OCCUPATIONAL THERAPY INTERNATIONAL

Occup. Ther. Int. 16(34): 175189 (2009)

Published online 5 June 2009 in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/oti.275

Task-specific training: evidence for

and translation to clinical practice
ISOBEL J. HUBBARD, MARK W. PARSONS, Acute Stroke Unit, John Hunter
Hospital, Hunter New England Area Health Service, Newcastle, and the
University of Newcastle, Newcastle, Australia
CHERYL NEILSON, Mt Alexander Hospital, Castlemaine Australia
LEEANNE M. CAREY, National Stroke Research Institute, Florey Neuroscience Institutes, Melbourne, and School of Occupational Therapy, LaTrobe
University, Bundoora, Australia
ABSTRACT: There is mounting evidence of the value of task-specific training as
a neuromotor intervention in neurological rehabilitation. The evidence is founded
in the psychology of motor skill learning and in the neuroscience of experiencedependent and learning-dependent neural plastic changes in the brain in animals and
humans. Further, there is growing empirical evidence for the effectiveness of taskspecific training in rehabilitation and for neural plastic changes following taskoriented training. In this paper, we position the evidence for task-specific training in
the context of rehabilitation; review its relevance for occupation-based neurological
rehabilitation, particularly in relation to upper limb function and everyday activities;
and recommend evidence-driven strategies for its application. We recommend that
task-specific training be routinely applied by occupational therapists as a component
of their neuromotor interventions, particularly in management related to post-stroke
upper limb recovery. Specifically, we propose five implementation strategies based on
review of the evidence. These are: task-specific training should be relevant to the
patient/client and to the context; be randomly assigned; be repetitive and involve
massed practice; aim towards reconstruction of the whole task; and be reinforced
with positive and timely feedback. Copyright 2009 John Wiley & Sons, Ltd.
Key words: motor rehabilitation, stroke, task specific training

Introduction: task-specific training

There is mounting evidence that therapists treating people affected by a neurological disorder should be prescribing task-specific training in their therapy
(National Stroke Foundation, 2005; Winstein et al., 2006; French et al., 2008).
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Task-specific training is a term that has evolved from the movement science
and motor skill learning literature (Schmidt and Lee, 2005) and is defined as
training or therapy where patients practice context-specific motor tasks and
receive some form of feedback (Teasell et al., 2008, p. 576). In the field of skill
learning, it may be associated with different practice conditions, feedback and
conditions of transfer (Schmidt and Lee, 2005; Winstein et al., 2006). Taskspecific training in rehabilitation focuses on improvement of performance in
functional tasks through goal-directed practice and repetition. The focus is on
training of functional tasks rather than impairment, such as with muscle
strengthening. Other terms used that reflect these elements are repetitive functional task practice, repetitive task practice (French et al., 2008), task-related
training (Carr and Shepherd, 1982) and task-orientated therapy (Bayona
et al., 2005).
A strength of the task-specific training approach is in its scientific origins.
The evidence informing task-specific training is based on animal (basic science)
research (Knapp et al., 1963; Nudo and Milliken, 1996; Nudo et al., 1996), has
been developed within the psychology literature of motor control and learning
(Schmidt and Lee, 2005), and has since been applied in human studies with
healthy participants (Schmidt and Lee, 2005) and following injury (Nelson et
al., 1996; Winstein et al., 2004; Michaelsen et al., 2006). Further, there is
increasing evidence of neural plastic changes associated with training (Richards
et al., 2008). Learning is reported to be maximal for the specific task trained
(Schmidt, 1991; Goldstone, 1998). Importantly, repetitive use alone may not be
sufficient to effect changes in cortical representation. Rather, changes are associated with specific skill learning, consistent with a learning-dependent model
of neural plasticity (Karni et al., 1995; Plautz et al., 2000). Neurophysiological
evidence also supports the value of the object used or task undertaken in the
organization of movement (Lemon et al., 1991; Turton et al., 1993). The evidence indicates that cortico-motor neuron pools are organized relative to specific tasks rather than specific muscles. Importantly, evidence suggests that
motor skill learning capability may be retained in stroke survivors under similar
conditions to healthy volunteers (Platz, 2004; Winstein et al., 2006).

Neural plasticity and task-specific training

A major contributor to the theoretical framework informing neuromotor rehabilitation is the evidence concerning brain plasticity. Neuroplasticity refers to
the brains ability to reorganize itself in response to changes in behavioural
demands (Rossini et al., 2003). It is important to remember that this is a capacity
of both the healthy and injured brain, and is therefore always active. Noninvasive technology, such as functional magnetic resonance imaging, provides
an opportunity to better understand how the brains circuits interact with one
another, and to explore the reorganization that occurs when one or more areas
Occup. Ther. Int. 16(34): 175189 (2009)
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DOI: 10.1002/oti

Task-specific training in clinical practice

of the brain are either partially or completely shut down following injury.
Researchers have suggested that in time, therapists should be able to decide on
the most optimal intervention for an individual based on evidence of residual
brain circuits (Guadagno et al., 2003; Dobkin and Carmichael, 2005; Johansson,
2005; Teasell et al., 2005; Duffau, 2006; Carey, 2007; Carey and Seitz, 2007;
Stinear et al., 2007).
Animal studies have demonstrated that task-specific training (e.g. skilled
reaching task) can restore function by using spared (non-affected) parts of
the brain which are generally adjacent to the lesion (Nudo et al., 1996)
and/or recruiting supplementary parts of the brain (Nudo et al., 2000). Many
authors, including Rossi et al. (2007), have detailed the neurobiological changes
underlying the brains reorganization in response to task-specific training,
concluding:
Regardless of concomitant interventions, the extent of functional improvement is strongly dependent on the specific external stimulation that the
rewiring circuits experience. Adaptive cortical reorganization in both intact
and injured CNS is not induced by generic use or activation, but requires
the application of task-specific training protocols. (Rossi et al., 2007, p. 19)
Neural plastic changes have also been demonstrated in the human brain
(Calautti et al., 2001; Carey and Seitz, 2007; Richards et al., 2008) following an
ischaemic stroke and neuromotor interventions. For example, the effect of taskoriented arm training on motor function and brain reorganization has been
investigated in randomized controlled trials with a small number of patients
(Nelles et al., 2001; Carey et al., 2002). Using a task-oriented training regime of
intensive finger movement tracking, improvement in finger control was found
in association with evidence of brain reorganization in chronic stroke patients
(Carey et al., 2002). There are now an increasing number of such studies measuring changes in brain activation patterns following task-specific training
which, although still relatively small in participant numbers, provided enough
data for meta-analysis (Richards et al., 2008). Findings from this analysis suggest
that task-specific training can influence functional outcomes and brain activation patterns.
As summarized by Bayona et al. (2005):
Task-oriented therapy is important. It makes intuitive sense that the best
way to relearn a given task is to train specifically for that task. In animals,
functional reorganization is greater for tasks that are meaningful to the
animal. Repetition alone, without usefulness or meaning in terms of function, is not enough to produce increased motor cortical representations. In
humans, less intense but task-specific training regimens with the more
affected limb can produce cortical reorganization and associated, meaningful
functional improvements. (p. 58)
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Evidence for task-specific training in rehabilitation

Evidence indicates that task-specific training could have relevance for people
affected by a traumatic brain injury (Canning et al., 2003; Chua et al., 2007),
Parkinsons disease (Mak and Hui-Chan, 2008), a total hip replacement (Drabsch
et al., 1998), a work-related injury (McCannon et al., 2005) and/or a spinal cord
injury (Betker et al., 2007; Kubasak et al., 2008). However, most of the taskspecific training evidence relates to post-stroke recovery. It has been found to
be effective in cognitive neurorehabilitation (Calvanio et al., 1993), sensory
retraining (Carey et al., 1993), gait retraining (Hesse, 1999; Peurala et al., 2004;
Sullivan et al., 2007), sit-to-stand retraining (Canning et al., 2003) and motor
training of the upper limb (Feys et al., 1998; Byl et al., 2003; Blennerhassett and
Dite, 2004; Page et al., 2004, 2005; Hakkennes and Keating, 2005; WoodDauphinee and Kwakkel, 2005; Michaelsen et al., 2006; Wolf et al., 2006).
Task-specific training is a core element of a number of interventions, as discussed below. It may be augmented by strategies to enhance learning, as used
in the motor relearning/movement sciences approaches, or to force use of the
limb in daily activities, as in the constraint-induced movement therapy (CIMT)
approaches (Winstein et al., 2006). Equipment or virtual environments may also
be used to facilitate the movement or learning environment. A recent systematic review of repetitive functional task practice in stroke rehabilitation included
31 trials with 1078 participants (French et al., 2008). Overall, it was found that
some form of task-specific training resulted in improvement in global motor
function, and in both arm and lower limb function, although the evidence for
upper limb interventions was less clear because of insufficient good-quality evidence. Nineteen trials, with 634 participants, measured arm or hand function.
The pooled effects for the impact of repetitive functional task training across
all trials showed small effect sizes, which were statistically significant for arm
function and marginally non-significant for the hand. There was little or no
evidence for modification of treatment effects because of time post-stroke or
dosage of task practice. However, for the upper limb, the type of intervention
did impact on treatment effects, with findings from the CIMT studies showing
a large, statistically significant effect. Improvement in activities of daily living
was also reported, and it was recommended that adverse effects should be monitored with this therapy. Retention effects persisted for up to 6 months, with
retention beyond this time unclear. Economic modelling suggested that taskspecific training was cost-effective.
Post-stroke, there is evidence that task-specific, upper limb training not only
impacts functional recovery, but also brain activation patterns. This evidence
includes a meta-analysis by Richards et al. (2008) and a review by Carey and
Seitz (2007). Examples of upper limb, task-specific training used included: taskoriented motor training (Nelles et al., 2001); CIMT and household tasks such
as eating, opening and closing jars and spring-loaded clothespins (Hamzei
et al., 2006, p. 712); CIMT and gross and fine motor skills, such as grasping and
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Task-specific training in clinical practice

using a spoon and picking up an object with a specified grasp (Schaechter

et al., 2002, p. 328); and CIMT and gross motor activities such as throwing a
ball and simulating hockey, and fine motor activities using pegs and putty, and
general activities related to daily living (ADL) (Kim et al., 2004, p. 242). It is
worth noting that much of this task-specific training was supervised by physiotherapists, and the rationale for this is not discussed.

Task-specific training: how does it relate to current interventions?

It will be increasingly obvious to the reader that firstly, the term task-specific
training is part of a broad range of interventions, and secondly, it is difficult
to differentiate it from routinely used neuromotor interventions in current
occupational therapy practice. For occupational therapists, neuromotor interventions have been historically driven by three primary approaches: neurodevelopmental, sensorimotor and motor relearning approaches (Trombly, 1995;
Umphred, 1995). The Bobath (1980) approach, sometimes referred to as neurodevelopmental therapy (NDT), is based on the concept of abnormal patterns
of movement and stresses the importance of breaking down the abnormal or
maladaptive patterns with the use of limb and trunk positioning and/or weight
bearing, and is still very much in use today (Langhammer and Stanghelle,
2000). Walker et al. (2000) surveyed therapists in the United Kingdom and
found that most reported that they used the Bobath approach when treating
stroke patients. While the approach focuses on patterns of movement, it also
includes incorporation of these movement strategies in daily activities, once
improvements in patterns of movement have been achieved (Davies, 1994), and
thus has an element of task-specific practice. It does not, however, recognize
that movement is organized according to the object used or the environment.
The sensorimotor approach, originating from the research of Ayres (1965)
and further developed by others [e.g. Case-Smith (2005)] is based on theories
of a childs healthy development through a series of motor skill milestones.
Ayress approach, although primarily aimed at paediatric neurorehabilitation,
has also been used in adult neurorehabilitation (Moulton, 1997). In the sensorimotor approach, therapists selected tasks and activities which enabled them
to modulate the amount of stimulation and were of interest. The sensorimotor
approach has some similarities, therefore, with task-specific training in that it
is task orientated, uses tasks which are meaningful to the patient and involves
repetition and practice. It does not, however, incorporate motor learning
principles.
The motor relearning approach, as described by Carr and Shepherd (1982,
2000), is derived from the movement science literature and incorporates principles closely aligned with task-specific training. It includes isolated training
practice of impaired essential movements, and then immediate practice within
the relevant, specific functional task. As such, it emphasizes specific training of
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motor control in everyday activities and represents a shift away from facilitation
of movement and exercise therapy. This approach formally identifies the task
as integral to effective motor relearning. The repetitive task training is combined with techniques to enhance cognitive involvement (e.g. through functional relevance of tasks used and knowledge of performance). Task-specific
training is most closely related to the motor relearning approach, but the two
are not synonymous.
An approach that has gained interest more recently and is supported by
evidence from animal studies (Knapp et al., 1958, 1963; Taub et al., 1993; Nudo
et al., 1996) and systematic review (Hakkennes and Keating, 2005) is CIMT.
CIMT is primarily designed to reverse the conditioning that leads to learned
non-use and aims to promote spontaneous use of the hand through using of
shaping procedures (Taub et al., 1993, 2002). The approach involves a constraint applied to the less affected limb and intensive upper limb training of the
more affected limb. The shaping procedure is based on operant conditioning,
with the aim of eliciting a behaviour (task goal) and reinforcing it (positive
feedback). This involves intensive periods of task practice using shaping and
progressive increments in task difficulty, feedback and encouragement (Wolf
et al., 2002). Although the approach is task based and involves practice of
graded activities, the focus is not on the acquisition of a voluntary skill nor the
optimization of motor skill learning (Winstein et al., 2006).

Task-specific training and use of everyday activities

It is recognized that movement emerges from an interaction between the individual, the task, and the environment in which the task is being carried out
(Shumway-Cook and Woollacott, 1995). This model is consistent with the taskoriented, occupation focus of occupational therapy. It has been suggested that
the organization of movement of the upper limb for reaching is positively influenced by the conditions in which it is undertaken (Trombly and Wu, 1999).
Further, movement kinematics of the upper limb are different under different
conditions, from real-life action to simulated conditions, in healthy volunteers
(Ross and Nelson, 2000). Similarly, van Vliet et al. (1995) found that there was
a difference in movement kinematics of the upper limb when undertaking a
more functional goal of drinking from a glass compared to only moving a glass
of water, further highlighting the goal of the task. Wu et al. (2000) concluded
that the use of real and functional objects might be an effective way of facilitating efficient, smooth and coordinated movement with the impaired arm after
stroke.
Task-specific training often uses real-world or everyday tasks as the therapeutic medium in functional recovery. In combination with high levels
of massed practice, it aims to achieve optimal function, which in turn allows
the patient/client to adequately undertake everyday activities (Dobkin and
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Task-specific training in clinical practice

Carmichael, 2005). To review the importance of tasks and everyday activities

in neurorehabilitation, and further, to report this to occupational therapists
could well be preaching to the converted. However, the authors would suggest
that this body of evidence serves to validate the focus of occupations, tasks and
activities in neuromotor interventions. Suffice to say that researchers and
opinion leaders are in agreement that there is ample evidence to support neuromotor interventions, which are task specific and based in and around everyday
activities (Blennerhassett and Dite, 2004; Mathiowetz, 2004; Bayona et al.,
2005; Dobkin and Carmichael, 2005; Teasell et al., 2005; Kelly et al., 2006). In
this context, we may define task-specific training as: training or intervention
which utilizes, as its principal therapeutic medium, ordinary everyday activities
which are intrinsically and/or extrinsically meaningful to the patient or
client.
Recommendations for application of task-specific training in clinical
practice
Taking into consideration the limitations and strengths of the evidence available, the authors recommend that: task-specific training be routinely applied by
occupational therapists as a component of their neuromotor interventions,
particularly in post-stroke upper limb management. Further, authors/researchers
should consider using task-specific terminology if reporting on outcomes relating to neuromotor interventions, particularly those based in and around everyday tasks, occupations and/or activities.
Following a review of the task-specific evidence, it is also possible to recommend five strategies to guide application of task-specific training in clinical
practice. These are consistent with guidelines put forward by others (e.g. Byl
et al., 2003; Mathiowetz, 2004; Bayona et al., 2005; Dobkin and Carmichael,
2005; Carey, 2006; Davis, 2006; Krakauer, 2006). The strategies are presented
in practice-ready dialogue with the aim of assisting therapists in translating
them into clinical practice. To facilitate recall, they have been formulated as
the five Rs: (i.e. task-specific training should be relevant, randomly ordered,
repetitive, aim towards reconstruction of the whole task and positively
reinforced).
Strategy 1: task-specific training should be relevant to the patient and to the
context
Firstly, it should involve activities which are intrinsically and/or extrinsically
meaningful to the patient (Byl et al., 2003; Bayona et al., 2005; Davis, 2006).
A patient-generated index such as the Canadian Occupational Performance
Measure (Law et al., 2005) can be used to formally identify these tasks,
and this, in turn, can serve as an outcome measure for later reassessment. The
evidence infers that to spend large amounts of time and effort on tasks and
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activities which, although appearing important to the therapist and/or institution, have no such value for the patient, could be counterproductive.
Secondly, evidence indicates that where possible, the task trained should be
real world or context specific (Shumway-Cook and Woollacott, 1995). For
example, if a patient/client is relearning to use a knife and fork, then they should
be doing this in sitting and if possible, with real food and using ordinary cutlery
and crockery. This evidence supports the move in many neurorehabilitation
settings to set up the treatment environment to reflect the usual home and/or
community environment. Some may also refer to this as enriching the environment (Johansson, 2005; Davis, 2006).
Strategy 2: task-specific training practice sequences should be randomly ordered
Task variability has been identified as important to increasing generalisation of
learning to new tasks (Krakauer, 2006, p. 85). Further, evidence indicates that
utilizing randomly ordered practice facilitates retention and transfer, thus
increasing the tasks generalizability (Schmidt and Lee, 2005). Task-specific
therapy, therefore, should be random in its application using differing contexts
and settings, and differing occupational demands and sequences (Bayona et al.,
2005; Dobkin and Carmichael, 2005; Teasell et al., 2005; Davis, 2006). If taskspecific training is too task or movement specific, and applied in only one
context or sequence, then potentially the skills re-learned or learned are not as
readily applied across similar tasks and alternate settings. Clearly, there are times
when this is neither practical nor feasible (e.g. showering), but for the most part,
where possible, therapists should randomly schedule therapy routines and task
selection.
Strategy 3: task-specific training should be repetitive
Task-specific training should be repetitive and involve massed practice (Schmidt
and Lee, 2005; Winstein et al., 2006). The old adage of practice makes perfect
applies in this context as it is practice which assists the healthy and injured
brain alike to master skills and to reorganize to accommodate the new learning. Most researchers (Blennerhassett and Dite, 2004; Mathiowetz, 2004; Bayona
et al., 2005) recommend that the more a task is practiced, the better the overall
performance. However, Page (2003) suggested that task specificity is clinically
more significant than intensity, and recommends that task-specific training is
still worth considering even if patients are not able to manage high-intensity
treatment regimes.
Bearing in mind that for much of the day, patients in hospital are frequently
doing very little (Bernhardt et al., 2007; Hubbard and Parsons, 2007), therapists
should assume that more is better and that most patients are not practicing
enough. It is recommended that the maximum amount of repetition feasible
should be prescribed in task-specific, neuromotor interventions and that the
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Task-specific training in clinical practice

task-specific environment should be as occupationally demanding as possible

(Johansson, 2005), with every opportunity afforded to patients to practice realworld tasks (Teasell et al., 2005).
Strategy 4: task-specific training should aim towards reconstruction of the whole
task
When formulating a treatment plan, a therapist will:
deconstruct a task into its component parts
assess the patients performance of the whole task and of its component
parts
identify which skills and/or component parts are adversely affected and
why
formulate a treatment plan targeted at the mismatch between can do and
need/want to do.
Task-specific training should start with skill acquisition and massed practice
of the individual component parts (shaping) (Page et al., 2005), moving towards
the regrouping and normal sequencing of some, most and, if feasible, eventually
all of the component parts. However, in the midst of all the planning, prescribing, goal setting, documenting and discharge planning, the achieving of whole
tasks may become lost in the day-to-day activity of the neurorehabilitation
setting. Nevertheless, the overriding goal should be the reconstruction of the
whole task to maintain focus and motivation.
The evidence suggests that it is unwise to simply prescribe a series of selfdirected upper limb exercises, with an increasing dose of practice which, although
seemingly advantageous, bears no relationship to the mastering of a task that
is important to the patient. If the patients interest and motivation are to be
maintained, task-specific interventions should be in the context of eventual
mastery of a whole task that has been identified as relevant. Further, interventions should include complex tasks as a means of involving more regions of the
brain in the reorganization response (Mathiowetz, 2004; Davis, 2006; Kelly
et al., 2006; Krakauer, 2006).
Strategy 5: task-specific training should be positively reinforced
The evidence indicates that task-specific therapy should include timely and
positive feedback, but that all rewards should fade over time to prevent unnecessary dependency (Mathiowetz, 2004; Dobkin and Carmichael, 2005; Seitz, 2005;
Davis, 2006). Therapists can enhance the feedback environment by using commentary and positive encouragement; however, this augmented reinforcement
or artificial feedback should fade over the duration of a task, session and admission as it is potentially maladaptive. Dobkin and Carmichael (2005) recommend
that this feedback is always positive.
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The five strategies arise out of the task-specific evidence and expert commentary. Again, much of this may not be new to readers, but may provide evidence to support practices already applied. However, there is some evidence that
the inpatient setting particularly can raise competing agendas for therapists
(Danils et al., 2002), and these strategies may serve to refocus the efforts of
therapists in their prescription of neuromotor interventions.
Implications of task-specific training for occupational therapists and future
practice
The evidence relating to task-specific training has direct application to occupational therapy practice and resonates with the theory and ideology associated
with occupational science (Christiansen and Townsend, 2004) and occupational therapy. The strategies are steeped in long-held, professional values concerning client-centred practice and the importance of involving the patient/client
in goal setting and rehabilitation agendas (Armstrong, 2008). However, while
the premise of occupation and our approach to learning new motor skills are
highly consistent with task-specific training, it is not a term that is commonly
used by us. Further, despite the growing evidence for task-specific training,
rehabilitation is commonly based instead on accepted practice or custom. The
theoretical and empirical foundations for task-specific training, derived from
research on brain plasticity and motor learning, provide a strong, evidencebased platform for occupational therapists to confidently select neuromotor
interventions which involve task-specific training and everyday tasks and
activities.
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