance, reflecting on their teaching skills, and,
above all, persisting and expecting to see improved
motor performance at every session.
Practice Scenario 37.1 shows how Leo, an occu-
pational therapist, developed his teaching and analy-
sis skills, and applied evidence-based practice in
adult rehabilitation.
Practice Scenario 37.1 Leo
and Mary
Leo is an experienced occupational therapist working
in a large district hospital in rural Australia. He has
over 10 years experience in adult neurological reha-
bilitation. Leo is dedicated to developing his skills. He
has attended upper-limb motor training workshops,
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videotaped clients, and discussed his training pro-
grammes with peers. He has organised fortnightly
peer review sessions where staff observe each other
conducting a therapy session, and provide feedback
about analysis and teaching skills. Leo regularly
attends rehabilitation conferences as he feels they
‘are a great pick-me-up’. More recently, Leo
increased his knowledge and skills by commencing
a major research project, a randomised controlled
trial of task-specific training, as part of a Masters
degree.
Here, Leo gives an example of a lady, Mary, he
saw recently following her stroke. He describes her
motor control problems and compensations, and the
upper-limb training programme provided over several
months to improve occupational performance. Mary
could not use her affected arm much when
engaging in daily occupations. She could not hold or
transport objects such as a cup or a knife during
meals.
Mary
“I saw Mary recently. She had recovery of
some muscles in her arm, but a lot of
overactivity, many compensations and little
control in her hand. For example, when
attempting to reach forwards to grasp a cup,
she elevated her shoulder and abducted her
arm, clenched her fingers, flexed her elbow,
and moved her whole body forwards instead of
just her arm and hand. She compensated for
poor shoulder flexion, loss of external rotation
and thumb adduction by using every muscle
possible in her arm. It was hard work.
Training sessions targeted Mary’s shoulder
flexors in a lying position, which reduced the
effect of gravity. We focused on the anterior
deltoid muscle. Mary was asked to rest her
hand on her forehead with the elbow flexed,
and control her anterior deltoid in that position.
When she could hold her arm there, she
started sliding her hand back from her forehead
to the pillow and the crown of her head, to
control anterior deltoid in lying, then reaching
higher to the wall to touch a marker. It was too
hard in sitting. She couldn’t lift her arm up
against gravity without compensating. Other
practice tasks focused on her shoulder external
rotation, elbow, wrist and finger extension and
thumb abduction. We pieced each component
together, then eventually began working on
functional reaching in a seated position (see
Figure 37.5).
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Practice of essential components
required for reaching (forward flexion and external
rotation) and drinking from a cup
Since her stroke, this woman has had limited
opportunities to engage in occupations such as drinking
from a cup with her dominant right hand. She has weak
shoulder flexors and external rotators, and cannot open
her thumb or fingers to pre-shape correctly. The
occupational therapist is helping her to practise shoulder
flexion and external rotation – essential components of
reaching – while also maintaining wrist extension and
forearm supination.
In this photograph, she is sliding the cup forwards while
staying inside the black lines (electrical tape stuck to the
table). The practice environment encourages external
rotation, wrist extension and supination, and discourages
compensations such as internal rotation and abduction.
Two drinking straws have been applied to her arm, one to
the inner elbow and another on to the back of her wrist.
These straws act as visual cues, reminding her to
maintain shoulder external rotation (the straw stays in
contact with the wooden block) and wrist extension (her
knuckles stay in contact with the flexible straw). She is
also learning to monitor her own performance, so that she
can practise alone outside of therapy sessions. Notice the
timer near the therapist’s right hand, to record practice
time and repetitions
Mary practised for about two hours a day for
three months (unsupervised for some of the
time); then one hour daily for another three
months; then about three hours a week for the
last three months. It took 36 weeks or six
months before she had a functional grasp and
release. In the first six weeks she completed
12,810 repetitions, with an average of 427 reps
per session or 85 per exercise. After 36 weeks,
she achieved a score of 16/57 on the Action
Research Arm Test, compared to 2/57 at the
9khj_dU9^&)-UcW_d$_dZZ


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CHAPTER 37
beginning, a 14 point change. With a
combination of task–specific training,
persistence on both our parts, objective
measurement, intensive practice and
feedback, Mary achieved improved hand
function. Without this persistence and practice,
I don’t think she would have achieved this
outcome.”
Ensuring enough practice by people with a stroke
or brain injury is always a challenge: to help ensure
individuals spend plenty of time each day practising,
Leo uses typed practice records with imported digital
photographs. The rehabilitation team runs a cross-
disciplinary upper-limb group several times a week,
where people with stroke or brain injury follow their
own practice programme with co-learners, and
supervision from therapists. Therapy assistants and
relatives also help supervise individual practice after
this has been documented with instructions, goals
and illustrations by the therapist. Family members are
involved in helping with practice as early as possible,
because of the limited time available for one-to-one
therapy.
Evidence-based intervention to
improve upper-limb motor
performance
There are several reasons why a person may be
unable to reach for, grasp and drink from a cup.
Different causes will require different intervention/s.
A person with a paralysed arm, who is unable to
elicit any muscle contractions, will require interven-
tion targeting muscle strength. A person with a con-
tracture will require intervention to lengthen, and
then strengthen, their weak overstretched muscles.
In this chapter, we have emphasised the impor-
tance of identifying the correct motor control
problem, in order to select appropriate, targeted
intervention. A number of interventions have now
been tested in randomised trials, and the collective
findings synthesised in systematic reviews. It is the
effective interventions we highlight here. Where
interventions and training strategies have not been
tested using more rigorous research, we will indicate
if we are relying on lower level evidence or personal
experience.
In adult rehabilitation, interventions that improve
performance of upper-limb motor control appear to
593
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 SECTION FIVE Working with the individual
involve greater intensity of practise and repetitions
(Kwakkel 2006, van der Lee et al 2001), and use
task-specific training strategies to improve strength
(Ada et al 2006b). However, the evidence is still
scattered and limited. By definition, more intense
practise and repetitions requires active involvement
of the learner. One of the biggest challenges in reha-
bilitation (and this is not limited to motor rehabilita-
tion) is how to increase the amount of practise a
person completes in the hospital and community.
For a thoughtful discussion of the feasibility of pro-
viding intensive practise, see Kwakkel (2006). It is
important that people spend as much time as pos-
sible practising. One hour of therapy doing 100 rep-
etitions is better than 1 hour of therapy doing 10 or
20 repetitions. Keeping a record of repetitions com-
pleted during each therapy session is one way of
ensuring practise intensity. Such records provide an
insight into just how much practise is needed before
people acquire particular skills.
Strength training for weak or
paralysed muscles
Some individuals may be unable to elicit a muscle
contraction due to paralysis or weakness. They need
practise which helps them elicit a single muscle
contraction then gradually increase the duration and
strength of contractions. There is a growing body of
evidence demonstrating that muscle strengthening
and repetitions improve strength and function
without any increase in spasticity (e.g. Ada et al
2006a, Butefisch et al 1995).
One of the few randomised trials targeting very
weak muscles has already been highlighted (Feys
et al 1998). These researchers recruited 100 people
early after stroke, and provided a novel training
strategy to improve shoulder control. Participants
were seated in a rocking chair with their affected
arm in an airsplint, and practised protraction and
retraction for 30 minutes daily for 6 weeks. The
median score on the Action Research Arm Test
(ARAT) was 0 at baseline for control and experi-
mental groups (total maximum score  57). At the
5-year follow-up, the mean difference in improve-
ments between groups was 17 points on the ARAT
(Feys et al 2004). As previously noted, greater gains
were seen in people with severe motor deficits at
baseline. While there was a wide range and variabil-
ity in responses, the mean effect in this very weak
population was large.
594
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Examples of practice tasks aimed at increasing
muscle strength are shown in Figures 37.6–37.9.
Electrical stimulation
Electrical stimulation should be provided to people
with no palpable muscle activity after a stroke. Ada
and Foongchomcheay (2002) conducted a meta-
analysis involving four trials of electrical stimulation
to prevent subluxation early after stroke (average 17
days post-stroke), involving a total of 145 subjects.
Electrical stimulation reduced subluxation by an
average of 6.5 mm, but had no worthwhile effect on
reducing pain or improving functional recovery. No
clinically important differences were found when
stimulation was applied later (60 days or more post-
stroke), based on meta-analysis of data from three
randomised trials.
More recently, Pomeroy and colleagues (2006)
examined the effect of electrical stimulation on
upper- and lower-limb motor recovery. A total of
24 randomised trials were included, involving 888
participants from 9 days to 4 years post stroke.
When compared to no treatment, function was
improved (statistically significant difference between
groups) on the Box and Block tests, motor reaction
time and isometric muscle torque. Another explor-
atory study involving nine people with chronic
stroke who had moderate-to-severe motor weakness
and intact sensation reported improved motor func-
tion after only 2 hours of electrical stimulation to
the sensory nerves of the hand (Wu et al 2006). In
summary, electrical stimulation is being used
increasingly in adult neurological rehabilitation,
although further research is still needed, including
research involving children.
Constraint-induced movement
therapy
Constraint-induced movement therapy (CIMT) is a
relatively new and popular treatment aimed at
increasing use of the affected hand after stroke,
brain injury, and cerebral palsy in children and
adults. Typically, a splint or mitt and a sling are used
to restrain the unaffected hand for up to 6 hours a
day, for 2 weeks, during which time the person
intensively practises using their hand. The aim is to
discourage use of the ‘good’ hand and greater use of
the affected hand. For a detailed description of a
CIMT protocol, see Morris and colleagues (1997).
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 Optimising motor performance following brain impairment CHAPTER 37

Goal one: To lift your wrist back to straight. Hold for 10 seconds
CIMT for paediatric populations has been studied
x 20 repeats x 1 day less. A small number of randomised controlled trials
with low methodological quality and small sample
Wrist sizes have been reported (e.g. Taub et al 2004, Willis
et al 2002). Consequently, the effect remains uncer-
tain (Hoare et al 2007, see Wallen 2007 for an
overview and key references). Readers should follow
Table Hold for 10 sec the work of Eliasson and colleagues in Sweden. They
describe a programme of CIMT, which involves
shorter periods of restraint using a mitt, for 2 hours
Instructions over 8 weeks with adolescents who had cerebral
1. Tape straw on forearm palsy (Eliasson et al 2003). More recently, they
2. Hand on table; elbow straight evaluated the effect with young children with
3. Let wrist drop down so fingers hang over edge of table cerebral palsy using a non-randomised study design
4. Keep fingers straight
5. Bring your hand back to straight by moving your wrist
(Eliasson et al 2005).

Critical features Mental practice

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17/7 15/20
26/7 21/25
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02/8 20/25
03/8 22/25
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Wrist extension
Wrist extension is essential for most activities involving
reaching, such as picking up a cup to drink. The page
shown above is taken from a practice book and illustrates
the wrist extension exercise, where the goal is to lift the
wrist back to the ‘straight’ position and hold for 10 seconds,
and to repeat this exercise 20 times in one session.
The collective research in stroke rehabilitation
(14 randomised trials and four systematic reviews)
shows a moderate effect of CIMT on upper-limb
motor performance, as measured by the Action
Research Arm Test (Hakkennes & Keating 2005).
However, all participants have had active wrist and
finger extension at study commencement. We do
not yet know if this intervention can drive recovery
in people with a paralysed arm, as occurred in early
studies involving monkeys. Currently in adult stroke
rehabilitation, CIMT is used with small cohorts of
individuals but may have the potential to drive
recovery if used more widely.
Mental practice and imagery have been used to
promote motor recovery. This type of practice is
used routinely in sports training to improve skill
acquisition. In rehabilitation, a person with stroke
or brain injury might mentally rehearse the task of
picking up a cup and imagine the transport and pre-
shaping actions, without physically attempting the
actions (Bell & Murray 2005). A recent systematic
review (Braun et al 2006) summarised the effects
of several studies in stroke rehabilitation but again
found underpowered studies with small sample
sizes. No definite conclusions could be reached, but
this intervention is promising for people with no
active movement. Interested therapists will need to
devise their own script and tape to give to interested
people. For an example see Dijkerman and col-
leagues (2004).
Reducing muscle force
during grasp
Some individuals turn on too many muscles, or the
wrong muscles, when reaching for and grasping
objects. This is a normal response to skill acquisition
(not spasticity) in most cases. Until we have mas-
tered or refined a new skill, we will try a range of
strategies, and use too many muscles. Therefore,
one aim in therapy is to reduce effort, and help the
person focus on the muscle actions required for task
performance.
Changing the demands of a task and the environ-
ment can reduce effort. For example, asking a

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 SECTION FIVE Working with the individual

Goal one: Keep texter pentip touching the X mark for 5 seconds
x 3 times in a row
Goal two: Draw a line with the texter 5 cm up the wall
x 3 times in a row

Instructions
1. Stick the paper onto the wall with tape (X mark at hip height).
2. Stand beside the poster with pen in hand.
3. Rotate the pen out so the pentip touches the X mark.
keep shoulder rotated out.
4. Hold for 5 seconds, rest and repeat.
5. Try drawing a line up the wall – no further than 5 cm initially

Check
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Practice for shoulder external rotation and forward

flexion in standing
Both external rotation and shoulder forward flexion are essential for
transporting the arm and hand forwards to reach for a cup or telephone. While
this man is using extra muscle force to hold the pen (increased finger flexion),
his response is typical of new skill acquisition, and is not a concern to the
therapist.
The first goal (Goal 1: Keep the texta pentip touching the X mark on the paper
for 5 seconds) demands a sustained contraction of his external rotators
combined with full supination. Without some external rotation, the goal cannot
be achieved (except by trunk rotation). The second goal (Goal 2: Draw a line
5 cm up the wall) demands sustained external rotation and shoulder flexion

596

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 Optimising motor performance following brain impairment CHAPTER 37

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Practice to improve fork control

This lady cannot sustain flexion of her fourth and fifth digits around a fork handle when trying to pick up food. When she
tries to use her fork, the handle rotates and she loses her grasp. Part-practice has been devised to help improve flexion of
her ring and little fingers around a fork handle. Figures 37.8A and 37.8B show her setting up the practice. She has been
asked to hold a coin between plastic tweezers for 5 seconds. This task sustains her attention. She gets feedback instantly
if her grasp weakens, because the coin drops onto the table.
Figure 37.8C shows her still holding the tweezers and coin (coin no longer visible), flexing her wrist and fingers, and
pressing the index finger down on the end of a spoon. She finds it much more challenging to keep her fourth and fifth
digits flexed in this position while her index finger is extended, as it needs to be while using a fork. Again, she receives
instant feedback if her grasp weakens because the coin drops out of the tweezers – feedback which would not be
provided by a standard fork.
Figure 37.8D illustrates how the tweezers and fork handle can be taped together, to enable fork practice to progress. This
lady can continue her practice with the coin held between plastic tweezers, and learn to transport small pieces of soft
vegetable or bread squares from plate to plate, without dropping the coin

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 SECTION FIVE Working with the individual

Goal: After 10 minutes stretch, to move your forearm over so that ‘When you next reach forwards for the cup,
the cup touches the blue ‘blob’, hold for 10 seconds x 30 slide rather than lift your hand. Watch your
repeats hand and keep it the same shape as the cup.
Notice if your fingers and thumb are closing as
Stretching you reach. If they are, see if you can keep your
position fingers and thumb ‘soft’ as you reach.

or:

‘This time, when you close your fingers around

Instructions
1. Sitting with your right arm supported on a table, elbow straight
2. Tape a cup into your hand so that your thumb web space is
stretched
3. Use your left hand to take your arm over and hold it
in a stretch
4. Take your left hand off, hold the cup on the ‘blob’
for 10 seconds
5. Come back so that the cup is upright
6. Move the cup back so that the lip touches the ‘blob’
Date No. correct
10/7 0/30
21/7 0/30
27/7 0/20
30/7 3/30
03/8 5/30
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Supination practice
Practice book showing the exercise (Forearm Supination)
and goal, in the learners own words: ‘After 10 minutes
stretch, to move your forearm over so that the cup touches
the blue ‘blob’, hold for 10 seconds’. Additional instructions
have also been added, and a section for recording practice
attempts
person to lift a light plastic cup off the table instead
of a glass, or slide rather than lift a cup along the
table will help to reduce effort. If a person is unable
to grasp while reaching, taping a cup into their hand
will reduce the task demands and help the person
to concentrate on specific features of reaching. If too
much force is used, use a disposable polystyrene cup
which deforms easily when grasped, to give the
person feedback about their force production
(Figures 37.10 and 37.11).
Different instructions may also help the person
to become more self-aware, and learn to use some
muscles more and others with less force. For
example:
the polystyrene cup, don’t press so hard. Try
not to squash or deform the cup. If you press
too hard, the water will come up above the
marked line. Just use light pressure on the sides
of the cup’.
Dexterity training
Some individuals can grasp and pick up objects, such
as a cup, knife or fork, but cannot manipulate them.
Training of advanced hand function involves more
than cutting up slices of bread or repeatedly copying
lines of writing. Careful analysis enables therapists
to determine which components of skilled perfor-
mance are missing or altered, in comparison to
normal manipulation. This stage of analysis and
training is most interesting but demands careful
observation and problem solving. Tasks requiring
advanced skill performance (and analysis) include
handwriting, use of cutlery or chopsticks, putting on
jewellery, applying contact lenses, tying shoes, doing
up buttons, using a screwdriver or mobile phone.
With small objects, training of grip force during
lift-off and manipulation will be required, with rep-
etitions and feedback. Healthy adults typically apply
a force slightly higher than the minimum required
in order to prevent object slippage (Nowak &
Hermsdorfer 2003). However, people with chronic
stroke and intact sensation (n  10) have been shown
to apply significantly greater mean grip forces (q
39%) at lift-off compared to healthy adults (Quaney
et al 2005). The participants with stroke used a
greater safety margin. Blennerhassett and colleagues
(2006) reported different findings for 45 people
with stroke and 45 healthy adults, who were able to
pick up a pen lid concealed from view, using a pinch
grip. These authors reported prolonged time and
excessive grip force prior to commencing the lift in
half the people with stroke, as well as fluctuating
forces and extreme slowness, but excessive safety
margins were not present in all cases.

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 Optimising motor performance following brain impairment CHAPTER 37

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Practice to decrease finger and wrist flexion force while transporting a cup to drink or while
carrying liquid
The person has been asked to gently press the side of the polystyrene cup, and move the cup edge between the two lines
on the wooden stick (Figure 37.10A).
When the short-term goal has been achieved, the person can progress to transporting the cup of liquid up onto a box,
stand up while holding the cup, and, finally, walk while carrying the cup.
Short-term goal: Press the cup inwards 1 cm to the second pen mark, release and repeat 3 times.
Medium-term goal: In sitting, maintain the round shape of the cup (see Figure 37.10B) and lift onto a 5 cm box.
Medium-term goal: Maintain the round shape of the cup (Figure 37.10B) while standing up and sitting down 5 times from a
45 cm chair.
Long-term goal: Carry a full cup of water 3 times, from the kitchen to the dining room table, without spilling any liquid

The combined message for therapists from these
studies is that people with stroke typically have dif-
ficulty preparing a suitable grip force and using the
normal feed-forward mechanisms. Impaired sensa-
tion is likely to compound these problems. However,
training strategies are likely to be similar for people
with and without sensory impairment. Training
needs to involve task-specific practice, with many
repetitions and feedback. If a person has difficulty
using a knife, fork or pen, they need to engage in
part-practise with these utensils. For example,
picking up an object precisely without spinning or
rotating the handle, cutting food and writing all
require appropriate force production and accurate
opposition of the forces of the thumb and fingers to
be successful. See Figure 37.12 as one example.
Preventing and managing
contractures
During the therapy planning process, therapists
need to not only consider the contractures that are
present, but also anticipate contractures that may
develop in the future. Loss of shoulder external
rotation range of movement is common after stroke.
In one study (n  25), people with stroke experi-
enced an average of 30% loss of external rotation
(Andrews & Bohannon 1989), with some experienc-
ing a loss of up to 60% of their range. This loss of
range correlates with shoulder pain (Bohannon
1988) and impacts on occupational performance,
particularly self-care tasks. Therefore, it is impor-
tant for therapists to anticipate and prevent
contractures.
Muscle stretching has become the main interven-
tion for managing muscle-length changes and con-
tracture. Animal studies suggest that muscle
stretches need to be sustained for more than a few
minutes to reverse length-related changes from
immobilisation (Goldspink & Williams 1990,
Williams 1990). However, it is not possible or eco-
nomical for stretches to be provided manually by
therapists for extended periods. Instead, stretches
need to be integrated into routine positioning pro-
grammes. For example, shoulder extensors and

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thumb flexion force while holding a plastic bottle
which deforms easily
The person has been asked to gently press the sides of the
plastic bottle, and control the water levels between the two
black lines on the tube. Too much pressure causes a jet of
water to shoot out the top, which gives immediate
feedback to the learner about the amount of force being
generated. The practice demands attention for successful
performance.
To construct the training device, first drill a hole in the top
of a plastic bottle cap. The hole should be just large B
enough to accommodate the suction tubing. Insert tubing
down through the hole, fill the bottle with water and seal
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Practice of pen rotation
with tape to prevent air escaping. This practice aims to improve pen control and handwriting.
Short-term goal: In sitting, push water up and down The short-term goal is to rotate the pen/pencil 10 times in
between the two black lines 5 times, without water 30 seconds by the end of one week. The medium-term
escaping from the tube. goal is to rotate the pen/pencil 10 times in 20 seconds by
Medium-term goal: In sitting, keep the water level with the the end of 2 weeks.
upper black line and lift the bottle up onto a 5 cm box, 5 Instructions remind the person to:
times, without water escaping from the tube }
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serial casts to immobilise joints in their stretched this skill
position. Serial casts should only be considered for
more severe contractures of the elbow, wrist or
fingers because they impede motor training and may
reinforce learned non-use. Studies investigating the
effect of hand splinting to prevent contracture after
stroke and brain injury have shown no difference in

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 Optimising motor performance following brain impairment
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Shoulder stretch to increase external
rotation for reaching
This is a gravity-assisted stretch aimed at lengthening the
right internal rotator muscles and increasing the range of
available external rotation. Limited external rotation is very
common after stroke and reduces reaching performance
during daily occupations such as eating and drinking.
This stretch can be done independently for up to 30
minutes daily, lying on the bed or floor. Some people find
this stretch more comfortable if a pillow or rolled-up towel is
placed under the humerus, as they can relax into the
stretch more easily.
In this figure, this man’s goal was to relax both shoulders
during the stretch so that his right elbow was 20 cm above
the floor (comparable with his unaffected left shoulder). At
the beginning of his outpatient therapy sessions, his right
elbow was 38 cm above the floor due to shortening of his
internal rotators.
wrist extensibility compared to controls (no splint),
even when splints were worn for many hours over
4 weeks (Lannin et al 2003, 2007) and 3 months
(Harvey et al 2006). A recent Cochrane review also
concluded that hand splinting had no effect on func-
tion, finger or wirst flexibility or pain, although this
conclusion was based on a small number of trials
(Tyson & Kent 2009).
Although anecdotal evidence suggests that con-
tractures are a common secondary complication
after brain impairment, evidence that long-duration
stretch lengthens shortened muscles or maintains
their length is limited (Harvey et al 2002). Two
trials involving adults with stroke (Ada et al 2005a,
de Jong et al 2006) reported that shoulder and arm
positioning to promote stretch slowed down, but
did not prevent, contracture development. Other
studies involving stroke populations were either
underpowered (e.g. Dean et al 2000, Turton &
9khj_dU9^&)-UcW_d$_dZZ


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CHAPTER 37
Britton 2005) or found no difference following
stretch/positioning.
There is, therefore, still uncertainty about
whether stretch interventions are effective in the
long term and, if they are, how long stretches should
be held for and how often they should be adminis-
tered. Animal research suggests that if stretches are
being used, they should be sustained for as long as
practically feasible (Harvey 2008). It may be that
stretches in humans need to be administered for
many hours a day, rather than minutes, and contin-
ued indefinitely in people with minimal motor
recovery.
Shoulder strapping appears to reduce shoulder
pain but not function. A Cochrane systematic review
(Ada et al 2005b) found that shoulder strapping
with adhesive tape delayed the onset of shoulder
pain but did not reduce pain, improve function or
contracture development. A more recent ran-
domised controlled trial post stroke (n  33) con-
firmed the effect of strapping (Griffin & Bernhardt
2006). These authors reported a mean of 26 pain-
free days for the intervention group compared to 19
pain-free days in a placebo controlled group, and 16
in the control group.
Shoulder slings and supports have not been well
researched despite their frequent use in practise
(Ada et al 2005b,c). Current expert opinion is that
external supports such as wheelchair and chair
attachments are needed to support the weight of the
arm (Foongchomcheay et al 2005). Triangular ban-
dages and collar and cuff slings may help to protect
the arm during transfers but do not physically reduce
a joint subluxation. Electrical stimulation shows
more promise as an intervention than slings and sup-
ports; however, ultimately individuals need active
motor training, in supine and side lying to help them
learn to switch on paralysed muscles around the
shoulder and upper arm.
Improving reaching and postural
control in sitting
Limited research has been conducted on sitting
balance training. A Cochrane review (Pollock et al
2003) highlighted the need for task-specific training
strategies instead of generalised ‘approaches’ which
have been used in the past. Task-specific training
strategies have been shown to be effective in ran-
domised trials involving people with stroke (Dean &
Shepherd 1997, Dean et al 2007). These studies,
601
/%'+%(&&/


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 SECTION FIVE Working with the individual

which have already been discussed, involved reach-
ing in sitting to the affected side at distances greater
than arm’s length. The ‘sham’ training or control
group received an equivalent amount of reaching
practise but within arm’s reach. After 2 weeks’
training participants in the intervention group all
improved in the distance and speed with which they
could reach in comparison to the control group. In
addition, the increased weight-bearing practise
improved the participants’ ability to stand up.
General principles for training reaching in sitting
include the following: minimise the effort required
to sit; check that both feet are on the ground;
provide good thigh support to maximise the base of
support; limit the distance reached initially; intro-
duce forward reaching, and reaching to the unaf-
fected side before reaching across to the affected
side which requires maximum leg extensor muscle
control; if unable to activate the leg extensor muscles
on the affected side, the person will be unable to
control movement onto the affected side; help
people learn to activate their leg extensor muscles,
and anticipate the need to turn those muscles on
prior to beginning to moving towards that side; as
the person improves their ability to turn their leg
extensor muscles on, task difficulty can be increased.
This can be done by reaching across to the affected
side, increasing the distance reached, decreasing the
amount of thigh support and increasing the chair
height (which increases the force required from the
leg extensors). Table 37.2 presents a detailed analy-
sis and training suggestions.
Future directions
These are exciting times. New technologies and
more rigorous methodologies provide increasing
support for theories of movement rehabilitation. We
know that the earlier rehabilitation begins, the
better the recovery from conditions such as stroke
and brain injury. Greater intensity of treatment
translates into better outcomes. Gains in motor
control and recovery continue for many years. Ther-
apists are moving away from one-on-one, hands-on
therapy and making better use of circuit and group
training programmes. And as rehabilitation research
continues to grow, so too will the evidence on which
therapists base their practice.
The need for increased intensity of practice has
led to the testing of two more novel rehabilitation
techniques, CIMT and robotics. Reinkensmeyer
and colleagues (2004) report that robotic therapy
allows for some of the labour-intensive training
tasks performed currently by therapists to be per-
formed by automated devices, thereby providing
people with greater access to therapy. As the evi-
dence grows in support of more intensive therapy,
constraint and robotics will be used more often
because they can increase practise and may lead

Table 37.2 Summary of motor control problems affecting the upper limb and seated reaching, and possible interventions for people
with neurological conditions

Motor control problem
Eliciting movement in paralysed
muscles
Increasing force generation or
strength in weak muscles
Decreasing force in overactive
bRW
Tc
P[
(($
muscles
Increasing dexterity, speed and
control
Preventing or reversing muscle
contractures
Possible interventions and evidence from key studies
} Repetitive contractions and practice of shoulder protraction in sitting (Feys et al 1998,
2004)
} Electrical stimulation of the wrist extensor and forearm (Powell et al 1999), and
shoulder muscles (Ada & Foongchomcheay 2002)
} Mental practice (Braun et al 2006, Dijkerman et al 2004)
} Mirror box therapy (Altschuler et al 1999, Yavuzer et al 2008)
}
4[TRcaXRP[
bcX\d[PcX^]
^U
cWT
faXbc
TgcT]b^a
P]S
U^aTPa\
?^fT[[
Tc
P[
(((
P]S

shoulder muscles (Ada & Foongchomcheay 2002, Pomeroy et al 2006)
}
AT_TcXcXeT
R^]caPRcX^]b
P]S
_aPRcXRT
faXbc
P]S
U^aTPa\
\dbR[Tb
1dcT
}
2^]bcaPX]cX]SdRTS
\^eT\T]c
cWTaP_h
4[XPbb^]
Tc
P[
!$
7PZZT]]Tb
Tc
P[
!$
} Task-related training in groups (Blennerhassett et al 2004)
}
BcaTcRWX]V
X]cTa]P[
a^cPc^ab
X]
bd_X]T
U^a
"
\X]dcTb
SPX[h
\Ph
WT[_
c^
STRaTPbT
[^bb

^U
TgcTa]P[
a^cPcX^]
aP]VT
^U
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0SP
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602

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 Optimising motor performance following brain impairment CHAPTER 37

to greater motor recovery. Mirror box therapy is
another intervention which is supported by two
randomised trials (Altschuler et al, 1999; Yavuzer
et al, 2008). Like CIMT, this intervention allows
independent practice by people with stroke. With
technologies improving all the time, it is not possible
to predict what advances will become routine prac-
tice in the future. The important message is, there-
fore, to remain abreast of current scientific evidence.
Conclusion
This chapter has focused on the process of analys-
ing and retraining motor performance in children
and adults with brain impairment. The content is
necessarily impairment-focused because much of
upper-limb rehabilitation, particularly in hospital
settings, focuses on eliciting muscle activity and
strength training prior to return of functional
grasp. At this stage, therapists need to remind
themselves and the people they work with of the
occupational goals of training, for example, eating
a meal with family members using cutlery in both
hands. Once a person has an effective grasp, can
hold and manipulate objects, tasks and goals are
more obvious. While the overall goal of occupa-
tional therapy is to increase engagement in occu-
pations, we cannot and should not ignore
impairment-focused intervention.

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RESEARCH ARTICLE Open Access

Barriers and enablers to implementing multiple

stroke guideline recommendations: a qualitative
study
Annie McCluskey1*†, Angela Vratsistas-Curto1,2† and Karl Schurr2†

Abstract
Background: Translating evidence into practice is an important final step in the process of evidence-based
practice. Medical record audits can be used to examine how well practice compares with published evidence, and
identify evidence-practice gaps. After providing audit feedback to professionals, local barriers to practice change
can be identified and targetted with focussed behaviour change interventions. This study aimed to identify barriers
and enablers to implementing multiple stroke guideline recommendations at one Australian stroke unit.
Methods: A qualitative methodology was used. A sample of 28 allied health, nursing and medical professionals
participated in a group or individual interview. These interviews occurred after staff had received audit feedback
and identified areas for practice change. Questions focused on barriers and enablers to implementing guideline
recommendations about management of: upper limb sensory impairments, mobility including sitting balance;
vision; anxiety and depression; neglect; swallowing; communication; education for stroke survivors and carers;
advice about return to work and driving. Qualitative data were analysed for themes using theoretical domains
described by Michie and colleagues (2005).
Results: Six group and two individual interviews were conducted, involving six disciplines. Barriers were different
across disciplines. The six key barriers identified were: (1) Beliefs about capabilities of individual professionals and
their discipline, and about patient capabilities (2) Beliefs about the consequences, positive and negative, of
implementing the recommendations (3) Memory of, and attention to, best practices (4) Knowledge and skills
required to implement best practice; (5) Intention and motivation to implement best practice, and (6) Resources.
Some barriers were also enablers to change. For example, occupational therapists required new knowledge and
skills (a barrier), to better manage sensation and neglect impairments while physiotherapists generally knew how to
implement best-practice mobility rehabilitation (an enabler).
Conclusions: Findings add to current knowledge about barriers to change and implementation of multiple
guideline recommendations. Major challenges included sexuality education and depression screening. Limited
knowledge and skills was a common barrier. Knowledge about specific interventions was needed before
implementation could commence, and to maintain treatment fidelity. The provision of detailed online intervention
protocols and manuals may help clinicians to overcome the knowledge barrier.
Keywords: Translational research, Implementation, Quality improvement

* Correspondence: annie.mccluskey@sydney.edu.au
†
Equal contributors
1
Discipline of Occupational Therapy, Faculty of Health Sciences, The
University of Sydney, New South Wales, Australia
Full list of author information is available at the end of the article

© 2013 McCluskey et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
McCluskey et al. BMC Health Services Research 2013, 13:323
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Background
Translating evidence into practice
Translating evidence into practice, also known as imple-
mentation, is an active process involving individuals,
teams and organisations [1]. Knowledge translation is an
essential phase of evidence-based practice which is chal-
lenging, as this phase often involves changes in know-
ledge, attitude and behaviour. It cannot be assumed that
an intervention which has demonstrated a positive effect,
been described in a journal and recommended in a clinical
guideline will be translated into practice [2]. Nor can it be
assumed that the majority of people with a health condi-
tion will routinely receive that intervention [1].
Barrier identification is an important step in the process
of knowledge translation [3]. As with quality improve-
ment, clinical audits of practice may be conducted and
audit feedback presented to staff [1], with opportunities
provided for discussion of practice gaps. Evidence-practice
gaps may arise because of systemic, team or individual
barriers to change. Barriers may include lack of knowledge
and skills, negative or out-dated attitudes, or inefficient
systems [4]. Some of these barriers may also be enablers.
For example, a senior clinician may reject a recommended
practice or conversely act as an opinion leader [5]. While
it is possible to anticipate some barriers, assumptions
should not be made about which barriers affect a team or
health service [6]. In addition, assumptions should not be
made that barriers will be the same across disciplines.
Translating stroke guideline recommendations
into practice
Australian clinical guidelines for stroke management [7]
aim to assist clinical decision-making and promote
evidence-based care. Yet guidelines contain multiple rec-
ommendations which compete for a clinicians’ attention.
For example, recommendation 6.3.4 (page 18) states that
patients with difficulty walking should be given the
opportunity to undertake as much repetitive practice as
possible, which may involve using a mechanically-
assisted device such as a treadmill. To implement this
recommendation, physiotherapists may need to purchase
a treadmill, learn how to operate the device confidently
and persuade patients to trial the equipment. Assuming
that clinicians agree with, and accept these recommen-
dations, major changes in practice are often required.
Implementation of guideline recommendations may
start by conducting a baseline medical record audit, to
monitor practice. Clinical audits are commonly used for
quality improvement, and the process is familiar to
many clinicians. Feedback can then be provided to clini-
cians about audit findings. Audit feedback has been
shown to influence practice [8]. A national audit of
stroke services is conducted every two years in Australia.
Subsequent audit reports provide valuable feedback
Page 2 of 13
about practice and allow benchmarking and comparison
of like-services [9-12].
Audits of medical records are often conducted by indi-
vidual stroke services between national sentinel audits.
Staff on our stroke unit conducted three medical record
audits between 2009 and 2011 to determine how much
screening, assessment and intervention were being pro-
vided. An audit checklist was developed which included
recommendations from the most recent stroke guide-
lines. A retrospective consecutive sample of 15 files of
patients admitted to the stroke unit was audited in No-
vember 2009. The audits were conducted by the authors
and additional staff on the unit. The audit revealed a
number of practice areas where compliance with guide-
line recommendations was low (less than 60% compli-
ance). Practice areas which became the focus for change
included: upper limb sensory impairments, mobility in-
cluding sitting balance and treadmill training; vision;
anxiety and depression; neglect; swallowing; communi-
cation; education of stroke survivors and carers; return
to work; and return to driving. After completing the first
audit and providing feedback to stroke unit staff, the
next step was to discuss potential barriers and enablers
to implementation [6,13]. The process of using audit
and feedback to drive behaviour change, and the out-
comes will be described in a companion publication.
Common barriers to implementation of stroke guideline
recommendations
Barriers have been identified and reported for several
areas of stroke care. These barriers include lack of re-
sources, knowledge and skills, lack of motivation to
change, professional’s beliefs about their capabilities, un-
helpful attitudes about a guideline recommendation and
role identity issues [14-20].
Professional’s beliefs about their capabilities have been
reported as one key barrier to implementing recommen-
dations [14,16,20]. For example, Canadian physical thera-
pists lacked confidence in their ability to appraise and
apply stroke research [16] recommended in guidelines.
Occupational therapists in two Australian stroke services
lacked confidence to take patients into the community for
escorted outings and travel training [14], as recommended
in national guidelines.
Attitudes to, and beliefs about, providing an interven-
tion were a barrier in other studies, as well as beliefs about
the original research. For example, Australian medical,
nursing and allied health professionals reported concerns
about patient safety and the impact on their workload
when asked to implement protocols for fever, hypergly-
caemia and swallowing management [15]. In that same
study, there was a reluctance to accept evidence-based
protocols for early management of swallowing problems
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using nasogastric feeding; that reluctance reduced compli-
ance with the protocols [19].
Limited knowledge and skills represent a third bar-
rier to implementing guideline recommendations in
stroke rehabilitation [14-18,20]. In one Australian
study, occupational therapists and physiotherapists
reported a lack of knowledge about the evidence for
providing escorted outings to people with stroke, to
promote community participation [14]. Some stroke
professionals in Canada reported difficulty appraising
research and implementing some guideline recommen-
dations [20], while others felt they possessed the ne-
cessary skills (and tools) to screen for depression [21].
Thus there can be differences across sites and disci-
plines. British occupational therapists wanted training
to improve their confidence when conducting depres-
sion screening, particularly when screening patients
with suicidal ideation [22].
Reduced motivation to change and implement a
recommended practice is another known barrier [15,18].
For example Canadian occupational therapists reported
low motivation to implement recommended neglect
management [18]. In Australia, health professionals were
resistant to implementing guideline recommendations
for managing fever, hyperglycaemia and swallowing in
acute stroke [15].
Limited resources is one of the most commonly
reported barriers to implementing stroke guideline rec-
ommendations including lack of equipment, time and
staff [14,15,17-20]. For example, equipment and time are
necessary for implementation of neglect training [18].
The importance of allocating dedicated work time can-
not be overstated; clinicians need to read and interpret
original research [20] to understand what they must ‘do’
when implementing a recommendation.
Finally, difficulty accepting that a treatment is part of
a discipline’s role is a sixth barrier to implementation of
guideline recommendations. For example some profes-
sionals may not identify that a particular intervention is
part of their role. Stroke professionals in Australia were
concerned about blurring of professional boundaries
related to management of fever, hyperglycaemia and
swallowing after stroke [15]. Some occupational thera-
pists and physiotherapists in Australia did not identify
outdoor journey training as part of their role, reducing
their compliance with guideline recommendations and the
evidence [14]. On the contrary, Canadian allied health
professionals generally perceived depression screening to
be part of their role when a small sample of 19 staff were
surveyed [21]. Similarly, in England, occupational thera-
pists were keen to assume a role screening patients for de-
pression in the absence of an on-site clinical psychologist,
since therapists already screened stroke patients for cogni-
tive impairments [22].
Page 3 of 13
In summary, the process of identifying then targetting
barriers is known to be important for successful know-
ledge translation. Failure to anticipate problems and bar-
riers may results in little or no practice change. Barriers
(and some enablers) have been reported to implementing
stroke guideline recommendations in acute care and some
areas of inpatient rehabilitation. While it is important to
build on this existing knowledge, attitudes, skills and re-
sources are likely to be different across settings, disciplines
and countries. Limited research has been published about
barriers facing Australian inpatient rehabilitation staff.
Furthermore, much of the published data were generated
from surveys, rather than in-depth interviews which can
provide rich data and examples.
To help local professionals implement multiple stroke
guideline recommendations, we engaged in a process to
identify local barriers and enablers, informed by this
prior research. We needed to determine what health
professionals knew about the published research in the
guidelines (knowledge), if they felt the research was
strong enough to justify practice change (attitudes and
intentions) and how able they felt to implement the spe-
cific recommendations and interventions with patients
(skills and capabilities). The methods which we describe
for obtaining the in-depth data, and the findings, should
be informative for other stroke services.
Aims of the study
The aim of this study was to identify local barriers and
enablers to implementation of multiple guideline recom-
mendations at one Sydney metropolitan stroke unit.
These barriers were then targeted through regular
coaching, audit and feedback to facilitate practice change
as part of a broader long-term project.
Methods
Design
A qualitative study design was used to explore experi-
ences, attitudes, knowledge and behaviour, and possible
reasons for any evidence-practice gaps. The primary
method of data collection was semi-structured focus
group interviewing, with the option of an individual
interview [23]. The aim of the group interviews was to
stimulate interaction, encourage participants to re-
spond and react to each other, and compare experi-
ences [24]. Participants were allied health, nursing and
medical professionals, employed at one stroke unit in
Sydney, Australia. Ethical approval to conduct the study
was obtained from a local area health service (Ref No.
2009/012).
The sample
Three allied health disciplines were initially invited to
participate (occupational therapy, physiotherapy and
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speech pathology). Ethics approval was extended to in-
clude additional disciplines involved in stroke patient
care (nursing, orthoptics and medicine). Medical sub-
specialties included geriatricians, rehabilitation special-
ists and neurologists, as well as registrars in training.
These team members all worked closely together on the
stroke unit, meeting weekly for case conferences, and
each weekday morning for nursing handover. A total of
28 health professionals from the one site were recruited
and interviewed. Written informed consent was obtained
from each participant before they were attended their
focus group.
Interview procedures
Most participants (n = 26) were interviewed in discipline-
specific groups, containing up to six people. Two
orthoptists were interviewed individually, as neither
worked onsite simultaneously. Interviews took up to one
hour, and were conducted onsite at the hospital, between
July and October 2010.
Interviews were moderated by the first and/or second
author (AM/AV). The second person managed the
audio-recordings, and kept detailed notes about the
order of speakers and quotes [25]. The interviews with
medical staff were not audio-recorded due to equipment
difficulties during the group, and/or participant prefer-
ence. Instead, in-depth handwritten notes were taken
concurrently by the second researcher, and used for
analysis.
The researchers
AM is an occupational therapist and health researcher
with 30 years of clinical experience mostly in stroke re-
habilitation. AM was not employed by the area health
service, and did not work on a day-to-day basis with
any of the participants. AV has an occupational therapy
and research background, with 11 years of clinical ex-
perience in acute care and rehabilitation. AV was
employed by the local health district and had contact
with some of the participants as a research project man-
ager. Most of the participants knew the interviewers per-
sonally or by reputation, because of their clinical and/or
research backgrounds. As the researchers’ roles and posi-
tions could influence what participants said, they were ad-
vised that judgments would not be made about what the
participants said or knew.
Focus of the groups and interviews
Questions focused on delivery of evidence-based treat-
ments previously nominated by each discipline for prac-
tice improvement. Nominated treatment areas included
management of upper limb sensation, neglect, sitting
balance, treadmill training, swallowing, communication
and education of patients and carers (see Table 1). The
focus of each group interview was therefore slightly

Table 1 Nominated areas for practice improvement based on national stroke guideline recommendations
Discipline Nominated area
Physiotherapy Improve the routine delivery and documentation of:
• Sitting balance training to eligible patients
• Treadmill training with harness support to eligible patients
Occupational therapy Improve screening, assessment and intervention of/for:
• Upper limb sensory deficits to eligible patients
• Neglect to eligible patients
Speech pathology Improve documentation of assessment, and intervention provided to eligible patients with:
• Communication disorders including aphasia
• Swallowing impairments
Improve delivery and documentation of education provided to eligible patients and carers about:
• Aphasia
• Alternate methods of communication
Periodic review of the severity of communication impairment.
Nursing Improve delivery of education to eligible patients and family/carers
Orthoptics Improve documentation and assessment of vision
Medicine Improve documentation and management of:
• Anxiety and depression for eligible patients
• Return to work advice for eligible patients
• Return to driving advice for eligible patients
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different. Questions posed during the medical staff
group interviews focused primarily on the management
of anxiety and depression, return to work, sexual func-
tioning and driving. With orthoptists, questions focussed
primarily on the management of vision impairments and
neglect.
Interview questions were developed by the first author.
Questions were designed to elicit responses about fac-
tors that might help or hinder the uptake of each
intervention.
them” was placed in two categories: ‘beliefs about cap-
abilities’ and ‘beliefs about consequences’. Statements
were then allocated to the one category that best
reflected the content topic. All quotes could be mapped
to the framework.
Tables were generated that contained distilled summar-
ies of participant experiences about barriers and enablers.
This process was influenced by our original aim (to iden-
tify barriers and enablers which could be strategically
targeted, with which behaviour change interventions).

Interview schedule
Results
After first describing their discipline, years since gradu-
Six group, and two individual interviews, were conducted
ation, and experience working with people following
with a total of 28 participants (see Table 2). Participants
stroke, knowledge of the evidence was explored. The
represented six disciplines, the majority of whom were
interviewer described the guideline recommendations,
medical professionals, occupational therapists or physio-
then enquired about group knowledge of these recom-
therapists (n = 22; 79%). Participants were mostly female
mendations. Next, evidence-practice gaps or areas with
(88%). Demographic data are presented in Table 3.
lower compliance were discussed, based on guideline
recommendations and audit findings. Reasons for these
gaps were explored. Participants were encouraged to re- Barriers and enablers
flect, share, compare and react to group interactions Factors that participants identified as barriers and en-
[24]. Barriers and enablers to change were discussed. ablers to practice change are presented in the following
Possible solutions or ways forward were identified. pages. There were six primary domains or categories of
Prompt questions were used to enquire about knowledge barrier; some were also enablers. For example, while one
and skills, staffing, physical resources, assessment, screen- individual might believe they were unable to deliver a
ing and report writing systems and treatment routines. therapy due to lack of time or skills, another person
Group members explored their beliefs, attitudes and might feel confident and able.
routines. The theoretical domains described by Michie The first three categories of barrier were: (i) Beliefs
and colleagues [4] were used to guide questions and about capabilities; (ii) Beliefs about consequences; and (ii)
data collection as reported in an earlier study by the Memory and attention. These domains were discussed
first author [14]. often by participants as potential or actual barriers to
implementing stroke rehabilitation. These domains will be
Data analysis discussed first followed by three less dominant but im-
Four of the six group interviews, and two individual in- portant domains: (i) Knowledge and skills; (ii) Motivation,
terviews were transcribed. In-depth handwritten notes intention and goals; and (iii) Resources.
from the two medical group interviews were typed up In addition to knowledge and skills, motivation,
for use during analysis. Data analysis began after the first intention and goals, the domain ‘Resources’ was identified
group meeting, and continued over seven months [26].
Participant statements were coded using the 12 concep-
tual domains described by Michie and colleagues as the
guiding conceptual framework or theory [4]. This theory Table 2 Focus group and individual interviews conducted
is intended for use by researchers who are exploring by discipline
behaviour change, particularly barriers to evidence im- Discipline n (%) Focus group Individual
plementation. The theory, now referred to as the Theor- interviews interviews
etical Domains Framework, has recently been refined Medicine 12 (43) 2 0
and includes 14 domains [27]. However the revised Occupational 5 (18) 1 0
framework was not available at the commencement of Therapy
this study. Physiotherapy 5 (18) 1 0
Statements obtained during interviews were initially Speech Pathology 2 (7) 1 0
allocated to one or more category of the framework. For Nursing 2 (7) 1 0
example, the statement “There was a patient of mine Orthoptics 2 (7) 0 2
(that) I would have never put them anywhere near it (the
TOTAL 28 6 2
treadmill). I would have argued that it wasn’t good for
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Table 3 Demographic characteristics of health “…it’s physically quite demanding (treadmill training)
professionals (n = 28) …half an hour of assisting someone’s leg …I personally
Demographic variable n % find [that] harder than overground walking” (PT4)
Discipline (n = 28)
Doctor 12 (43) Some physiotherapists preferred to involve patients in
overground walking rather than treadmill training be-
Occupational Therapist 5 (18)
cause of the high physical demands on therapists.
Physiotherapist 4 (14)
Speech Pathologist 2 (7) “Other sites prefer treadmill training…they say it’s
Registered Nurse 2 (7) easier… less manual handling…we prefer overground
Orthoptist 2 (7) [walking training]” (PT4)
Therapy Assistant 1 (4)
“You couldn’t sustain it [treadmill training]…
Gender (n = 16) *
[because] you’d get a sore back” (PT2)
Female 14 (88)
Male 2 (12) The physical ability of patients was another reported
Clinical experience (yrs) (n = 16)* barrier. One physiotherapist reported that some patients
0–5 9 (56) were not capable of participating in treadmill training.
6-10 1 (6) They did not offer the intervention to such individuals.
Yet sometimes patients surprised them and could use
11–15 2 (13)
the treadmill.
>15 4 (25)
Experience working in stroke (yrs) (n = 16) * “There was a patient [that] I would never have put
0-5 9 (56) anywhere near it [the treadmill]. I would have argued
6-10 4 (25) that it wasn’t good for them. And it actually finished
11-15 0 (0) up good” (PT4)
>15 3 (19)
“It made me go ‘oh my goodness! This person can
Note. * Data missing for medical professionals.
continuously practice for half an hour’. And I had to
stop them… I would have never have thought they
could…” (PT4)
often by participants as an enabler to implementing
evidence-based practice. Occupational therapists did not use sensation assess-
ments with some patients because of their beliefs
Beliefs about capabilities about patient ability. Poor communication and cogni-
This domain refers to attitudes or beliefs about clini- tive impairments made the assessment difficult. Fur-
cian’s individual ability, and the ability of their discipline thermore, these assessments were not available in
to provide an intervention, assessment or test. This do- many languages.
main also includes beliefs about their ability to encour-
age patients to participate, and the ability of patients to “…sensory assessment can be quite abstract… if we have
participate in an intervention. patients with quite severe communication problems, it
Physiotherapists described difficulties using treadmill can be very difficult to assess [them]” (OT2)
training to improve the ambulation of stroke patients.
First, they discussed the physical demands of this inter- Nursing professionals also reported concerns about
vention. Second, they were concerned about having to their ability to provide patient and carer education due
stay with patients throughout their treadmill session. to medical complications, cognitive and emotional im-
Due to safety concerns, they could not concurrently pairments. These factors affected the patient and carers’
spend time with other patients in the gym while an indi- ability to receive and understand information.
vidual patient was on the treadmill.
"Q: ‘What things might make it [patient education]
“We …[usually] move between patients…being stuck happen or not make it happen?’ A: How (medically)
continuously with somebody for half an hour of stable they [the patients] are to receive the
treadmill …it’s a bit difficult…you can’t go and change information… Are they able to cope or cognitively get
what other people in the gym are doing” (PT1) [receive/understand] the information” (RN1)
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Nurses used different strategies and ways of explaining
to help patients better understand information.
“Patients… learn differently. You have to apply
different things… explain things a certain way” (RN2)
Speech pathologists, like occupational therapists and
nurses, believed that patient factors including language
and education capabilities sometimes limited their practice
options. Many stroke patients came from a non-English
background, and had a low level of education. These pa-
tients had difficulty participating in a standardised aphasia
screening assessment. Many aphasia tests were not devel-
oped nor validated for use with patients from non-English
speaking or diverse cultural backgrounds. Communication
assessments became much more difficult.
“One of the problems … [with aphasia assessments] is
that visual problems can alter the outcomes… as well
as low education level …. in this demographic, some
[patients] have a lower level compared with other area
health services” (SP2)
“Some of those higher level language tasks in those
[aphasia] tests tend to be quite culturally specific…
[When] you’re asking somebody to finish a standard
sentence in Australian English or American English…
it doesn’t work for somebody of an Arabic background
because they don’t know the context of the question…”
(SP1)
In summary, individual clinician beliefs about their
ability to conduct a test or deliver an intervention and
beliefs about patient abilities were sometimes a barrier
to delivering evidence-based practice.
Beliefs about consequences
This category refers to clinician’s beliefs about the con-
sequences of providing, or not providing an assessment
or intervention. Beliefs that a treatment might produce
adverse outcomes reduced the use of some therapies
such as treadmill training. In other instances, the belief
that therapists could make a difference and improve pa-
tient outcomes was enabling.
One physiotherapist believed that some patients did not
exercise their affected leg adequately on the treadmill. This
therapist preferred to use overground walking with patients
in the gym, to avoid this potentially negative consequence.
“They can often get away without using their affected
leg all that much [on the treadmill]” (PT1)
The same physiotherapist weighed up the conse-
quences of delivering an evidence-based therapy such as
Page 7 of 13
treadmill training with very weak patients, when other
types of training might produce better outcomes.
“ If they’re that dependent, then we actually think it’s
more worthwhile for them to be pushing on a tilt table,
or doing sit-to-stand against a wall where they’re
being really forced to use their intact leg rather than
being put in a harness” (PT1)
Speech pathologists were concerned about the conse-
quences of wrongly interpreting results from standardised
aphasia assessments, when used with non-English speak-
ing or visually impaired people. These professionals
wanted to use the ‘best’ test possible. However, these as-
sessments had not been validated for use with non-
English people. Therapists were concerned that language
and vision problems would alter test scores.
“We’ve got a high non-English speaking population
here, which means a lot of validated [aphasia] tests
may not be that valid anyway [when] used [with] an
interpreter” (SP1)
A nursing professional reported that some patients
did not understand verbal information about their dis-
ease, medications or rehabilitation when delivered by
some treating doctors. Such misunderstandings could
have long term negative consequences for the patient’s
health.
A medical doctor believed that screening patients for
anxiety and depression was unnecessary. Yet this process
was recommended as best practice in the Australian na-
tional stroke guidelines. That doctor did not foresee any
negative consequences of ignoring the guidelines. They
also believed that a positive result on an anxiety or de-
pression screening tool did not always warrant treat-
ment. More often it seemed that the doctors based their
provisional diagnosis on clinical judgement and advice
from the rehabilitation team. If a patient was suspected
of having anxiety or depression only then would they be
referred for a psychological review.
Another doctor worried about embarrassing patients if
he asked about sexual activities, particularly patients from
culturally diverse backgrounds. He avoided discussing the
topic contrary to guideline recommendations. Another
doctor avoided the topic for other reasons. He believed
that sexual activities were less important to stroke patients
because of their age.
“I tend to talk about sex with MS patients [people with
multiple sclerosis] because they’re younger…and have
spinal cord involvement…..often they will initiate
discussion about sex….but stroke patients ….they tend to
be older and ….might be embarrassed if we asked about
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that [sexual functioning]…particularly patients from
other cultural groups here at this hospital” (MD2)
“I don’t routinely discuss sex with my patients unless
they raise it….in the past, very few [patients] have
asked about it” (MD1)
In summary, beliefs about the negative (or positive) con-
sequences of using evidence-based practice affected the be-
haviour of most professionals. Areas of practice which
were influenced include walking retraining, aphasia screen-
ing, delivery of stroke education and information including
advice about resuming sexual activities and screening for
anxiety and depression. These beliefs could be a barrier to
evidence-based stroke rehabilitation.
Memory and attention
This category refers to systems and prompts that
reminded clinicians to deliver an intervention, or con-
versely, prompts that were absent and resulted in failure
to act. Factors that made clinicians decide to act or not
included competing tasks and priorities, time constraints
and documentation systems.
Physiotherapists did not have an effective system in
place that prompted the routine delivery of sitting bal-
ance and treadmill training to suitable patients. One
physiotherapist said: “It’s not part of my usual thinking”.
Another physiotherapist talked about forgetting to
provide sitting balance training to patients who could
stand and walk. They knew that evidence existed
supporting the use of sitting balance training to improve
the performance of standing up, but forgot this fact
when busy.
“… we go straight into sit to stand… and standing and
walking, and we don’t then go back to doing it [sitting
balance]” (PT1)
Several physiotherapists knew they were forgetting to
record patient practice in the medical records.
“I think that’s [sitting balance] definitely one that we’re
not documenting enough. That came out recently
[from a file audit], that a number of people that
should be getting it, were not” (PT3)
“A lot of practice sheets hadn’t been put into the
[patient] notes…There was a pile on desks that I
collected and put into medical records” (PT2)
Speech pathologists routinely assessed communication,
but often forgot to provide or document interventions
which were recommended in the stroke guidelines.
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“We don’t necessarily [document] review of severity [of
communication impairment]… it often gets missed”
(SP2)
Nursing professionals provided education to patients
and carers during a weekly education group. However,
they often forgot to report this intervention in the med-
ical records. One nurse knew that they had educational
DVDs about stroke, but would often forget to offer them
to patients and carers.
“They [educational DVDs] were available at some
stage but I think if they’re locked up, we’re going to
forget to offer them” (RN)
Orthoptists discussed the management of visual im-
pairments and provision of education to patients. They
routinely provided education but again, this intervention
was not always documented in the medical records.
“I’ll admit this…I do not write down in the file when I
have given education to the patient” (Orth2)
“It wasn’t that it wasn’t being done [education] it was
that we weren’t documenting that information in the
file” (Orth1)
In summary, most disciplines reported forgetting to
provide and/or record some interventions or assess-
ments. They felt that better recording systems would
prompt them to practice differently. Thus, an improved
recording system was one possible solution to target the
memory and attention barrier.
Knowledge and skills
Limited knowledge and skills was a barrier for some
disciplines, but an enabler to others, to providing
evidence-based assessment and intervention. Disci-
plines such as physiotherapy and speech pathology
seemed to know the research well, and how to deliver
named interventions. That knowledge became an en-
abler to change.
Physiotherapy staff knew the research about sitting
balance and treadmill training. They were aware of
guideline recommendations that supported the use of
treadmill training for patients with severe mobility
impairment. Clinical protocols were already available
within the department and many physiotherapists had
the skills to provide the interventions to appropriate
stroke patients.
“[Researcher X] did a study where people were
allocated to either treadmill or overground walking…
for half an hour a day… the people in the treadmill
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group, 17% or 18% more achieved independent
walking” (PT1)
“Q: With seated reaching…do you know how to do that
already?” A:“We’re very familiar with [researcher X’s]
sitting balance research” (PT):
On the contrary, when occupational therapists talked
about management of sensation and neglect they reported
a knowledge and skills gap. They did not know where to
start, what assessments or interventions to obtain, nor
how to use these with patients.
“We don’t know an awful lot about it [sensation and
neglect rehabilitation]. This is a good opportunity to
learn…start to change our practice” (OT1)
“I was at XX [hospital]… for sensory retraining there,
we used to do… stereognosis in a bag of rice…but that’s
all we did… There was not much evidence to back up
what we were doing” (OT4)
Speech pathologists knew about the guideline recom-
mendations for managing swallowing and communica-
tion difficulties. They were also aware of other research
about best-practice management of communication im-
pairments. They demonstrated knowledge of various
standardised tools used to screen for aphasia.
“The guidelines do say [that] 100%… everyone…
should get a swallowing screen and everyone should
get a communication screen” (SP2)
Nursing professionals felt they had a good knowledge
of stroke but insufficient skills to teach patients and
carers effectively.
“A majority of the nurses have been working in stroke
longer than us on this ward together. So I think their
knowledge and their skills are huge and they are stroke
specialists” (RN1)
“Some of the staff have a very good knowledge base
[about stroke in order to educate patients and carers]
but they don’t put that into use” (RN2)
As previously reported, some medical professionals were
uncomfortable discussing sexual activities with stroke sur-
vivors. One doctor did not know what to say, or how to
advise patients who were keen to resume sexual activities.
‘I honestly don’t know what to say if a patient brings it
up [the topic of sex]…. I’m not sure whether Viagra is
Ok for patients to use or not’ (MD1)
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Medical professionals acknowledged that depression
and anxiety were important problems experienced by
patients. They knew that there was robust evidence
about the impact of these impairments on stroke out-
comes but were not yet screening patients for depression
and anxiety.
In summary, knowledge about research contained in
the national stroke guidelines varied across disciplines.
Not knowing the research, or how to implement a
guideline recommendation was a barrier to the provision
of evidence-based stroke care.
Motivation, intentions and goals
This category refers to clinician’s motivation or intention
to provide an evidence-based test or therapy. This cat-
egory also refers to how much they wanted or needed to
do a test or therapy and whether other priorities inter-
fered with their intentions.
Occupational therapists struggled to complete all the
necessary assessments and interventions in a working
day. They intended to prioritise assessments and inter-
ventions which would produce the best patient outcome.
Yet like many professionals they had difficulty fitting
their assessments and intervention around other re-
habilitation commitments.
‘There’s so many interventions that we need to do as
OT’s and … we have to pick the one that’s going to
have the biggest impact for the patient….balancing
what’s going to be most effective and have the best
outcomes for the patient?” (OT1)
“If we had a way of prioritising… ‘Yes, this (sensation)
is the thing that’s impacting their fine motor ability’….
That would certainly be more motivational … we
would have a focus on that for that patient” (OT1)
Speech pathologists used a prioritisation system that
some felt was a barrier to routinely providing interven-
tion for communication impairments.
“Our prioritisation is one of the reasons why we may not
get to [do] an intervention as frequently as the guidelines
say…the way we prioritise patients is very acute based. So
sometimes when you’ve got more patients…
communication patients go down the list” (SP2)
Some speech pathologists considered documentation
about aspects of patient education to be a lower priority.
“Swallowing education…. that tends to be reasonably
well documented. But … communication, it’s not
something that we tend to see as an urgent thing to
put in the notes …that you’ve done it (SP1)
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Motivation to provide an intervention was an enabler
for medical, nursing and allied health professionals.
Some participants were keen to provide best practice.
“We decided as a group to focus on sensation and
neglect …we thought this was a good opportunity to be
able to learn and start to change our practice” (OT1)
“Maybe that’s something [treadmill training] we really
should be doing …routinely with non-walkers” (PT1)
In summary, being motivated to provide evidence-
based care was an enabler for some participants, how-
ever, sometimes other priorities got in the way.
Resources
This domain refers to the presence or absence of re-
sources such as staff, materials, space, time and the pre-
dictability of these more tangible resources.
When physiotherapists talked about providing tread-
mill training, they lamented the time and staff required
to conduct each patient training session. A session took
almost 45 minutes including preparation and usually re-
quired the presence of two physiotherapists.
…it’s [going to] take a second person to get them on the
treadmill and once they’re on the treadmill, you’re
stuck with them” (PT1)
“What about the treadmill?” (PT4) “What stops us
using it?” (PT1): “I reckon it’s time more than
anything” (PT2)
Occupational therapists and speech pathologists reported
fluctuating staff levels, which affected the amount of inter-
vention they could provide. Reduced staffing was an on-
going barrier to best practice throughout the study period.
Occupational therapists had difficulty finding time to pro-
vide best-practice sensation rehabilitation in addition to
their usual care. Speech pathologists were limited in how
much communication training they could deliver for the
same reason.
“The other thing about intervention with
communication is… staffing levels dropping …with
winter coming…” (SP2).
“Our capacity to do intervention for communication is
a lot lower” (SP1)
Speech pathologists did not have enough written infor-
mation to give to patients and carers about the manage-
ment of swallowing and communication impairments.
Of particular concern was the lack of information that
Page 10 of 13
could be easily understood by patients with aphasia.
They also did not have standardised tools in the depart-
ment to formally screen patients for aphasia.
“We don’t own them [validated aphasia tests]… They
cost about $50-$100, so we just want to work out
which one to buy” (SP2)
Nursing professionals did not have enough written
educational materials to give to patients, including trans-
lated materials. They previously had videos to show to
patients and carers, but these had gone missing. The
cost of purchasing and replacing lost materials was a
barrier to education. Weekly education sessions were de-
livered in the ward dining room, but transporting pa-
tients to this area could also be difficult. Limited
availability of language interpreters was another reported
problem when providing education to some patients and
carers.
“The only way we’re offering it [education] at the
moment is when interpreters are booked. So if OT gets
an interpreter, that’s when they’re given the education.
But… that’s probably once during the admission, if it
happens at all” (RN1)
“The (educational) pamphlets in different languages…
are not available at the moment….” (RN1)
“We can get some good ideas [re: educational
material] and then look at cost as well… [cost] does
come into it (RN1)
“Patients have got to be able to get to the dining room
[for education sessions]… [mobility] can also be a
barrier” (RN2)
Finally, orthoptists reported making time to assess pa-
tients, but had little time for treatment. Both they and the
nursing professionals also reported difficulty accessing pa-
tients and carers for education sessions.
“You can see every patient, diagnostically speaking,
but you haven’t got time to do treatment” (Orth2)
“You’re also fighting the other professions because the
person’s in the gym, [or] they’re with the speechie…
(Orth2)
Resources could also be an enabler. Physiotherapists
had developed local protocols and had the necessary
equipment for sitting balance and treadmill training. Oc-
cupational therapists had found some prism glasses
which were one intervention they needed to provide as
part of neglect retraining. Nursing professionals had
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purchased some educational DVDs and pamphlets on
stroke. In summary, availability of staff, time and equip-
ment varied across disciplines and impacted on clini-
cian’s ability to provide evidence-based practice.
Discussion
There were three key findings in this study. First, reported
barriers and enablers were different across professions.
Many barriers were expected, but some beliefs were not
and may be more difficult to change. Second, gaps in
knowledge and skill were common. Many therapists did
not know what to do after reading a guideline recommen-
dation. Third, participants identified strategies while
reflecting during the interviews, which they could use to
change practice. Finally, this study provides applied exam-
ples of the convergence between evidence, clinical judge-
ment and patient values or circumstances [28].
Different barriers across professions
The theoretical domains framework proposed by Michie
and colleagues (2005) helped identify barriers and en-
ablers which were present, and those which were absent.
Using the framework was helpful during the interview
process. Individual professionals and disciplines became
clearer about which barriers needed to be addressed,
who needed to work differently, and what type of behav-
iour change strategies might be helpful [27].
The interviews allowed time for therapists to systemat-
ically reflect on potential barriers affecting their practice
or discipline, and behaviour change strategies that might
be needed. For example, to improve knowledge about
sensation and neglect rehabilitation, occupational thera-
pists left the interviews recognising that they needed to
obtain and read relevant journal articles, make contact
with known experts in the field, purchase and trial
equipment. Prompts were identified and welcomed
which could improve attention to procedures such as
depression screening or advice about return to driving.
For example, one team member suggested introducing a
‘standing item’ of business to the weekly case confer-
ence, to prompt memory and action. They decided to
check if driving has been discussed and documented for
individuals who had driven pre-stroke.
Asking each discipline to select one or two focus areas
for quality improvement worked well after barriers had
been identified. We recommend this strategy when ini-
tially trying to improve practice and change behaviour.
However, in the long term some guideline recommenda-
tions and some barriers are more important to address
than others, with practice and policy implications. For
example, underuse of swallowing screening, assessment
and retraining may be considered to be of greater im-
portance because of the risk of aspiration.
Page 11 of 13
Some barriers and practice areas proved too challen-
ging. One important practice area which none of the dis-
ciplines selected for improvement was sexuality. The
Australian guidelines recommend that stroke survivors
and their partners be offered the opportunity to discuss
sexuality with an appropriate health professional and be
offered written information addressing sexuality post
stroke [7]. A recent national audit found that only 17%
of Australian stroke patients received such advice (an
improvement from 0% in 2009) [29]. Sexuality education
and advice appear to be resistant to change. Many bar-
riers exist for patients, carers and staff.
Several barriers to providing best practice sexuality
advice were identified at our stroke unit, for staff and
patients. There were unhelpful beliefs about the conse-
quences of raising sexuality with patients, and gaps in
knowledge and skill. If discussions are occurring, they
were not being documented. The honest quotes from
participants imply a need for skills training. Such train-
ing might include role playing with simulated patients
and practice discussing sexuality, to improve communi-
cation, confidence and help change behaviour.
Role playing has been used as a behaviour change
technique in primary care by Cane and colleagues [27].
These researchers helped general practitioners to re-
hearse the process of telling patients with acute low back
pain that a plain film X-ray was unnecessary. Cane and
colleagues also disseminated a DVD which presented
‘model’ responses if a patient repeatedly asked for a plain
film X-ray to be completed. Implications for education
from our research include the potential for a DVD to
teach professionals how to better communicate about
sexuality post-stroke. Sample scripts or narratives could
be offered to replace the awkward silence that some-
times occurs. Such materials would be useful to many
services.
Addressing gaps in skill and knowledge
The skills and knowledge barrier to evidence-based re-
habilitation is surprisingly common, with implications
for graduate and entry-level education. Where interven-
tion protocols existed, the therapists were often able to
obtain and trial them. For example, the physiotherapists
had participated in randomised trials of sitting balance
and treadmill training and understood the protocols.
They knew what to do. If they had not been involved in
the original trials, they would have experienced similar
barriers to other professionals. Occupational therapists
in this study contacted a local expert who had presented
a conference paper about neglect rehabilitation. The ex-
pert visited the unit and demonstrated how to use visual
scanning. This consultation overcame the knowledge
and skill barrier which arose because no written treat-
ment protocol was freely available.
McCluskey et al. BMC Health Services Research 2013, 13:323
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Other areas of practice which were difficult to imple-
ment because of a skills and knowledge barrier include
sensation retraining, mental practice and constraint ther-
apy to promote upper limb recovery. Many hours were
spent working out ‘what to do’. Treatment protocols
need to be more easily available when trials of effective
intervention are completed. Protocols may include vid-
eos and photographs of procedures. One such example
is the GRASP program (Graded Repetitive Arm Supple-
mentary Program) for hand and arm rehabilitation, de-
veloped by Professor Janice Eng and colleagues in
Canada [30]. Following publication of their trial, the re-
search team prepared documents with photographs of
the GRASP treatment protocol, with additional imple-
mentation grant funding. The procedures are freely
available to stroke survivors and therapists at http://
neurorehab.med.ubc.ca/grasp/. Implementation becomes
easier when protocols are available to therapists. One re-
search and policy implication is that triallists could be
required to provide their treatment protocols freely to
clinicians, when an intervention is found to be effective.
Screening patients routinely for the presence of de-
pression was another practice affected by the skills and
knowledge barrier, as well as beliefs and attitudes. De-
pression screening is an international challenge. Low
compliance with guideline recommendations has been
reported in England [22], Canada [21] and our stroke
unit in Australia. Recent 2012 Australian audit data re-
vealed that only 50% of stroke patients were screened
or assessed for depression across over 100 hospitals
[29]. Kneebone and colleagues (2010) in England have
implemented behaviour change strategies to address
this evidence-practice gap. They trained occupational
therapists who volunteered to conduct routine depres-
sion screening, then tested their knowledge and skills.
Next, they checked the medical records, to ensure fidel-
ity and accuracy of screening procedures by participat-
ing therapists, and provided feedback. Similar training
could be provided in Australia, with implications for
education and practice.
Convergence between evidence, clinical judgement and
patient circumstances
Several examples were provided where therapists reported
using clinical experience and knowledge of patient cir-
cumstances alongside published evidence. Speech patholo-
gists knew that aphasia test results would be invalid if a
patient could not speak or understand English. Conse-
quently they chose not to conduct these tests on people
who were unable to speak English. Physiotherapists
weighed up the time taken to set patients on the treadmill
with a harness and two therapists against the potential
outcomes of using a much simpler therapy-sitting to
standing training to improve leg strength. They kept
Page 12 of 13
patient outcomes and benefit in the front of their mind
and thought carefully about time management in the busy
ward setting. These examples have implications for profes-
sional education, and could be used to highlight patient
circumstances that influence decision-making and compli-
ance with guideline recommendations.
Study limitations
As with all research, our study had limitations. First,
only one site was involved. Findings are unique to that
site and participating professionals. However, findings
are likely to be useful to other professionals and stroke
units with similar characteristics. Second, the study
would have been strengthened by conducting a second
round of interviews with staff.
A third limitation, but also a strength was the use of a
theoretical framework to guide the interview schedule
and data analysis. Use of this theory may have prevented
categories from emerging which did not ‘fit’ those docu-
mented by Michie and colleagues (2005). However, the
benefits of using this framework, including the efficiency
with which interview data could be coded, in our view
outweigh the limitations for busy clinical for education,
practice, policy and future research.
Implications for education, practice, policy and
future research
Education implications are relevant to universities and
professional associations, as well as peak bodies such as
the Australian National Stroke Foundation. First, there
was a need for communication training about sexuality
post-stroke, possibly involving model scripts and narra-
tives. Education needs also included ‘how to’ conduct
routine depression screening, neglect and sensation
training, and ‘how to’ deliver mental practice. Anec-
dotally, these skills and knowledge gap are known to be
common across many services. Professional associations
and the National Stroke Foundation are already collabor-
ating to address these knowledge gaps.
Policy and practice implications include the need to
target ‘high risk’ evidence-practice gaps, such as low
compliance with swallowing screening, assessment and
retraining. These practice gaps have implications for pa-
tient safety, due to the risk of choking and aspiration
pneumonia.
There are at least two research implications from this
study. First, more research is needed into behaviour
change strategies that can, and do influence ‘difficult to
shift’ practice areas such as sexuality education and de-
pression screening after stroke. Second, triallists who de-
velop effective rehabilitation interventions could be
required to make their treatment protocols freely avail-
able to clinicians.
McCluskey et al. BMC Health Services Research 2013, 13:323
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Conclusions
Knowledge translation is an important final step in the
process of evidence-based practice. This qualitative
study describes the process of identifying barriers to
implementing guideline recommendations in stroke re-
habilitation. The interviews enabled professionals to
identify areas in need of change, reflect on barriers, and
how each practice area could be targeted with behaviour
change interventions. Some practice areas generated in-
teresting attitudinal barriers and beliefs. Our qualitative
data add to the current body of knowledge about bar-
riers in these more difficult practice areas, and may be
informative for other teams.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
The first author AM conceptualised and planned the study, writing of the
manuscript, collection and analysis of data and writing of the manuscript
drafts. The second author AV-C helped collect and analyse data and
complete manuscript drafts. The third author KS advised on study design,
and manuscript drafts. All authors read and approved the final manuscript.
Acknowledgements
During this study, Annie McCluskey held a fellowship co-funded by the
University of Sydney, Royal Rehabilitation Centre Sydney and the National
Stroke Foundation (2009–2011). The study was also supported by a project
grant from the Ingham Medical Research Institute. None of these
organisations were involved in, nor influenced, data collection or analysis,
the writing or submission of this manuscript.
Author details
1
Discipline of Occupational Therapy, Faculty of Health Sciences, The
University of Sydney, New South Wales, Australia. 2Physiotherapy
Department, Bankstown Lidcombe Hospital, New South Wales, Australia.
Received: 29 November 2012 Accepted: 13 August 2013
Published: 19 August 2013
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doi:10.1186/1472-6963-13-323
Cite this article as: McCluskey et al.: Barriers and enablers to
implementing multiple stroke guideline recommendations: a qualitative
study. BMC Health Services Research 2013 13:323.
 Essential Components of Common Motor Tasks
Analyse FOUR tasks using the attached worksheets (the tasks are named at the top of
each page). Watch another person performing the tasks at home or work. From the
‘essential components’ checklist, select those that are relevant.

Transport [of the upper arm/shoulder during reach]:

• Elevation
• External/internal rotation
• Forward flexion /extension
• Adduction/abduction
• Protraction/retraction
• Elbow extension/flexion
• Horizontal shoulder flexion/extension
(also known as horizontal shoulder abduction/adduction)

Pre-Shaping [of the hand/forearm during reach leading to grasp]

• Supination/pronation
• Wrist flexion/extension
• Radial/ulnar deviation
• Finger adduction/abduction
• Metacarpophalangeal flexion/extension
• Interphalangeal flexion/extension
• Thumb flexion/extension
• Thumb adduction/abduction
• Conjunct rotation of thumb (at CMC joint; produces opposition)
• Conjunct rotation of carpometacarpal joints (which results
in palmar cupping and opposition of the thumb to fingers

Grasp [when the fingers make contact with the object] &
In-Hand Manipulation [may occur simultaneously with grasp]
• Finger adduction/abduction
• Metacarpophalangeal flexion/extension
• Interphalangeal flexion/extension
• Thumb flexion/extension
• Thumb adduction/abduction
• Conjunct thumb rotation (at CMC joint; produces opposition)
• Conjunct rotation of carpometacarpal joints (which results
in palmar cupping and opposition of the thumb to fingers
• [Supination/pronation] *
• [Wrist flexion/extension] *
• [Radial/ulnar deviation] *
* These components may also be observed during manipulation to
orient the object
 Essential Components of Common Motor Tasks

TASK 1: Reaching for and picking up a glass to drink

Transport:

Pre-Shaping:

Grasp:

In-Hand Manipulation (if relevant):

TASK 2: Picking up and writing with a pen (pen tip facing towards you)

Transport:

Pre-Shaping:

Grasp:

In-Hand Manipulation:
TASK 3: Reaching for, and using a knife and fork to cut up food
(Compare similarities and differences between knife and fork)

Transport:

Pre-Shaping:

Grasp:

In-Hand Manipulation:
TASK 4: task of your choice …………………………………………

Transport:

Pre-Shaping:

Grasp:

In-Hand Manipulation (if relevant)