Name: Date:

Evidence-Based Upper Limb

Retraining after Stroke

2013

Workshop Pre-Reading

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

Tel +61 2 9644 8217

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
_____________________________________________________________________

Dear participant,

Evidence-Based Upper Limb Retraining after Stroke

1. Pre-Reading
Thankyou for your application to attend our workshop. Three articles of recommended pre-reading
are enclosed for your convenience. The articles provide background to task-specific training, motor
learning, structuring independent practice and long-term follow-up. Recent research – particularly
randomised controlled trials and systematic reviews - will be presented during the workshop, along
with a reference list.

We suggest that you take time to read and re-read the material, in order to gain maximum benefit
from the workshop. The more prepared you are for the workshop the more likely you are to apply
the information in practice. By early afternoon on Day 1, groups of therapists (n = 4) will assess and
train a new patient – a person you will not have seen before. Therefore, the more reading and
thinking you have done before the workshop, the more prepared you will be for this first clinical
session.

2. Anatomy Revision
Previous participants have also suggested that therapists coming to the workshop would benefit from
revising their upper limb anatomy.

3. Upper Limb Assessment Kit – Please bring to the Workshop

Please bring your own personal upper limb assessment kit to the workshop including such items as: a
knife, fork, flexible straws, Micropore tape, a ruler, stopwatch or timer, pen and pencil, Texta pens,
wooden tongue depressor, plastic picnic cup(s), plastic tweezers from wound dressing trays,
clicker/counter for recording repetitions. If you have access to a full-arm blow up airsplint, please
bring this to the workshop. These items may be required when you are working with a patient during
the workshop, and will become useful to you upon your return to work. Please label your kit. Please
also bring a name badge to wear, if possible.

4. Electrical Stimulation (ES) Machine & Mirror Box

If you have access to an ES machine at work, and a mirror box, please bring these items to the
workshop. Also please 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.

Yours sincerely,

Annie McCluskey Karl Schurr

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

* Distributed and copied for teaching and learning purposes. Not to

be copied for any other purpose nor for financial gain*

…………………………………………………………………………………………………………………………………….

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 when 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.

……………………………………….…………………………………………………………………………………………..

Barker, R.N., & Brauer, S.G. (2005). Upper limb recovery after stroke: The stroke
survivor’s perspective. Disability & Rehabilitation, 27(20), 1213-1223.
(A qualitative study conducted in Queensland, Australia. Methods for data collection included focus
groups and in-depth interviews with 19 people with stroke and 9 spouses. Several participants describe
their disappointment at the limited time therapists’ spent focussing on their arm versus their leg during
rehabilitation. Participants wanted to practice regularly and intensively, but often did not know how to
progress after they were discharged from therapy. Patient’s information post-discharge came mostly
from other people with stroke and those attending support groups, rather than from therapists. People
with minimal muscle activity particularly lacked expert advice. Strategies for longer-term follow up and
‘top-ups’ were needed to help participants continue on their upper limb recovery. Useful suggestions
are provided for restructuring out-patient and community rehabilitation services).

……………………………………….…………………………………………………………………………………………..
Birkenmeier, R.L., Prager, E.M., & Lang, C.E. (2010). Translating animal doses of task-
specific training to people with chronic stroke in 1-hour therapy sessions: A proof-of-
concept study. Neurorehabilitation and Neural Repair, 24(7), 620-635.
(This study challenged 15 people with chronic stroke (>6 months) to complete 300 or more repetitions of
upper limb task-specific training (3 tasks x 100 reps), three times a week for six weeks. The treatment
protocol was prescribed by an OT or PT, and involved functional tasks and practice of grasping,
moving/manipulating, then releasing an object. A frequently used task was ‘lifting cans on shelves’.
Examples of practice tasks and progressions are provided in an appendix to the paper. Therapists
documented the number of repetitions. For 13 participants, the average number of repetitions per
sessions was 322, and 97% of the possible sessions were attended. Action Research Arm Tests scores
improved an average of 8 points (on a 57-point scale) post-treatment and were maintained four weeks
later. The COPM was also used as a secondary outcome measure; COPM self-reported performance
changed by an average of 2.2 points (on a 10 point scale).
 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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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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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-
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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
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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
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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

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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

A B

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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

A B

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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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 SECTION FIVE Working with the individual

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Practice to modulate finger and

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
the unit tightly with the screw top. If necessary, seal the unit 5XVdaT
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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
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)
}
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P]S

shoulder muscles (Ada & Foongchomcheay 2002, Pomeroy et al 2006)
}
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R^]caPRcX^]b
P]S
_aPRcXRT
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P]S
U^aTPa\
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Tc
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!$
} Task-related training in groups (Blennerhassett et al 2004)
}
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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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 Disability and Rehabilitation, 2005; 27(20): 1213 – 1223

RESEARCH ARTICLE

Upper limb recovery after stroke: The stroke survivors’ perspective

R.N. BARKER & S.G. BRAUER

Division of Physiotherapy, School of Health & Rehabilitation Sciences, University of Queensland, Brisbane, Queensland,
Australia

Accepted February 2005

Disabil Rehabil Downloaded from informahealthcare.com by University of Sydney

Abstract
Purpose. This study investigated stroke survivors’ perspective of upper limb recovery after stroke. The aim was to determine
factors other than medical diagnosis and co-morbidities that contribute to recovery. The objectives were to explore how
stroke survivors define recovery, identify factors they believe influence recovery and determine strategies used to maximize
upper limb recovery.
Method. A qualitative study consisting of three focus groups and two in-depth interviews was conducted with stroke
survivors (n = 19) and spouses (n = 9) in metropolitan, regional and rural Queensland, Australia. Data were analysed using
principles of grounded theory.
For personal use only.

Results. Stroke survivors maximize upper limb recovery by ‘keeping the door open’ a process of continuing to hope for and
work towards improvement amidst adjusting to life with stroke. They achieve this by ‘hanging in there’, ‘drawing on support
from others’, ‘getting going and keeping going with exercise’, and ‘finding out how to keep moving ahead’.
Conclusions. This study provides valuable insight into the personal experience of upper limb recovery after stroke. It
highlights the need to develop training strategies that match the needs and aspirations of stroke survivors and that place no
time limits on recovery. It reinforces the benefits of stroke support groups and advocates their incorporation into stroke
recovery services. These findings can be used to guide both the development and evaluation of stroke survivor centred upper
limb training programmes.

Keywords: Stroke survivors’ perspective, upper limb, recovery

Any attempts to improve upper limb recovery after

Background
Upper limb recovery after stroke is unacceptably
poor with only 50% of stroke survivors likely to
regain some functional use [1] compared with 82%
who could expect to walk independently again [2].
This disparity has been attributed to minimal time
spent on the upper limb during rehabilitation [3], the
lack of spontaneous use of the arm for function and
the complexity of upper limb function necessitating
greater recovery of motor control to achieve function
[4]. Although allocation of stroke recovery services
have been traditionally based on the belief that
recovery occurs within the first three months and is
complete by twelve months [5], further improvement
has been shown to occur with intervention beyond
that period [6,7].
stroke across the population must be investigated
within the context of the current health climate. Over
the last decade an increasing number of people are
surviving stroke but with rising levels of disability [8].
Greater demand is being placed on rehabilitation
services at a time when cost containment is leading to
reduction in hospital length of stay. With time
available for upper limb training rapidly diminishing,
the search for effective and efficient strategies to
maximize upper limb recovery has become more
pressing.
As the first step, consideration must be given
to factors known to contribute to recovery.
Previous studies have shown that the site and
severity of the lesion [9] and the impact of co-
morbidities [10] is associated with recovery of the

Correspondence: Ruth Barker, Division of Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, Qld 4072, Australia.
Tel: 61 7 33652275; Fax: 61 7 33652775. E-mail: r.barker@shrs.uq.edu.au
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2005 Taylor & Francis
DOI: 10.1080/09638280500075717
 1214 R.N. Barker & S.G. Brauer
arm and hand after stroke. Upper limb training
programmes involving intensive and repetitive task
related practice [7,11] have been shown to
improve recovery. What has not been investigated
is the extent to which stroke survivors want to or
are able to use these interventions [12] that
demand time, energy and long-term commitment.
With no studies on upper limb recovery from
stroke survivors’ point of view, little is known
about what upper limb deficits mean to indivi-
dual stroke survivors, or their differing beliefs and
behaviours with regards to upper limb recovery.
Clearly the perspective of stroke survivors is
essential in building a comprehensive framework
to promote upper limb recovery and in ensuring
adherence to demanding rehabilitation routines.
This study arose out of the belief that stroke
Disabil Rehabil Downloaded from informahealthcare.com by University of Sydney
survivors had a story to tell and that much could
be learnt from their experience. Explanations as
to why some individuals experience an unexpect-
edly good recovery compared with others could
reveal mechanisms used by stroke survivors to
enhance recovery. Stroke survivors views on
current health service provision could provide
insight into why some aspects of rehabilitation are
For personal use only.
more acceptable than others and highlight a
broader range of issues that need to be con-
sidered in planning of services [13]. Their
experience of transitions of care from the acute
admission through rehabilitation, discharge and
cessation of services may assist in anticipating
needs and tailoring services to meet them [14].
Stroke survivors’ perspective casts light on long-
term recovery to which rehabilitation staff are
rarely exposed and to which scant attention is
given in the literature [15]. Ultimately, training
programmes developed will apply to stroke
survivors, and will most likely require them to
adopt new practices and take on new responsi-
bilities [16] as well as greater responsibility as
demand for services increases. Their continued
participation is essential to ensure strategies
developed will be acceptable, relevant and acces-
sible to stroke survivors within the context of
their lives.
In an effort to provide fresh insights and a new
perspective for the development and delivery of
effective training strategies, this paper reports the
results of a qualitative study investigating stroke
survivor’s perspective on upper limb recovery. The
aim of the study was to determine factors other than
medical diagnosis and co-morbidities that contribute
to recovery of the upper limb after stroke. The
objectives were to explore how stroke survivors
define recovery, identify factors they believe influ-
ence recovery and lastly, determine strategies used to
maximize upper limb recovery.
Methodology
A qualitative research design was chosen for this
study. Three focus groups (n = 19 stroke survivors +
9 spouses) and two in-depth interviews (n = 2 stroke
survivors) were used to gather the raw data over a six
month period. The data were collected, analysed and
compared with the literature using principles of
grounded theory [17] for the purpose of gaining
insight, not to generate theory.
The nature of the research question and the
decision to collaborate with two stroke groups,
determined the method. Principles of grounded
theory were considered most appropriate for explor-
ing the experience from stroke survivors’ point of
view and for discovering the methods used by them
to promote recovery. Face to face forums were
preferred as a more natural setting for conversation
with the advantage that non-verbal and spontaneous
reactions of participants are witnessed. Focus group
interviews were used to collect information from
various points of view and to take advantage of the
richness of group data. In-depth interviews were
used to complement this method by providing more
personal and individual responses that would not be
influenced by the group or could not be drawn out in
a group, due to the personal nature or lack of
approval from the group. They also offered the
opportunity to address or challenge issues or points
that had either not been mentioned or not discussed
in sufficient depth. The number of focus groups and
in-depth interviews conducted was determined by
saturation of data, deemed to be the point where
nothing more was added to enhance or distinguish
emerging concepts.
Sampling process
Initial sampling was purposive and self selected in an
attempt to include those from whom most could be
learnt and to ensure a wide range of opinions.
Participants had experienced stroke affecting the arm
from 3 months to 13 years previously. Following the
initial focus group interview, thematic sampling [17]
was used to broaden and challenge emerging
categories, with participants selected according to
rural, regional or metropolitan residence, self re-
ported good and bad recovery, functional level,
absence or presence of a spouse or carer, time since
stroke, arm affected, age and gender. Finally,
participants for two in-depth interviews were selected
on the basis of a self reported bad recovery of the arm
but not the leg and a good recovery of the arm, but
not the leg. The demographics of study participants
are summarized in Table I.
Participants were recruited using a network app-
roach via two stroke support groups in Queensland.
 Stroke survivors’ perspective on recovery 1215

Table I. Demographics of study participants.

ID Interview Age* Years** Since Stroke Gender Location Arm affected Arm function Spouse present

1 Focus group 1 66 3.5 M Rural L Nil + spouse

2 Focus group 1 67 1.5 M Rural R Nil + spouse
3 Focus group 1 75 2.5 M Rural L Nil + spouse
4 Focus group 1 55 7 M Rural R Nil + spouse
5 Focus group 1 71 10 M Rural R Nil + spouse
6 Focus group 1 72 10 M Rural R Some + spouse
7 Focus group 1 61 6 M Rural L Nil + spouse
8 Focus group 2 79 4.5 F Regional L Functional
9 Focus group 2 71 13 F Regional L Functional
10 Focus group 2 71 2.5 F Regional R Nil + spouse
11 Focus group 3 59 3 M Metro L Functional
12 Focus group 3 54 4.5 F Metro L Nil
13 Focus group 3 59 5 M Metro L Functional + spouse
14 Focus group 3 42 4.5 M Metro R Some
15 Focus group 3 62 1.5 M Metro R Some
16 Focus group 3 62 6.5 M Metro L Functional
17 Focus group 3 42 4 F Metro L Some
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18 In-depth 61 3 F Metro L Nil

19 In-depth 82 .4 F Metro L Functional

*Mean age * 64 yrs, age range 42 – 82 yrs.

**Mean time since stroke* 4.9 yrs, range 3 months – 13 yrs.

Members were advised of the specific criteria for the questions was developed to frame the information to
For personal use only.

first and each subsequent interview as well as the
time, date and venue. Those members and others
known to them who fitted the criteria were invited to
attend. This method of recruitment led to all
participants being members of one of four stroke
support groups in Queensland. It also resulted in
attendance by not only those who had themselves
had a stroke but also by their spouse or partner,
particularly those with aphasia. Based on their belief
that as a couple they were stroke survivors and that
their differing perspectives and roles were both
critical in stroke recovery, no differentiation was
made between the views expressed. As the researcher
had worked as a physiotherapist with stroke survivors
in metropolitan, rural and remote areas of Australia
some members of both stroke support groups had
previous knowledge of the researcher. While this
could have led to reluctance to criticize it appeared to
enhance the contribution made with participants
holding the belief that the study offered real potential
for change.
Collection of data
Each focus group and in-depth interview was held on
one occasion in the homes of participants and
conducted by one researcher. The length varied with
earlier focus group interviews taking over ninety
minutes and the final in-depth interview taking only
thirty minutes. All interviews were taped once
consent had been given by all participants. A semi-
structured format based on a set of open ended
be gathered and to encourage participants to con-
tribute information in their own words. There was no
strict adherence to the style and type of questioning
beyond these four key questions with probes used to
follow or challenge themes that were emerging.
These questions are included in Table II.
Procedure for focus group and in-depth
interviews
Each focus group interview consisted of stroke
survivors as participants, the one researcher as group
leader and an experienced scribe who managed
taping of the session and took notes to record the
group dynamics and non-verbal language. Firstly,
the study purpose and process was explained and
interview questions distributed. Participants were
encouraged to immediately write down their an-
swers, to capture spontaneous responses and those
that had not yet been shaped by the group process.
Each participant was then invited to tell their
personal story of stroke and their reasons for
attending. This was designed to build rapport and
trust that individual experiences would be valued and
to allow presentation of information of particular
importance to participants. The questions specific to
the aims of the study followed with additional probes
used to ensure reflection on their own experience
and that of others with whom they had come in
contact. All interviews were drawn to a close with the
group leader summing up the discussion and asking
each participant to add to or dispute what had been
 1216 R.N. Barker & S.G. Brauer
Table II. Focus group questions.
1. What is recovery?
Probes included: What is a good recovery? What is a bad recovery?
Think about someone who had a ‘good recovery’ and explain why.
Think about someone who has had a ‘bad recovery’ and explain why.
Do you consider yourself to have had a good or bad recovery and why?
2. What factors influence recovery?’
Probes included: How do you think we can influence recovery?
How can we enhance recovery? What are the obstacles to recovery?
How could your recovery have been better or worse? What can you do to influence your recovery? What can others do to influence your
recovery?
3. How do you think we can maximise recovery?
Probes included: How can we maximise recovery with the same resources we have now? How could we do it differently to get a better
result?
Disabil Rehabil Downloaded from informahealthcare.com by University of Sydney
said and add his or her final comments. Written
responses to the focus group questions were col-
lected and included as data. The group leader and
scribe debriefed after the session documenting what
might be considered the ‘group data’.
In each focus group, participants consistently
encouraged each other to share their unique story,
showing respect and sensitivity particularly when the
For personal use only.
personal impact of the experience resulted in
expression of strong emotions. However concern
for the feelings of others could limit the depth of
discussion particularly with regards to the attitudes
and behaviour of those with a good recovery
compared with those with a bad recovery. For this
reason the in-depth interviews provided the oppor-
tunity to gain greater depth in this regard.
The same order and content was used to conduct
the in-depth interviews but with less structure
imposed on the interview. Participants were encour-
aged to talk with questions raised only when a
particular aspect was not covered or clarification was
required. Consistent with the purpose of the inter-
view, probes were more personal and often related to
the interviewee and others known to them.
Ethical approval was obtained from the University
of Queensland Behavioural and Social Sciences
Ethical Review Committee. All participants con-
sented to taping of interviews, having been informed
in writing and verbally that all tapes would be
transcribed verbatim and that confidentiality in
reporting of study findings was assured.
Data analysis
Analysis occurred continuously throughout the
study. During data collection, naı̈ve interpretation
followed immediately after each interview to ensure
that what had been learnt could be used to extend
questioning, seek further clarification or challenge in
the following interview. Once all data were collected
and tapes transcribed verbatim, focus groups and
interview transcripts were explored by a process of
reading and re-reading. On the first reading tran-
scripts were read in their entirety to acquire a sense
of the whole. On the second reading, using line by
line analysis, themes, patterns or concepts were
identified and listed, being mindful of core themes or
patterns emerging. Those that predominated were
tentatively placed into four (4) conceptual categories.
The third reading involved returning to the data to
check the ‘fit’ of the categories, pursuing patterns
both consistent and inconsistent with the categories
defined. The original categories were modified to
more effectively represent or ‘fit’ the emergent
patterns in the data. The analysis then involved
specifying the properties of each category, noting the
conditions under which it arose, relating how it
changed, describing its consequences and ultimately
specifying its relationship to the other categories.
Finally, a core category was identified as the central
phenomenon underpinning, linking and integrating
the emergent categories and accounting for varia-
bility in the data.
Whilst limited attention was given to the literature
for the initial conception of the study, specific review
of the literature only occurred after commitment to
the categories and to the main analytical message, in
order to guard against preconceived categories or
ideas emerging from the literature. This review was
undertaken according to the four (4) categories and
the core category. As a result, concepts were not
borrowed from the literature, rather the categories
that emerged influenced the selection and ordering of
relevant literature. Concepts that appeared repeatedly
in the literature, were used to check the data to
discover whether or not they applied in this context.
In order to verify and extend the emerging
framework [18] member checking occurred through-
out the study. Due to the geographical spread of
study participants, the researcher reported back to

participants when they were attending stroke group
meetings. This occurred on five occasions, twice with
each of the two main stroke groups and once in the
final stages, during a meeting with representatives of
both rural and metropolitan focus groups in atten-
dance. This led to small additions or modifications
to content at each stage as well as the renaming of
conceptual categories in the final stage, reinforcing
the personal rather than clinical nature of the
experience. During the period of analysis the
researcher also interacted extensively with stroke
survivors involved in a larger research project of
which this study was a part. Peer review was
undertaken with an experienced qualitative research-
er and coder checking with a novice researcher who
had an acquired disability. Over the length of the
study, findings were presented to clinical experts and
Disabil Rehabil Downloaded from informahealthcare.com by University of Sydney
to a number of professional audiences.
Results
Upper limb recovery was viewed by participants as a
critical but neglected issue, with most participants
feeling the magnitude of their loss was poorly under-
stood or appreciated. Expressions of disappointment,
For personal use only.
frustration and anger prevailed in this regard.
It’s a big deal to be able to use your arm again. I think most
of the doctors think it’s not. It’s a big deal to be able to use
your arm again psychologically as well physically.
Participants frequently spoke about the experience of
stroke in general, but expressed the enormous losses
associated with arm impairment, with many reduced
to tears during the discussion.
It would almost be easier if the arms came back. You could sit
in a wheelchair, at least you could do something. When the
leg comes back the only thing you learn to do is walk. But the
number of things you can do with an arm ..
Their definitions of recovery were often intensely
personal, conveying sentiments such as a sense of
hope, a familiar identity, valued activities and lifestyle
choices. When asked individually what recovery
meant to them, participant’s responses varied con-
siderably as is evident in the following examples.
. . .some hope for recovery. . . a sign at least to say recovery
was possible . . .. . .
. . .this was the hand that worked all the time and it
doesn’t respond. I was a right-handed man. What I have to
do is control that hand . . .. . .
. . .become independent and that summarises it . . . . you
don’t want to be a burden
Stroke survivors’ perspective on recovery 1217
. . .some use . . . to hold something . . ...I just want to hold
the nail and hammer it in . . .you have to have two
hands. . .. . .woodwork . . . in the shed . . .
A bad recovery was to lose hope, forget about
even trying to use the arm and to find no way
around or substitute for what had been lost. A
good recovery was to have some return of
movement and feeling, use of the hand, to do
what you want to do and to get on with your life
again, believing there could always be further
improvement. Interestingly, participants believed
recovery only came to an end if the stroke
survivor ‘gave up’.
Keeping the door open
The core conceptual category, identified as the key
process used by stroke survivors to maximise upper
limb recovery, is described as ‘keeping the door
open’, a process of ‘continuing along in life hoping
for and working towards improvement’. Participants
emphasized the importance of not placing time limits
on recovery, and of remaining open to future
possibilities, better services, more answers or further
spontaneous recovery. They frequently supported
this optimistic and open ended approach by citing
their own or others experience of progress many
years after stroke.
Even years later things are still changing as long as you
haven’t accepted this is all over.
Participants highlighted the reality of striving for
recovery amidst adjusting to the stroke event and
stroke consequences, navigating rehabilitation
services while getting back on with their life
again as the consequences of stroke endure.
Efforts were directed at not only ‘keeping the
door open’ but also preventing it from closing
against the pressure of others, such as doctors
who may insist there is no hope, or from within
themselves, such as a sense of hopelessness.
While this sometimes required the stroke survi-
vor to be a ‘maverick’, at other times or in
other cases, a gentler approach was needed
whereby keeping an open mind and a flexible
arm allowed future recovery to remain a
possibility.
Overall, the processes used by stroke survivors in
‘keeping the door open’ are described as ‘hanging in
there’, ‘drawing on support’, ‘getting going and
keeping going with exercise’ and ‘finding out how to
keep moving ahead’. As the four conceptual cate-
gories which emerged from the data, these processes
are interrelated and frequently occur simultaneously
(Figure 1).
 1218 R.N. Barker & S.G. Brauer
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For personal use only.
Figure 1. Processes used by stroke survivors to maximise upper limb recovery.
Hanging in there
The expression ‘hanging in there’ was used by
participants to accentuate the personal commitment
required to persist and not give up. The importance
of keeping hope alive and maintaining a strong
reason to recover was highlighted.
. . .It’s what comes from inside. What you bring out of
yourself.
. . .You have to take responsibility for yourself, you have
got to work at it. Don’t ever give up.
The constant reminder of the losses and the
frustration of repeated failure overwhelmed those
with severe paresis. Not knowing what to do or
how to get help eroded the will to continue.
Feeling scared of doing harm especially where pain
was present led to a loss of confidence to ‘have a
go’. Depression commonly overcame them, allow-
ing hope for recovery to fade. Negative or
dismissive attitudes from others created or con-
founded the desire to ‘give up’. Alternatively, this
fired the motivation of others who used such an
attitude as a driving force to recover, just to prove
them wrong.
Because that doctor knocked me so far down with what she
said I fought her, not me.
Maintaining hope and a sense of humour and being
surrounded by others who were positive and
encouraging helped to overcome obstacles. Many
advocated setting small goals to ensure small
successes could be celebrated along the way.
. . . you can’t look from nothing to everything you have to
take it step by step. As each piece comes back you practise
until you have encouragement to try something else.

One stroke group routinely reported successes
during their meetings so that individuals were
acknowledged for their achievement, others were
encouraged and the whole group celebrated.
Hanging in there through the highs and the lows,
often with support from others, provided the stability
necessary for getting going and keeping going with
exercise and the impetus for finding out how to keep
moving ahead.
Drawing on support from others
Participants believed they could not hang in there
and achieve a good recovery of their arm without
support from others. This included their spouse,
family, friends and community, other stroke survi-
vors and health professionals who together provided
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physical, emotional and social support.
Support has been the biggest thing for me. I come to the stroke
group, I don’t have to try to explain what happened .. they
have been there and done that. If I have a problem I can talk
to anyone of these carers and they know where I am coming
from and even if they can’t help me at least I know they
understand.
For personal use only.
A number of participants were unable to imagine
how recovery was possible for those who did not have
a spouse. In contrast, some who were on their own
felt they were forced to do more for themselves and
fared better than those whose spouse was fearful and
did too much or pushed too much. As with all
participants, they looked to the stroke group for
support, appreciating the camaraderie, humour and
information that was shared, as well as the benefits of
both giving and receiving support. However, indivi-
duals who would not help themselves could be seen
as a burden to the group.
Participants also looked to health professionals for
support, believing they had the knowledge, authority
and responsibility for promoting recovery of their
arm. The ‘therapy’, the training, guidance and the
encouragement provided were frequently credited
with the positive outcomes made.
. . ..The rehab is critical. If you haven’t got it to start with
you don’t know where you are going. Those are the people
who sort of set you up and get you going.
. . ..The courage the physiotherapist gave me is what I
needed. That he had faith in me.
Conversely, many resented the attitude of health
professionals and the power of their predictions.
Being told they would never use their arm again
shattered hopes and often limited or precluded them
from therapy, leaving them feeling disadvantaged or
Stroke survivors’ perspective on recovery 1219
abandoned. Rather than accepting negative predic-
tions, many strongly advised not to listen to health
professionals because ‘they are not always right’.
Working hard was seen as a way of making it easier
and worthwhile for therapists to be supportive. Being
proactive in seeking support was advocated including
‘knocking on doors’ or seeking complementary
health medicines once traditional avenues were
exhausted.
Stroke survivors drew on the support of others so
that they were able to hang in there, gain help with
getting going and keeping going with exercise and as
a source of information on how to keep moving
ahead.
Getting going and keeping going with exercise
Exercising was seen as the means to physical
recovery. Emphasis was placed on starting soon after
stroke onset, practicing regularly, intensively, appro-
priately and continually and using the arm in
everyday tasks. To not exercise was to do nothing
and without exercise recovery would not occur.
If you sit in a chair and do nothing you definitely won’t
improve. There is no might about it you definitely won’t. At
least doing something you’ve got a sporting change of it
having an effect.
However many participants did not exercise in the
manner advocated. Although most persisted with
some form of stretching, they felt they did not know
how to exercise or how to progress, a fact they
attributed to insufficient attention to the arm during
rehabilitation. Many also believed they did not have
enough movement to work with and therefore had
nothing they could do to practise.
. . ..I have got no use so I can’t improve what I’ve got if I
haven’t got anything.
A question repeatedly posed was whether the arm
would have recovered as well as the leg, had it been
‘worked on’ in the same manner as the leg. Many felt
that in the beginning they had no movement in either
their leg or arm, but that extreme effort was used to
get the leg going and to start walking. This was not
the case with the arm. Consistent with this reasoning,
the final interview participant believed her arm was
better than her leg because it had been ‘worked on
from the start’ while she was immediately assigned to
a wheelchair on what proved to be a faulty assump-
tion that she would never walk again.
While a few participants found some therapists
‘useless’, all believed access to suitably skilled
therapy services could help them to get going with
exercise. However, keeping going with exercise was
 1220 R.N. Barker & S.G. Brauer
also recognized as an issue that needed to be
addressed. Therapists teaching stroke survivors how
to exercise independently and how to progress was
seen as a priority. Yet even with the best knowledge,
maintaining the motivation to exercise over a long
period of time was highlighted as a problem.
. . .Its difficult to remain positive and willing to do the
exercises everyday. It really takes a lot of dedication and
determination. . .. because other things come into play.
Participants agreed that attendance at therapy, one to
one or in classes, helped maintain the motivation to
keep going. While some incorporated practice into
everyday tasks, it was recognized as a strategy not
available to those with severe paresis.
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. . .Once I got home all the exercises they had been showing
me were so damn boring I tried incorporating the exercises
into the daily things I did so that . . .they became extensions of
the exercises. So they were happening whether I wanted them
to happen or not.
Participants were in no doubt that ‘getting going and
keeping going with exercise’ was the physical means
For personal use only.
to keeping the door open for recovery. Achieving this
was dependent on their ability to persist, on support
from others for encouragement, as well as therapy
and advice on how to get started and how to
progress.
Finding out how to keep moving ahead
This involved pursuing information and guidance,
with emphasis on demonstration and feedback.
Participants believed that professionals working
within rehabilitation services were the most qualified
to provide this. However in practice, other stroke
survivors and the stroke support groups had played
this role. Participants who felt confident in moving
ahead attributed it to their sense of responsibility and
the teaching and encouragement of therapists at
some point along the way. Equally important was the
knowledge that the ‘door was open’ for them to
return to a rehabilitation service for feedback and
further guidance when they needed it.
They give you feedback. And that’s what you need. You need
that feedback. I myself I am striving to get better and better
all the time but you need their help.
In contrast, most participants felt ill equipped to
continue moving ahead. It was common to have
difficulty understanding and remembering informa-
tion given in the early stages, to find little relevance
in the information they were given and to experience
frustration over failed attempts to acquire help when
they needed it. Not being able to access services
beyond a prescribed period or over a certain quota
was a barrier. Those from a rural area felt the lack of
services with any expertise in stroke recovery was a
major disadvantage. Written material in the book-
shop, library or via the internet was found to be
sparse and inadequate for their needs.
Participants recommended upper limb training
based on a self-help principle with spouses or carers
involved at least until the stroke survivor could
absorb the information they needed. Traditional one
to one therapy was valued, as were group-training
sessions particularly if held within their stroke group
environment. Other resources such as stroke survivor
friendly pamphlets, books, videos and websites were
considered necessary to consolidate and broaden
their understanding. Rather than receiving all ser-
vices in the earlier stages of recovery, participants
believed a more staggered arrangement would allow
them to access information and guidance when they
were ready and as it became relevant to them in their
life. An annual review by a visiting team of stroke
experts was requested for the stroke survivor and
carer from a rural area.
By finding out how to keep moving ahead stroke
survivors were able to continue working for recovery.
This involved drawing on the support of others to
gain the necessary information and guidance that
would help to build the confidence to hang in there
and keep going with exercise. In this way, partici-
pants reinforced that together, these processes
enabled the stroke survivor to keep the door open
for recovery.
Discussion
This study explores stroke survivors’ perspective on
upper limb recovery and the strategies believed to
maximize recovery. It provides a retrospective view
of stroke survivors with 3 months to 13 years
experience living with stroke. The findings portray
an optimistic open ended approach to upper limb
recovery that presumes the value of the stroke
survivor’s contribution to their own recovery and
explores the potential for more meaningful interac-
tion with stroke recovery services to enhance upper
limb recovery.
The outcomes of this study offer new and valuable
insight into upper limb recovery after stroke that has
implications for stroke recovery services. However
methodological limitations need to be considered to
place the findings within proper perspective. Firstly,
as all study participants volunteered to attend and
were members of stroke support groups, the findings
may reflect the views of those for whom upper limb
recovery is a priority, the views that result from
attendance at a stroke group or the views of the type

of person who chooses to attend a stroke group.
Stroke survivors who can not or did not choose to
attend a stroke support group or for whom upper
limb recovery is not a priority may have had different
views. Not to be forgotten however, is that as
members of stroke support groups with experience
of a variety of rehabilitation services across both
metropolitan and rural areas, participants’ contribu-
tion will have been influenced by not only their own
recovery, but also the recovery of a large number of
other stroke survivors with whom they have inter-
acted. In addition, a follow-up study has been
conducted with a larger and more representative
sample of stroke survivors.
Secondly, the interpretation will have been influ-
enced by the background and perspective of both the
researchers and stroke survivors who volunteered to
Disabil Rehabil Downloaded from informahealthcare.com by University of Sydney
participate. The researchers had witnessed stroke
survivors who had made unexpected recoveries,
regardless of the services received, leading to the
belief that personal factors have a role in recovery.
Collaboration on this study came about because of a
shared belief that stroke survivors had much to
contribute and that the potential for upper limb
recovery had not yet been exploited. The researchers
For personal use only.
believe that this led to a positive outlook within each
interview, rigorous questioning by the researchers
and open, honest and forthright opinions from
participants.
As with previous studies, the stroke survivors in
this sample defined recovery according to ‘what
matters to them’ and that frequently this was not
what mattered to health professionals [19 – 21].
Similarly, the stressors and challenges involved in
pursuing recovery were mediated by the process of
adjusting to life with stroke and the persistence of the
consequences of stroke into future life [22]. In this
study, stroke survivors attempted to maximise upper
limb recovery by ‘keeping the door open’ a process
that allowed them to continue in life hoping for and
working towards improvement while remaining open
to future possibilities. This involved ‘hanging in
there’, ‘drawing on support of others’, ‘getting going
and keeping going with exercise’ and ‘finding out
how to keep moving ahead’. It is important to note
that these practices existed on a continuum with
some people engaging in them more consistently
than others, an important consideration given the
heterogeneous nature of stroke, stroke survivors and
their experience of upper limb recovery.
This view of recovery differs from previous studies
which have looked at stroke recovery in general,
within the first two years after stroke. Some studies
have described a recovery path with an endpoint
where personal goals were achieved [23] or con-
versely when nothing more could be done [21].
Others reported a long term view of recovery,
Stroke survivors’ perspective on recovery 1221
identifying a recovery path [24] or trajectory [19]
that did not have an endpoint. While the findings of
this study are similar to this latter view, emphasis is
placed on recovery as part of life’s path, whereby
recovery is incorporated into stroke survivors lives,
rather than a distinct recovery path. As participants
were members of stroke groups with up to 13 years
experience, this may represent a view of recovery that
has evolved over time and become part of a stroke
group ethos that is embraced by newcomers. It may
also reflect the unique experience of upper limb
recovery where priority is often only given after some
adjustment to stroke and resumption of life has
occurred.
Clearly, the processes used to keep the door open
for recovery echo a self-management and self-
improvement approach, specifically tailored to pro-
gression. Based on the goals and aspirations of stroke
survivors, attention is given to the psychological,
social, emotional, physical and educational require-
ments to achieve these goals. While this perspective
represents those who chose to attend a stroke
support group or self help group, it highlights the
value of stroke support groups as a positive mechan-
ism for promoting recovery, through which existing
services could work.
What is most striking about the findings of this and
previous studies [19,21,25] is the mismatch between
stroke survivors’ view and their experience of stroke
recovery services. Rather than a long-term view with
no time limit placed on recovery, the services they
received reflect an historical viewpoint that recovery
occurs within a finite period. Emphasis on mobility
seemed to represent rehabilitation priorities devel-
oped prior to the advent of motorized wheelchairs,
mechanical hoists and disabled access that have
enabled greater inclusion in the community. Even
though intensive and repetitive task related practice
is known to promote upper limb recovery, incon-
sistent attention was given to the upper limb during
rehabilitation. The inequity in intensity of exercise
for the upper limb compared with the lower limb
appeared to leave stroke survivors with the sense that
their potential for upper limb recovery had not really
been explored. The difficulties participants experi-
enced in ‘finding out how to keep moving ahead’ is
likely to also reflect the belief that recovery occurs
within a finite period as well as the inability of shorter
term services to address changing needs and goals as
recovery progresses.
Clinical implications for upper limb training
This perspective of upper limb recovery provides
some insight into the experience of upper limb
recovery and an appreciation of the processes used
by stroke survivors to maximize recovery. In an effort
 1222 R.N. Barker & S.G. Brauer
to support stroke survivors in their endeavour, the
outcomes of this study highlight the need to match
services to the individual aspirations of stroke
survivors and to assist them to continue working
for recovery amidst adjusting to life with stroke.
Keeping the door open for recovery implies
removing time limits placed on recovery by health
professionals and stroke rehabilitation services [26]
as well as providing services to promote recovery
from stroke onset until life ends, as previously
suggested [19,23,27]. Accommodating the obvious
budgetary limitations will no doubt demand
creative solutions such as an annual quota of services
that can be accessed by stroke survivors when
difficulties are encountered or further direction
required. A variety of services could address not
only the varying stages of recovery but also the needs
Disabil Rehabil Downloaded from informahealthcare.com by University of Sydney
of individuals. In particular, the provision of an
annual review by an expert stroke recovery team is
indicated.
Ideally service delivery would benefit from a self-
management and self improvement approach that
would prepare and guide stroke survivors through
the psychological, social, physical and educational
demands for recovery. Staged self-management
For personal use only.
training programmes and user friendly information
resources that interface with mainstream rehabilita-
tion services could reinforce and extend the lessons
learnt.
In an effort to thoroughly explore the potential for
upper limb recovery, therapy services need to
consistently implement upper limb training in a
manner shown to promote recovery and of similar
intensity as applied to the lower limb. In the face of
severe upper limb paresis and the difficulties
associated with compliance to exercise in the long
term, new and innovative interventions and services
may be required.
Finally, the benefits of stroke support groups need
to be explored and perhaps formally incorporated
into stroke recovery services. These findings suggest
they offer a tangible resource for support of more
recent stroke survivors as well as a discreet group that
existing services could work with to help maximize
recovery in the long term.
Conclusion
This stroke survivors’ perspective on upper limb
recovery highlights a long-term view of recovery
described as ‘keeping the door open’. To achieve
this, stroke survivors are involved in ‘hanging in
there’ while ‘drawing on support from others’,
‘getting going and keeping going with exercise’ and
‘finding out how to keep moving ahead’. In order to
support stroke survivors in this endeavour, the
findings of this study can be used to guide the
development and delivery of upper limb training
programmes.
Acknowledgements
We would like to acknowledge support given to this
project by the members and friends of the Lockyer
Valley Stroke Support Group and the Acacia Ridge
Young Stroke Group who participated in the focus
group and in-depth interviews and provided feed-
back on the analysis as it proceeded. Not to be
forgotten is Miriam Trevis, the group scribe and
observer who provided her valuable skills during data
collection and transcription of tapes. We are grateful
for the financial support provided by the Toowoom-
ba Hospital Foundation with the award of the 2001
Infront Outback Research Grant and to the War
Widows Guild Queensland Inc., for the award of the
Jessie Mary Vasey Scholarship. Thanks also go to Dr
Alun Williams for assistance in project planning, Dr
Samantha Bursnall, Dr Glenys Carlson and Scott
Kenny for their assistance and advice during data
analysis and Dr Pim Kuipers, Liz Logan and Toby
Gill for helpful comments and editing in the final
stages.
References
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term outcome of arm function after stroke: results of a
follow-up study. Disability and Rehabilitation 1999;21:
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2. Kwakkel G, Kollen BJ, Wagenaar RC. Therapy impact on
functional recovery in stroke rehabilitation: A critical review
of the literature. Physiotherapy 1999;13:457 – 470.
3. Goldie P, Matyas T, Kinsella G. Movement rehabilitation
following stroke. Department of Health Housing and Com-
munity Services: Victoria, 1992.
4. Feys HM, De Weerdt WJ, Selz BE, Steck GAC, Spichiger R,
Vereeck LE, et al. Effect of a therapeutic intervention for the
hemiplegic upper limb in the acute phase after stroke - A
single-blind, randomized, controlled multicenter trial. Stroke
1998;29: 785 – 792.
5. Jorgensen HS, Nakayama H, Raaschou HO, Vivelarsen J,
Stoier M, Olsen TS. Outcome and Time-Course of Recovery
in Stroke .2. Time-Course of Recovery - the Copenhagen
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tion 1995;76: 406 – 412.
6. Dean C, Shepherd R. Task-related training improves
performance of seated reaching tasks after stroke - A
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Nepomuceno CS, et al. Technique to improve chronic motor
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biennial health report of the Australian Institute of Health
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Welfare, 2000.
9. Shelton F, Reding MJ. Effect of lesion location on upper
limb motor recovery after stroke. Stroke 2001;32:107 – 112.

10. McLean DE. Medical complications experiences by a cohort
of stroke survivors during inpatient, tertiary-level stroke
rehabilitation. Archives of physical medicine and rehabilita-
tion 2004;85:466 – 469.
11. Butefisch C, Hummelsheim H, Denzler P, Mauritz KH.
Repetitive training of isolated movements improves the
outcome of motor rehabilitation of the centrally paretic hand.
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12. White G. Consumer participation in disability research: the
golden rule as a guide for ethical practice. Rehabilitation
Psychology 2002;47:438 – 446.
13. Bendz M. Rules of relevance. Social Science and Medicine
2000;51:713 – 723.
14. Hafsteinsdottir TB, Grypdonck M. Being a stroke patient: a
review of the literature. Journal of Advanced Nursing
1997;26:580 – 588.
15. Kwakkel G, Wagenaar RC, Twisk JWR, Lankhorst GJ,
Koetsier JC. Intensity of leg and arm training after primary
middle- cerebral-artery stroke: a randomised trial. Lancet
1999;354:191 – 196.
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16. Holman H, Lorig K. Patients as partners in managing chronic
disease. British Medical Journal 2000;320:526 – 27.
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procedures for developing grounded theory. 2nd ed. Thousand
Oaks: Sage Publications, 1998.
18. Miles MB, Huberman MA. Qualitative data analysis. 2nd ed.
Thousand Oaks, California: Sage Publications, 1994.
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19. Burton CR. Living with stroke: a phenomenological study.
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Nursing 1999;30:401 – 409.
21. Dowswell G, Lawler J, Dowswell T, Young J, Forster A,
Hearn J. Investigating recovery from stroke: a qualitative
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stroke. Rehabilitation Nursing 1992;17:122 – 125.
24. Folden SL. Managing the effects of stroke: the first months.
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Warelow P. Recovery after stroke: A qualitative perspective.
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26. Page SJ, Bach-y-Rita, P. Reconsidering the motor recovery
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Research Articles
Neurorehabilitation and

Translating Animal Doses of Task-Specific Neural Repair

24(7) 620–635
© The Author(s) 2010
Training to People With Chronic Stroke Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav

in 1-Hour Therapy Sessions: DOI: 10.1177/1545968310361957

http://nnr.sagepub.com

A Proof-of-Concept Study

Rebecca L. Birkenmeier, MSOT1, Eliza M. Prager1,

and Catherine E. Lang, PhD1

Abstract
Objective. The purposes of this study were to (1) examine the feasibility of translating high-repetition doses of upper-
extremity (UE) task-specific training to people with stroke within the confines of the current outpatient delivery system
of 1-hour therapy sessions and (2) to gather preliminary data regarding the potential benefit of this intensity of training.
Methods. A total of 15 patients with chronic ( 6 months) UE paresis caused by stroke underwent 3 weeks of baseline
assessments followed by 6 weeks of the high-repetition intervention (3 sessions/wk for 6 weeks). During each 1-hour session,
participants were challenged to complete 300 or more repetitions of UE functional task training (3 tasks 100 repetitions).
Assessments during and after the intervention were used to measure feasibility and potential benefit. Results. For the
13 participants completing the intervention, the average number of repetitions per session was 322. The percentage of
sessions attended was 97%. Participant ratings of pain and fatigue were low. Action Research Arm test scores improved an
average of 8 points during the intervention and were maintained at the 1-month follow-up. Secondary measures of activity
and participation increased, but the measure of impairment did not. Conclusions. It is feasible to deliver hundreds of repeti-
tions of task-specific training to people with stroke in 1-hour therapy sessions. Preliminary outcome data suggest that this
intervention may be beneficial for some people with stroke.

Keywords
stroke, UE, task-specific training, function, translational research

Introduction that hundreds of repetitions of task-specific practice may be

Converging evidence suggests that task-specific practice may
be the best way to promote functional recovery after stroke.1,2
Repeated practice of challenging movement tasks results in
larger brain representations of the practiced movement.3,4
These findings and others from the neuroscience literature5,6
indicate that extended, task-specific practice is critical for
producing lasting changes in motor system networks, motor
learning, and motor function. Paradigms designed to investi-
gate neural adaptations in animal models often require “sub-
jects” to engage in hundreds of daily repetitions of functionally
important upper-extremity (UE) task practice.3,7,8 Studies
designed to investigate motor learning in humans also involve
large amounts of practice, although usually for fewer sessions.
The numbers vary, but different studies have used ranges
between 300 and 800 repetitions per session.9-11 Although the
definitive number of repetitions needed for optimal human
learning is unknown, these paradigms collectively suggest
required to optimize function poststroke.
The reality of stroke rehabilitation is that there is limited
task-specific practice taking place.12,13 In a small pilot study
and a larger, multisite study, we observed that most UE prac-
tice during rehabilitation was devoted to basic exercises,
including both active and passive movements. Substantially
less practice was devoted to movements in functional, task-
specific contexts. Task-specific UE training occurred in only
51% of the therapy sessions that involved UE rehabilitation,
and the average number of repetitions of task-specific training
was 32.13 Thus, the current dose of task-specific practice
1
Washington University, St. Louis, MO, USA
Corresponding Author:
Catherine Lang, Program in Physical Therapy, Washington University,
4444 Forest Park, Campus Box 8502, Saint Louis, MO 63108, USA
Email: langc@wustl.edu

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Birkenmeier et al
provided during stroke rehabilitation is an order of magnitude
lower than what is currently provided in animal models of
stroke and in human motor learning studies.
This proof-of-concept study was an attempt to translate
the high-repetition doses of task-specific training from animal
models to people with stroke. Constraint-induced movement
therapy (CIMT) was one of the first successful translations
of a rehabilitation intervention, from deafferented, nonhuman
primates to people with stroke. CIMT has been found to be
beneficial for those with mild to moderate motor deficits
later14-17 but not more immediately after stroke.18,19 Three
components of CIMT include the following: constraint of the
unaffected upper limb, a behavioral agreement (transfer pack-
age), and high doses of movement training.20,21 The high
doses of movement training, counted in minutes and hours,
not repetitions, are provided in 3- to 6-hour therapy sessions.
Because CIMT has 3 components, the specific benefit of the
movement training is unclear. Additionally, the requirement
of multihour therapy sessions makes it challenging to imple-
ment these high doses in routine clinical practice.22
The purposes of this study were to (1) examine the feasibil-
ity of translating high-repetition doses of UE task-specific
training to people with stroke within the confines of the current
outpatient delivery system of 1-hour therapy sessions and
(2) to gather preliminary data regarding the potential benefit
of these doses. We started this line of investigation in people
with chronic stroke (operationally defined as 6 months)
because their motor deficits and UE function are relatively
stable.23-25 We hypothesized that people could repeatedly
achieve 300 repetitions per session without inducing pain
or significant fatigue and that performing these high-repetition
doses would improve UE function. We chose a target of 300
or more repetitions because 300 is the lower end of the num-
ber of repetitions achieved in the animal and human studies
cited above. Furthermore, we believed that this was likely the
upper limit of what could be achieved in 1 hour and that it
would still make the practiced movements sufficiently chal-
lenging to an individual’s motor capacity.
Methods
This proof-of-concept study was a within-participant,
repeated-measures design (Figure 1). Patients participated in
3 baseline assessments, 1 week apart prior to starting the
intervention. The intervention was 1 h/d, 3 d/wk for 6 weeks
(18 total sessions). During the intervention, brief weekly
assessments were used to gather data on the time course of
changes. Postintervention assessments occurred at the end of
the intervention and 1 month later. The study was approved
by the Washington University Human Research Protection
Office, and all participants signed an informed consent docu-
ment prior to participating.
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621
Figure 1. Schematic of experimental design illustrating
the time course of assessments and treatment; abbreviated
weekly assessments included the Action Research Arm Test
and grip strength
Participants
People with chronic UE paresis poststroke were recruited from
the St Louis metropolitan area via the Cognitive Rehabilitation
Research Group Stroke Registry, from local outpatient stroke
rehabilitation clinics, and from the community. Inclusion
criteria for participation in the study were as follows: (1) clini-
cal diagnosis of stroke, meeting ICD-9 criteria; (2) time since
stroke 6 months; (3) sufficient cognitive ability to participate,
as indicated by scores of 0 to 1 on the Questions and Com-
mands items of the National Institutes of Health Stroke Scale
(NIHSS); and (4) unilateral UE paresis, as indicated by a score
of 1 to 3 on the NIHSS Arm item. Exclusion criteria for par-
ticipation in the study were as follows: (1) severe hemineglect,
as indicated by a score of 2 on the NIHSS Extinction and
Inattention item; (2) inability to follow 2-step commands;
(3) history or current diagnoses of any other neurological or
psychiatric conditions; (4) concurrent participation in other
UE stroke treatments (eg, Botox); or (5) nonavailability of the
participant for assessment or treatment sessions.
The number of participants enrolled was chosen based on a
reasonable number to make an assessment of feasibility and an
a priori power estimate using a repeated-measures analysis of
variance (ANOVA). Based on the parameters entered, estimated
effect sizes ranged from 0.63 to 2.0, with potential participant
numbers ranging from 8 to 44. During the 1-year period of the
study, 27 people were screened, and 15 were enrolled to test
feasibility and to obtain preliminary estimates of the effect size
of the intervention.
Measures
General characteristics (Table 1) of all participants were col-
lected for descriptive purposes. Feasibility measures were
assessed at each treatment session by the therapist providing
treatment. Measures to assess preliminary benefits were
assessed at baseline, during the intervention, and after the
intervention (Figure 1) by the treating therapist or by another
trained assessor. Because all participants received the interven-
tion, none of the assessors was blinded with respect to the
622 Neurorehabilitation and Neural Repair 24(7)

Table 1. Participant Characteristics

Time Dominant Other Stroke-

Age Poststroke Side Side Baseline Related
Participant (years) Gender (months) Affected Affected ARAT Scorea Spasticityb Deficitsc

R001 47 F 36 L N 3 4 Somatosensation
R002 50 M 19 L N 12 2
R003 75 M 12 L N 8 2
R004 55 M 60 R Y 3 4
R005 44 F 6 R Y 38 1
R006 44 F 36 R Y 4 2 Aphasia, Somatosensation
R007 55 F 120 L Y 20 3
R008 28 F 48 R Y 43 0 Aphasia, Emotionally labile
R009 57 M 18 L N 9 3
R010 50 F 48 R Y 40 0 Aphasia
R011 65 F 36 L N 27 2 Ataxia
R012 56 M 57 R Y 20 4
R013 57 F 36 L N 15 1
R014 90 M 48 L N 22 4 Somatosensation
R015 33 M 22 R Y 20 1 Aphasia
Mean/% 54 53% F 40 47% R 53% Y 19 2.2
Abbreviation: ARAT, Action Research Arm Test.
a
Maximum (normal) score 57; value is mean of the 3 baseline scores.
b
Spasticity assessed with the Modified Ashworth Scale52 at the elbow; normal 0, with higher scores indicating greater spasticity.
c
Additional motor and nonmotor deficits as documented from the National Institutes of Health Stroke Scale, clinical examination, and/or medical
records.

intervention. All assessments were videotaped, and videotapes
were reviewed periodically by all assessors together to check
agreement on grading criteria.
Measures of feasibility. The number of repetitions of task-
specific training was recorded for each treatment session and
was the primary measure of feasibility. For any given task, a
single repetition was operationally defined as reaching to,
grasping, moving or manipulating, and releasing an object.
The percentage of sessions attended was used as a measure
of compliance with the intervention. The number of treatment
sessions attended was divided by the number of possible treat-
ment sessions (18) and expressed as a percentage. The duration
of each treatment session was tracked to compare the dose of
treatment provided here with previous and ongoing UE stroke
rehabilitation studies that report dose in minutes. Rest breaks
longer than 1 minute and breaks between tasks were not
counted as part of the duration. Although each session was
scheduled for 60 minutes, the duration was recorded as the
number of minutes that the participant was performing task-
specific practice.
Ratings of pain in the UE were used to assess side effects of
the intervention. The Wong-Baker FACES Pain Rating Scale26
was used to determine the presence and severity of pain at the
beginning and end of each treatment session. Participant ratings
were an overall measure of UE pain and no pain at individual
joints. Pain ratings presented in the Results section are the change
scores for each treatment session—that is, the rating at the end
of the session minus the rating at the beginning of the session.
Ratings of fatigue were used to assess tolerability and side
effects of the intervention. The Stanford Fatigue Visual
Numeric Scale (http://patienteducation.stanford.edu/research/
vnsfatigue.html) was used to determine the presence and
severity of mental and physical fatigue at the beginning and
end of each treatment session. This scale was chosen because
it was the only one that considered mental and physical
fatigue, both of which we thought might be important in this
high-dose intervention. Although reliability and validity of
the Stanford scale have not been published, the psychometric
properties of general numeric rating scales are well estab-
lished.27,28 Fatigue ratings presented in the Results section are
the change scores for each treatment session—that is, the rat-
ing at the end of the session minus the rating at the beginning
of the session.
Measures of preliminary benefit. The Action Research Arm
Test (ARAT) was the primary measure used to assess benefit
of the intervention.29 The ARAT was chosen as the primary
measure because it (1) has a low testing burden, (2) has strong
psychometric properties in people with stroke,25,30,31 and (3)
is widely used in UE rehabilitation trials around the world.
Grip strength, measured on a Jamar hydraulic hand-held
dynamometer,32 was used as a secondary measure to capture
changes in UE impairment.33,34 Three measurements were taken
at each assessment, and the average of the 3 measurements,
reported in kilograms, was used to represent grip strength.
Two subscales of the Stroke Impact Scale (SIS) were used
to capture self-perceived UE function in everyday life, outside

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Birkenmeier et al
of the clinic or laboratory.35-37 The SIS-Hand and SIS-ADL
(Activities of Daily Living) subscales were used. The 2 SIS
subscales were administered by face-to-face interview at
baseline and postintervention assessments.
The Canadian Occupational Performance Measure (COPM)
was used for 2 purposes: as a goal setting tool to aid in choos-
ing appropriate tasks to practice during the intervention and
as an individualized measure of potential treatment benefit.
The COPM is designed to detect changes in a patient’s self-
perception of their own occupational performance over time.38
It is a structured interview that assesses patient-specific areas
of concern and progress in 3 domains: self-care, productivity,
and leisure. The interview results in a list of activities the
individual wants, needs, or is expected to perform.38,39 The
COPM’s 10-point rating scale is then used to indicate the
importance, performance, and satisfaction of these everyday
activities. At the postintervention assessments, participants
were asked to repeat the rating of performance and satisfac-
tion. On both scales, higher scores indicate better perfor-
mance and greater satisfaction with performance on specific,
individualized activities.
Treatment Protocol
The intervention was delivered in 1-hour treatment sessions
by an occupational or physical therapist or by an occupational
therapy student supervised by one of the licensed therapists.
All therapists were trained and monitored to ensure fidelity to
the protocol. Task selection, task grading, and task progression
were discussed and documented for each participant by the
treating therapists. The principal investigator reviewed the
selected tasks, the grading of each task, and the decisions to
change tasks or progress to a more challenging version of the
same task on a weekly basis.
The high-repetition intervention consisted of supervised,
massed practice of functional daily tasks, which were appro-
priately graded and progressed for each participant. Most
functional UE tasks require 4 essential movement compo-
nents: reaching for, grasping, moving/manipulating, and then
releasing an object. What varies across the repertoire of daily
UE tasks is how the combinations of the components are
strung together and the specifics of the component (eg, direc-
tion of reach, type of grasp, manipulative forces required). We
provided progressive training of these essential components
through repeated practice of various tasks, with the desired
goal of building the participant’s capacity to perform a mul-
titude of UE functions.
Participants were given the COPM to assist in determining
activities of interest and specific tasks to address during treat-
ment sessions. An individualized approach to task selection40
and not a general one (all participants do the same tasks) was
selected because severity of paresis and personal interests vary
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623
across people with stroke. Additionally, being given a choice
of tasks may enhance motivation and participation in rehabili-
tation.41,42 The general target number of repetitions of task-
specific training was 300 per session, from practice of 3
specific tasks each session. Three tasks per session ( 100
repetitions per task) were selected to allow for variability in
task practice and to avoid the boredom that might come from
performing 300 repetitions of a single task.
Using information from the baseline assessments, selected
tasks were graded to match the motor capabilities of the par-
ticipants. The job of the therapist was to grade tasks such that
they challenged, but not overwhelmed or underwhelmed, the
motor capabilities of each participant. In other words, we did
not want participants simply repeating tasks that they were
already skilled at performing nor did we want them to repeat-
edly fail at a task. Guiding principles for delivering the inter-
vention were derived from the animal rehabilitation paradigms
and motor learning literature and are provided in detail in the
Appendix. An example of a frequently used task was “lifting
cans on shelves.” This task simulated the real-world activity
of storing and retrieving objects on shelves, such as putting
away groceries. This task could be graded by (1) changing the
size, weight, or shape of the cans; (2) changing the height of
the shelf; (3) changing the location of the shelves with respect
to the participant; and/or (4) changing the depth of the cans
on the shelves. Algorithms were developed to determine when
to progress a task, that is, grade up or grade down, and when
to switch tasks. During each session, the treating therapist
documented the tasks and specific grading levels, the number
of repetitions, and participant ratings of pain and fatigue. More
information and examples regarding task selection, grading,
and progression are provided in the Appendix.
Statistical Analyses
Statistica version 6.1 software (StatSoft Inc, Tulsa, OK) was
used for all analyses, and the criterion for statistical signifi-
cance was set at P .05. Data were found to be normally
distributed. Means, standard deviations (SDs), and 95% con-
fidence intervals (CIs) were generated for the feasibility data.
For the number of repetitions, calculated averages excluded
the first week of treatment (first 3 sessions) because we
expected that participants would require a few sessions to build
up to the 300 repetition target. Repeated-measures ANOVAs
were used on the repetitions, pain, and fatigue data to evaluate
if they increased over the course of the intervention. Our
a priori criteria for determining if the intervention was feasible
were that the average number of repetitions per session would
be 300 and that average percentage of sessions attended would
be 85%. We anticipated that the major consequence of
increased pain or fatigue ratings would be a reduction in the
number of repetitions completed or sessions attended.
624
Figure 2. Number of repetitions achieved at each session for the group (A) and for 2 individual participants (B-D); group values are
means and standard errors
Within-participant, repeated-measures ANOVAs were used
to determine if the intervention provided benefit to participants.
Planned contrasts were as follows: (1) comparison of baseline
assessments to evaluate the stability of the initial motor and
functional deficits, (2) comparison of the baseline assessments
and the first postintervention assessment to evaluate benefit,
and (3) comparison of the first and second postintervention
assessments to evaluate any persisting benefit. Because base-
line scores were not significantly different, baseline scores for
each variable were averaged and used in further statistical
analyses. Comparisons with only 2 time points were done with
paired t tests. Spearman and Pearson correlation coefficients
were used to explore relationships between the feasibility and
outcome data.
Results
Fifteen participants were enrolled, and 13 completed the study.
Table 1 provides descriptive information about the sample.
The sample was heterogeneous with respect to age, time since
stroke, initial UE functional limitations (as measured by the
ARAT), and the presence of deficits in other domains.
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Neurorehabilitation and Neural Repair 24(7)
Feasibility Data
Two participants dropped out: R001 and R004. R001 com-
pleted 4 treatment sessions prior to withdrawing for personal
reasons. R004 completed 8 treatment sessions before with-
drawing. He achieved 300 or more repetitions by the fourth
treatment session but then reported painful leg cramps; over-
flow contractions in his affected lower extremity were noted
during UE task-specific practice. The increased activation of
lower-extremity muscles could have contributed to the leg
cramps, so he was withdrawn. Data are presented from the
13 participants who completed the intervention.
After the first 3 sessions, the average number of repetitions
per session was 322 (95% CI 285-358). Figure 2 shows
group and representative, individual data for the number of
repetitions. As a group (Figure 2A), the number of repetitions
increased over the course of the intervention (main effect of
time, F17,136 7.72, P .0001). Figure 2B shows an example
of someone who achieved nearly 300 repetitions right away and
then fluctuated around 400 repetitions per session. Figure 2C
is an example of someone who took much longer to achieve
the target number of repetitions. The total repetitions during
Birkenmeier et al
Figure 3. Participant ratings of change in pain (A) and fatigue
(B), calculated from numeric scale ratings reported before
and after each treatment session; values are means standard
deviations; negative values indicate that pain and fatigue
diminished at the end of a treatment session compared with the
beginning of that treatment session
the intervention ranged from 3849 to 7568 with a mean of
5476 1088 (SD). The average duration of treatment was 47
3 minutes out of the scheduled 60-minute session (78% of
the scheduled time).
The percentage of sessions attended was 97% (95% CI
94-100). Ratings of pain (Figure 3A) were low, with an average
of 0.3 (95% CI 0.2 to 0.9) out of 10. Ratings of fatigue
(Figure 3B) were somewhat higher and more variable across
participants and sessions, with an average of 1.9 (95% CI
0.9-2.8) out of 10. We recorded numerous instances where
participant ratings of pain and fatigue decreased from the
beginning to the end of the session as represented by negative
change scores. Neither pain nor fatigue ratings increased
over the course of the intervention (main effects of time: pain,
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625
F17,102 1.26, P .23; fatigue, F17,102 0.80, P .69). No
participant reported missing sessions because of pain or fatigue.
Preliminary Outcomes
ARAT data (Table 2) showed a significant repeated-measures
effect overall (F4,48 14.19; P .0001). Initial deficits were
stable, as indicated by no differences between the baseline
ARAT scores (F2,24 0.26; P .77). ARAT scores were higher
after the intervention (t12 3.66; P .003). The average change
score from baseline to the first postintervention assessment
was 8 points (95% CI 4-12 points). No differences were
found between the first and second postintervention assess-
ments (t12 0.23; P .82), indicating that the benefit of the
intervention was largely retained 1 month later. The secondary
measures showed similar results (Table 2), except for grip
strength, which did not change after the intervention.
Figure 4 shows the time course of ARAT changes during
the intervention. On average, ARAT scores increased steadily
during the 6-week intervention (Figure 4A). Exploratory
analyses indicated that improvement during the intervention
may be moderately related to both the initial deficit (baseline
ARAT vs change in ARAT: 0.64; P .02) and the doses of
training received (change in ARAT vs total repetitions: r 0.46;
P .10). The relationship between improvement and the dose
of training received is illustrated in Figure 4B. The dose of
training received was not related to the initial deficit (total
repetitions vs initial ARAT: r 0.14; P .65).
Discussion
Those with chronic UE paresis were able to achieve 300
repetitions of task-specific UE training without inducing pain
or substantial fatigue. Participating in this intervention resulted
in improved UE function as measured by the ARAT. Improve-
ments were also seen on self-report measures of UE activity
and participation but not on the measure of UE impairment
(grip strength).
Feasibility of the Intervention
Our main finding was that the high-repetition intervention was
feasible in 1-hour therapy sessions. Numbers of repetitions
attained and the time course of achieving them varied across
participants and within sessions. A common observation was
that more repetitions were achieved earlier in a session. The
moderate increase in fatigue at the end of each session was
appropriate, indicating that participation required both mental
and physical effort. Our study builds on earlier literature (see
Introduction section) to show that it is feasible to achieve high-
repetition doses of task-specific training in 1-hour sessions. In
hindsight, we wondered if we could have asked for even higher
numbers of repetitions in each session. Achieving even higher
626 Neurorehabilitation and Neural Repair 24(7)

Table 2. Outcome Data (n 13)a

Measureb Baseline 1 Baseline 2 Baseline 3 Post 1 Post 2

ARAT 21.1 3.6 21.4 3.5 21.7 3.3 29.2 4.8c 29.5 4.7c
Grip strength (kg) 14.0 1.9 12.7 1.1 12.0 1.2 14.5 1.5 15.4 1.8
SIS, Hand subscale 45 8 40 9 — 48 8d 49 8d
SIS, ADL subscale 70 6 67 5 — 78 4c 78 3c
COPM, performance 3.3 0.5 — — 5.5 0.6c 5.4 0.6c
COPM, satisfaction 2.8 0.4 — — 5.3 0.7c 5.4 0.8c
Abbreviations: ARAT, Action Research Arm test; SIS, Stroke Impact Scale; ADL, Activities of Daily Living; COPM, Canadian Occupational
Performance Measure.
a
Values are means standard error. For measures taken multiple times during the baseline, no significant differences between baseline assessments
were found. No significant differences were found between the first and second post-intervention assessments.
b
ARAT, 0- to 57-point scale; SIS, 0- to 100-point scales; COPM, 0- to 10-point scales. Higher numbers indicate better results on all scales.
c
P .05 for difference between baseline and postintervention assessments.
d
P .08 for difference between baseline and postintervention assessments.

above 350 repetitions in 1 hour would have required us to make

the practiced tasks easier. This would mean that we would be
more likely to have participants repeat tasks they could already
do quickly instead of challenging their motor capacity. It is
unknown how the number of repetitions performed here com-
pares to the number of repetitions achieved with the modified
form of CIMT43-46 because dose is reported only in time sched-
uled for therapy. Our feasibility results indicate that it is pos-
sible for rehabilitation clinicians to move from providing
minimal amounts of task-specific training12,13 to hundreds of
repetitions within the current outpatient service delivery model.
Our sample contained individuals with deficits from stroke
other than paresis (Table 1): 3 had diminished somatosensa-
tion, 4 had aphasia, and 1 had ataxia in addition to their UE
paresis. The sample was therefore consistent with the clinical
presentation of stroke, where the majority of patients experi-
ence deficits in multiple domains. The manner in which the
intervention was delivered was modified to fit the needs of
people with the other deficits. For example, for those with
aphasia, conversation was limited during treatment sessions
so as to not distract the participant. Paper and a black marker
were provided so that the participant could write down any
statements he or she was having difficulty verbalizing. The
finding that this intervention was successfully applied to
individuals with deficits beyond paresis enhances its clinical
utility.

Preliminary Benefit of the High-Repetition

Figure 4. A. Time course of changes in the Action Research
Arm Test (ARAT) for the group; values are means and standard
errors. B. Scatterplot of total number of repetitions of task-
specific training versus change in ARAT score
numbers in 1-hour sessions is unlikely for 2 reasons. First,
participants were fatigued at the end of the session. Many
provided feedback that they could not continue to work this
hard for another hour. And second, achieving targets much
Dose Intervention
Those participating in this intervention improved their UE
function as measured by clinical tests of UE activity and
participation. The average 8-point change seen here on the
ARAT was larger than a 4-point minimal detectable change
for this measure47 and larger than its 6-point minimal clini-
cally important change identified in people with chronic
stroke17 but smaller than its 12- to 17-point change estimate
in people with acute stroke.48 The magnitude of improvement
seen here is similar to the magnitude of improvement in the

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Birkenmeier et al
experimental groups of other enhanced, task-specific, or
CIMT studies in people with chronic stroke.14,15,17,45,49 As
with other studies, some participants did not respond to the
intervention, and this may be partially related to the severity
of their initial motor deficits. Note that the 2 participants who
dropped out had the most severe initial deficits (Table 1).
From these preliminary data, we can only surmise that this
high-repetition intervention is likely no worse than other
interventions tested.
We propose that the main utility of this intervention is as
a vehicle for investigating the dose–response relationship
between movement practice and functional improvements.
The dose–response relationship is a critical issue facing
neurorehabilitation clinicians and researchers.50-52 Under-
standing the dose–response relationship is important as new
treatments are emerging, particularly for treatments where a
novel agent (eg, drug, robot, cortical stimulation, transcranial
magnetic stimulation) is paired with physical practice. The
number of repetitions is a useful way to quantify dose, either
session-by-session or in total, as is done in animal models of
stroke. The correlation analysis suggests that more repetitions
may result in better outcomes. The time profiles of ARAT
data indicate that patients were improving over the course of
the intervention. Because the duration was set at 6 weeks for
practical reasons, we do not know if continuing the interven-
tion, thereby achieving larger total doses, would have resulted
in greater functional improvements. Further studies are needed
to map the dose–response relationship poststroke and the
potential modifiers of this relationship.
Several limitations should be considered when interpreting
our data. First, we had a small sample, which limits the gen-
eralizability of the findings. Second, the sample was hetero-
geneous. Average data could have masked important findings
in specific subgroups, if there had been a sufficient number
of participants. Third, assessments were not blinded, which
likely introduced bias into our measurement, particularly for
the assessments of benefit. Because of the pilot nature of the
project and amount of available funding, we were unable to
use a blinded rater. Fourth, we did not have a control group.
Although the baseline data indicate that the motor function
was stable prior to the intervention, the improvements may
have been a result of participating in any therapy versus par-
ticipating in the specific intervention tested here.
Conclusions
This is the first attempt to translate the high-repetition doses
from animal models to people with stroke in 1-hour therapy
sessions. Our data indicate that it is possible to achieve 300
repetitions of task-specific UE training without inducing pain
or substantial fatigue. Preliminary outcome data suggest that
this intervention may be beneficial for some people with stroke.
The benefit of the intervention may be a function of initial
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627
motor deficits, with lesser impaired participants performing
better, and the dose of training provided. Further studies are
needed to examine optimal dosing for people with stroke.
Appendix
Treatment Protocol for High-Repetition Task-Specific
Intervention
The high-repetition intervention consisted of supervised,
massed practice of functional daily tasks, which were appro-
priately graded and progressed for each participant. Most
functional UE tasks require 4 essential movement compo-
nents: reaching for, grasping, moving/manipulating, and then
releasing an object. What vary across the repertoire of daily
UE tasks are how the combinations of the components are
strung together and the specifics of the component (eg, direc-
tion of reach, type of grasp, manipulative forces required).
We provided progressive training of these essential compo-
nents through repeated practice of various tasks, with the
desired goal of building the participant’s capacity to perform
a multitude of UE functions.
Guiding Principles for Providing Treatment. Principles for how
the treatment was implemented were developed prior to the
study and are summarized in Table A1. Information on motor
learning principles and animal model paradigms are primarily
derived from recent reviews and chapters.
Matching Participant Goals With Specific Tasks. Participants
were given the COPM to assist in determining activities of
interest and specific tasks to address during treatment sessions.
They were encouraged to select activities/tasks that included
a primary UE component. For instance, an individual who
chose ballroom dancing as a goal was encouraged to identify
another goal because ballroom dancing is primarily a lower-
extremity activity. Using the goals selected by the participant
on the COPM in addition to the subscale scores on the ARAT,
the study therapist was able to choose related treatment activi-
ties even if the participant was unable to perform the whole
task selected as a goal. Every attempt was made to perform
the whole activity as a treatment activity. In cases where this
was impossible, a component of the whole task was chosen.
Examples of goals identified by participants and the tasks
chosen to address those goals are provided in Table A2.
Grading Tasks to Challenge Motor Capabilities. Using informa-
tion from the baseline assessments, selected tasks were graded
to match the motor capabilities of the participant. The job of
the therapist was to grade tasks such that they challenged, but
not overwhelmed or underwhelmed, the motor capabilities of
each participant. In other words, we did not want participants
simply repeating tasks that they were already skilled at per-
forming nor did we want them to repeatedly fail at a task.
(continued)
628
Appendix (continued)
Table A1. Guiding Principles for the High-Repetition Intervention
Principle
Practice of a movement results in
improvement in that movement
Large amounts of practice are
required to truly master a motor
skill
Learning requires solving the motor
problem and not rote repetition of
overlearned tasks
Learning does not occur in the
absence of feedback
Intrinsic feedback is optimal for
promoting self-learning and
generalization
Optimal learning occurs with
high levels of motivation and
engagement
Variable practice conditions
are optimal for learning and
generalization
Within-session, massed practice
promotes learning better than
within-session, distributed practice
Random practice of several tasks
results in better learning than
blocked practice of the same tasks
in healthy adults
This principle is often tested as
randomization of small blocks of
trials of up to 3 tasks
Practice of a whole task results in
better learning than practice of
parts of the task, unless the task
can be broken down into clearly
separable components
Insights and Implementation in Animal
Models and Motor Learning Studies
Animals practice purposeful movements:
reach–grasp–retrieve
Animals perform hundreds of repetitions
daily for up to 3 months
To date, animal studies have not
determined an optimal number of daily
repetitions
Brain reorganization continues for a short
while after behavior plateaus
Brain reorganization occurs with learning
and not simply repetition
Animals have clear intrinsic feedback on
each trial about knowledge of results (ie,
eat the food pellet vs not eat)
Animals are food deprived, and the task is
to retrieve food, creating very high levels
of motivation and engagement
Animals practice a single task under limited Essential movement components stay the same,
variable conditions (eg, changing well
sizes, well locations)
Animals continually perform their
movement task throughout the session
Animals only practice 1 task, so this is not In the current protocol, task practice is done
an issue
Animals practice the whole task of
retrieving and eating a pellet
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Neurorehabilitation and Neural Repair 24(7)
Implementation in Our Protocol
Each task incorporates the essential
components of reach, grasp, move/manipulate,
and release
The target number of repetitions is 300 per
session
Setting the target as instead of allows us
flexibility to see how much participants can be
challenged.
Duration of the intervention (for future studies)
should extend 1 to 2 weeks beyond the
anticipated behavioral plateau
Tasks have grades of increasing difficulty. Rules
for progressing to more difficult grades
are designed to continually challenge the
participant’s motor capabilities
Tasks have clear goals so participants can easily
determine knowledge of results
Participants are given summary feedback on
knowledge of results (number of repetitions
achieved) at the end of each task
Participants help select tasks for practice to
increase engagement and motivation
Tasks can be changed each week to minimize
boredom
Participants practice 3 tasks each session to
minimize boredom
but contexts of the components change
Variation is accomplished across tasks (eg,
practice of 3 tasks, change 1 task weekly) and
within tasks (eg, vary objects, location, weight,
speed, accuracy, etc)
The environment is set up to allow continuous
practice
Participants are given encouragement by the
therapist to continue practicing
Rest breaks are only provided at the request of
the participants
in blocks for simplicity. Future studies are
needed to address this issue
Basic underlying movement components of
reach, grasp, move/manipulate, and release
represent a whole sequence of movements as
performed in the real world
(continued)
Birkenmeier et al 629

Appendix (continued)
Table A2. Examples of Goals and the Tasks Chosen to Address Them

Goal Tasks Chosen to Address the Goal Rationale for Chosen Task

Handwriting Practice writing; incrementally write Handwriting is necessary for signing documents and work duties
faster to improve quality and accuracy
Typing on a Practice typing Typing is often necessary for work, including communication
keyboard (eg, E-mail)
Fishing Picking up fishing lures; sorting a tackle Fishing is an important leisure activity for many individuals.
box Manipulating fishing-related equipment addresses finger dexterity
Playing games Playing Connect Four; dealing cards Playing social games is an important leisure activity for many
individuals. Different games that are of interest to the participant
can be selected to address motor impairments of the proximal
and/or distal upper extremity
Folding towels Folding towels or washcloths Folding is a bilateral activity and an integral part of many household
tasks. Grasping and releasing clothing is important for dressing as well
Stacking and Lift/remove cans onto shelves This task mimics many common daily movements such as unloading
removing cans on a grocery bag and getting out craft/hobby supplies. This task can
shelves be graded to address proximal and distal motor impairments
Sorting silverware Pick up silverware and sort into Silverware is used at most meals. This activity addresses grasp and
container release of objects
Managing and Pick up a variety of coins and place in a Manipulation of money is an everyday task and addresses finger
manipulating coins metal piggy bank with slotted top dexterity
Scrapbooking Cutting paper with scissors Scrapbooking is a growing leisure activity, involving cutting, pasting/
gluing, and manipulating different sized papers and photographs.
The variety of movements required can be structured to address
proximal and/or distal motor impairments

Following the selection of tasks, the participant attempts 3. Changing the weight of task materials
to perform each activity. For example, 1 participant had a. Heavy objects
decreased shoulder range of motion but was able to use her b. Light-weight objects
hand to pick up small objects with decreased coordination. 4. Changing the size of objects
Because she enjoyed playing games with her grandchildren, a. Use large items.
the task of playing Connect Four was selected. During the first b. Use small items (eg, small buttons vs large
attempts at this task, the participant was seated with the Con- buttons).
nect Four grid placed directly in front of her, on dycem (to 5. Using adaptive equipment/materials
prevent slipping). As she continued to improve, the grid posi- a. Use dycem to prevent an item from moving.
tion was moved further away from the participant to challenge b. Allow therapist to hold items in order to sta-
shoulder range of motion. These changes to the activity did bilize task materials.
not occur until the criteria detailed in the Progressing Tasks c. Increase the grip of objects used in tasks (eg,
section (below) were met. use cylindrical foam to increase the size of a
Several universal ways to grade tasks were adopted: pencil/pen for handwriting).
d. Other adaptive equipment may be used as long
1. Physical position of the participant it encourages the performance of the selected
a. Sitting task with the affected UE.
b. Standing
2. Changing the position of task materials.
Keeping Track of the Tasks, Task Grading, and Number of
a. Change the height of task materials.
Repetitions. The solution for keeping an accurate count of the
b. Change the depth/change distance of reach
tasks, task grading, and the number of repetitions in each task
(move task materials closer or further away).
was for the study therapist to record repetitions on an
c. Place task materials midline/right/left of the
materials. (continued)

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630 Neurorehabilitation and Neural Repair 24(7)

Appendix (continued) movement. Again, this activity was related to a goal selected
on the COPM.
easy-to-use form we developed. The form had a separate page
for each task. At the top of the page, there were fields to write Example Tasks and Ways to Grade Them
in the specific task and how it was graded that session. On the
rest of the page, there were numbers from 1 to 150, arranged Activity: writing
in 6 rows of 25. At the start of the session, the therapist filled
in information about the task and grading. During the session, Materials
the therapist made a slash mark through each number as he or 1. Paper
she watched the participant perform each repetition. Whenever 2. Pen
possible, we grouped items used for a given task into groups 3. Pencil
of 5 or 10 to make counting the repetitions task easier. If the 4. Dry erase board
therapist was unsure if all repetitions were counted, the vid- 5. Cylindrical foam
eotapes were reviewed to determine this.
Progressing Tasks. The following rules were used to Method
determine when to progress a task, that is, grade up or grade 1. Patient sits at table with paper and writing utensil
down. Generally, tasks were graded up (made more diffi- of choice at midline.
cult) if the participant had successfully achieved 100 or 2. Patient practices free writing signature or words/
more repetitions in less than 15 minutes for a given task on sentences/paragraphs.
2 occasions. Additionally, if a participant achieved 100 3. Patient can fill out forms similar to those used at
repetitions at the 15-minute mark, the task was graded up work/school.
for an additional few minutes to challenge the participant.
After this occurred on 2 or more occasions, the graded-up Grading
version of the task was adopted and used until the partici-
pant achieved 100 repetitions. Tasks were graded down 1. Increase task difficulty by increasing the number
(made easier) if the participant was unable to achieve 50 of words/components of written work (ie, phone
repetitions of a task within 15 minutes. Tasks were also number, address, form letter).
graded down within the 15 minutes if the participant began 2. Decrease task difficulty by using built-up writing
exhibiting extreme fatigue or was unable to perform the utensil to aid with grip.
task. For example, 1 participant, who was diabetic, expe- 3. Decrease task difficulty by using dry erase board
rienced low blood sugar during 1 treatment session and was and writing large letters, then progress to writing
not performing the task as well as was typical. After provid- on a pad of paper.
ing her with the appropriate food, her tasks were graded Repetition description
down to accommodate her performance level for the rest
of that session. On other occasions, a few participants 1 Repetition Completed signature (pick up pen–
experienced fatigue from not sleeping well and did not write–release pen), or
perform at typical levels. On these occasions, the task was 1 Repetition 1 Word.
graded down as well for that particular session. For both
instances, in the next treatment session, the task was Activity: typing on a keyboard
returned to the pre-event level. Materials
Changing to New, Different Tasks. If a previous activity was
no longer challenging or if the participant desired to do a 1. Computer/Keyboard
different activity, 1 new task could be selected at the begin- 2. Mouse
ning of each week. In cases where the participant was able 3. Typing program (to challenge speed/accuracy)
to perform the whole activity without difficulty (100 repeti-
tions in 15 minutes on 2 occasions), the study therapist was Method
permitted to choose another activity to further challenge the
1. Patient sits at computer table with both hands on
participant, again relying on the identified COPM goals. On
the keyboard.
rare occasions, the participant stated that he or she did not
2. Patient practices typing with both hands using a
like a treatment activity. The therapist then evaluated the
typing program.
treatment activity to determine which movements were being
addressed and selected another activity to work on the same (continued)

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Birkenmeier et al 631

Appendix (continued) Activity: playing games (Connect Four)

Grading Materials

1. Connect Four game

1. Increase task difficulty by typing longer words/ 2. Table
sentences or paragraph.
2. Decrease task difficulty by typing single letters.
Method
3. Increase task difficulty by typing memos dictated
from third party.
4. Increase task difficulty by using a speed/dexterity 1. The Connect Four game board is placed on the
typing program. table at patient’s midline. Checkers are placed on
the table on the patient’s affected side.
Repetition description 2. Patient will be instructed to place checkers in the
Connect Four grid.
1 Repetition 1 Word typed, or
1 Repetition 1 Letter typed Grading

Activity: fishing (sorting tackle box) 1. Increase or decrease task difficulty by changing
the position (depth) of the grid.
Materials 2. Increase or decrease task difficulty by changing
the position of the checkers.
1. 10 Fishing lures 3. Increase or decrease task difficulty by changing
2. Various sized bobbers the height of the table.
3. Fishing weights 4. Increase or decrease task difficulty by changing
4. Tackle box the patient positioning (sitting vs standing).
Decrease task difficulty by placing the grid on
Method dycem to stabilize.

1. Tackle box is placed at patient’s midline.

Repetition description
2. Fishing weights, bobbers, and fishing lures are
placed on the affected side.
3. Patient is instructed to pick up items and place in 1 Repetition 1 Connect Four checker picked up and
the tackle box. released in grid.
4. Patient is instructed to pick up items 1 at a time.
5. Variation: patient can remove specific items from Activity: folding towels
the tackle box and place on the table.
Materials
Grading
1. 20 Wash cloths
1. Increase or decrease task difficulty by increasing 2. 10 Hand towels
or decreasing the size of the items in the tackle 3. 10 Bath towels
box.
2. Increase or decrease task difficulty by moving the
Method
tackle box closer or farther away from the patient.
1. Patient will sit or stand at the table.
Repetition description
2. Patient will fold the towels at midline while sitting
or standing.
1 Repetition Reach, grasp, release 1 fishing item
3. All towels should be folded in half and then in half
into the tackle box, or
again using bilateral UEs.
1 Repetition Reach, grasp, release 1 fishing item
from box back onto table. (continued)

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632 Neurorehabilitation and Neural Repair 24(7)

Appendix (continued) 4. Increase or decrease task difficulty by changing the

weight of objects (light–empty vs heavy–full cans).
Grading 5. Decrease task difficulty by beginning with the
patient just moving objects from the shelf to the
1. Increase task difficulty by alternating the location counter (downward).
of the towel piles to necessitate reach to facilitate 6. Decrease task difficulty by stabilizing objects with
goal movements. therapist assistance while patient is attempting grasp.
2. Decrease task difficulty by decreasing the number
of “folds” necessary to complete the folding task. Repetition description
3. Increase or decrease task difficulty by changing
the number of towels to be folded. 1 Repetition Reach, grasp, release 1 can onto shelf, or
4. Increase or decrease task difficulty by changing 1 Repetition Reach, grasp, release 1 can onto
the size of the towels. countertop.

Repetition description Task: sorting silverware

1 Repetition Towel is folded in half and then in half Materials

again.
1. Fork, spoons, knives (5 of each), standard stainless
Note: therapist unfolds towels in order for the patient to steel
fold again. 2. Fork, spoons, knives (5 of each), standard plastic
3. Sorted utensil container
Activity: lifting cans onto shelves (organizing kitchen shelves) 4. Table/Kitchen counter

Materials Method

1. Twenty 16-ounce cans 1. Patient will sit or stand at the counter, with utensils
2. Countertop with overhead cabinet containing 3 placed on the affected side and sorter placed on
shelves or the unaffected side.
3. Stacking shelves to simulate overhead cabinet 2. Patient will pick up 1 utensil at a time and place
in the correct slot.
Method
Grading
1. Therapist will place all materials on the counter.
2. Patient will stand at the countertop with kitchen 1. Decrease task difficulty by beginning with plastic
shelves directly in front of the body. utensils before changing to stainless steel.
3. Objects will be placed on the lowest shelf. 2. Increase or decrease task difficulty by increasing
4. Patient will be instructed to lift all objects onto the or decreasing the number of utensils to be sorted.
shelf one by one. 3. Increase task difficulty by alternating the position
5. When the patient has lifted all objects onto the of the utensil sorter to necessitate reach to facilitate
shelf, all objects must then be returned one by one goal movements.
to the counter. 4. Increase or decrease task difficulty by standing or
sitting.
Grading 5. Decrease task difficulty by using built-up utensils
to aid with grip.
1. Decrease task difficulty by using bilateral UEs to
complete task. Unaffected UE must be used as a Repetition description
gross assist.
2. Increase or decrease task difficulty by changing
1 Repetition Reach, grasp, release 1 utensil into
the height of the shelf.
container.
3. Increase or decrease task difficulty by changing
placement (depth) of items placed on the shelf. (continued)

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Birkenmeier et al 633

Appendix (continued) Grading

Task: managing and manipulating coins 1. Increase or decrease task difficulty by increasing
or decreasing the size of the paper.
Materials 2. Increase or decrease task difficulty by increasing
or decreasing the thickness of the paper.
1. Various coins (pennies, nickels, dimes, quarters) 3. Decrease task difficulty by beginning with plastic
2. Coin bank loop scissors (childproof scissors) and progress to
standard scissors.
Method 4. Increase task difficulty by changing the type of
line to cut (straight, zigzag, wavy lines).
1. Patient will sit or stand at the table with the coin
bank placed at midline. Repetition description
2. Patient will pick up coins 1 at a time with the
affected UE and place in the slot on the top of the 1 Repetition Cutting 1 line.
coin bank.
Declaration of Conflicting Interests
Grading
The authors declared no conflicts of interest with respect to the
1. Increase task difficulty by alternating the position authorship and/or publication of this article.
of the coin bank to necessitate reach and facilitate
goal movements. Funding
2. Increase task difficulty by rotating coin bank slot, Support for this study was provided by HealthSouth Corporation,
challenging wrist movements. the Missouri Physical Therapy Association, NIH K01 HD047669
3. Increase or decrease task difficulty by standing or (CEL), and NIH TL1 RR024994 (EMP).
sitting.
4. Decrease task difficulty by picking up coins and References
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