Task Specific Practice in
Neurorehabilitation
Darcy Reisman, PhD, PT
Associate Professor
Physical Therapy
Biomechanics & Movement Science
University of Delaware
Task-specific practice/training
• repetitive practice of a task that is specific
to the intended outcome (Sullivan et al,
2007).
• systematic and repetitive practice of
functional tasks (Winstein et al, 2004)
Why is task specific practice
important in neurorehabilitation?
• Neuroplasticity
• Motor learning
…cells that fire together wire together…
Kandel, Schwartz & Jessell, Principles of Neural Science, 2000
Based on the article by Kleim and Jones, 2008
• Principle 3: Specificity Matters
• Changes in specific brain areas occur relative
to the task that is practiced
• Skilled practice results in changes in neural
connectivity
• Squirrel monkeys trained to retrieve pellets from the smallest
well possible for 30 min for at least 11 days or until the
number of daily retrievals was greater than 600 for 2
consecutive days showed substantial changes in their digit
representations.
Nudo et al, 1996
•Skilled practice results in changes in
neural
• Rats
thatconnectivity
learned to reach onto a rotating
platform for pellets displayed more distal
changes in their motor maps compared to rats
who learned to press a bar.
Kleim et al, 1998
Why is task specific practice
important in neurorehabilitation?
• Neuroplasticity
• Motor learning
Motor Schema Theory
(R. Schmidt, 1975, 2003)
• Subjects learn a schema or rule (algorithm) for
producing an action.
• Learning the rule requires practice under a range
of task conditions or environmental constraints.
• Once learned and practiced under a sufficient
range of conditions, the rule can be used to
extrapolate performance to a broader range of
conditions or constraints not previously
encountered.
Lashley (1942) classic study
• blindfolded subjects wrote words with their
dominant hand, nondominant hand, and foot. The
similarity of the individual’s handwriting
characteristics under the different conditions and
with different effectors was remarkable
Keetch et al (2005)
• Skilled basketball players produce set shots from a variety
of locations.
• Greater percent success from the foul shot location,
suggesting that massive amounts of practice from this
location result in greater skill at this specific task.
Summary
Data from animals and healthy humans suggests
that specificity of training is important for
neuroplasticity and motor learning
How does this apply to persons with neurological
injury or disease?
How specific should the practice be? Does my
patient have to practice each specific task they need
to accomplish?
What about other important features of practice?
Task specific training
How specific is specific enough?
Shah et al 2012
• Trained 20 spinal rats walking on the treadmill in
either forward, sideways or backward directions over
28 sessions
• Tested walking in forward direction on treadmill
• Rats trained in backward and sideways direction
had greater step consistency and coordination and
greater muscle activity during forward walking
Schaefer et al., 2013
•
Trained 11 persons with chronic stroke on a simulated
feeding task over 5 days with 50 trials of practice/day
•
Tested for improvements on feeding task and on
buttoning and sorting task
•
Improvements observed on both the trained and nontrained tasks
Sullivan et al., 2007
•
Trained 80 persons with chronic stroke in 4 groups
• The resisted cycling program incorporated some of the weightbearing and task-related demands of walking including cyclical
activation of flexor and extensor muscles in a locomotor like
pattern.
• Are similar improvements in walking speed observed between
the 2 tasks?
•
4 one hour sessions/week for 6 weeks (24 sessions)
•
BWSTT - 5 min bouts at 1.5-2.0 mph for total of 20
minutes of walking in the one hour session
• CYCLE - Loaded limb resisted cycling on Biodex semirecumbent bike. 10 sets of 15 to 20 revolutions in each
session. At least 2 minutes to rest between sets
• 
BWSTT/UE-EX
•  CYCLE/UE-EX
Winstein et al, 1989
• 21 post-acute persons with stroke received
standing balance training to improve asymmetry
over a 3-4 week period. All subjects improved
static standing asymmetry but did not improve
asymmetry in walking after stroke
Summary
• Data suggests that when tasks share important
key features, practice on one task will “transfer”
to the other.
• Postural requirements critical?
Other important principles for
neuroplasticity and motor learning
• Principle 4: Repetition Matters
• Repetition of new task required to see neural
changes
• Changes at the neuronal level not observed
until significant repetition of new task, even
when behavioral improvements observed
Kleim & Jones, 2008
• Rats trained in skilled reaching showed improved
accuracy at 3, 7, 10 days of training.
• No
difference in accuracy between 7
and 10 days, even though map
changes continued.
Kleim et al, 2004
• Amount of practice is the single MOST
important variable affecting motor learning
(Schmidt & Lee, 2011)
Ericsson et al, 1993
Baker and Cote, 2003
• Principle 5: Intensity Matters (Kleim & Jones, 2008)
• High intensity stimulation = long-term potentiation
• Low intensity stimulation = long-term depression
• 1800 stimuli of 5 Hz transcranial magnetic
stimulation, but not 150 stimuli, can induce a
long-lasting and muscle-specific increase in
resting corticospinal excitability (Peinemann et al, 2004).
• Need to differentiate between intensity and
repetition
Intensity and repetition are as
important as task specificity
Yang et al, 2012
• Trained 20 persons with chronic spinal cord injury on
obstacle walking vs. BWSTT for speed and endurance
• Primary outcome: SCI-FAP - (7 tasks: (1) Carpet, (2) Up &
Go, (3) Obstacles, (4) Stairs, (5) Carry, (6)Step, and (7)
Door).
Hypothesis was that task-specific over
ground obstacle course training would
result in greater improvements.
• High specificity, but low intensity and limited
repetition = less improvement
Duncan et al, 2011
LEAPS trial
• Randomized 408 sub-acute
stroke survivors into 3 groups:
early locomotor training, late
locomotor training or home
based PT.
• Average HR in locomotor
training groups was 90 bpm and
in home therapy group was 77
bpm
Variability, challenge and errors are critical
aspects of task specific practice. Without
these components, benefits of task-specific
practice are reduced.
Assist as needed robotic locomotor training is
superior to standard robotic training providing full
assistance in animal models of SCI….
Ziegler et al, 2010; Lee et al, 2011
…and in persons with chronic stroke (Krishnan et
al, 2013)
Full assist assist as needed
The opportunity to make and correct errors
is important for learning
Error augmented practice may be superior to repetitive task
practice alone in those with chronic stroke
(Reisman et al, 2013)
Summary
Repetition, intensity and variability (opportunities to
make and correct errors) are just as important as
task specificity of practice and should be considered
when designing neurorehabilitation interventions
How can I apply these principles in my
patients with neurological injury/disease?
One major goal of PT is to return
patients to their previous level of
function and community
participation
Recovery: return to, or emergence of, a
desired level of function
 as viewed from the perspective of the
patient and family
 What does the patient
want/need to do that
they currently cannot do
 Set goals relative to these
activities and then….
PREPARE
• Preparation is key
• Identify all aspects of the desired activity
•Need variety of objects
•Need variety of contexts –
•total trips into community after stroke
predicted by postural transitions and temporal
characteristics (Robinson et al, 2013)
•Need appropriate assistance
•Need to increase intensity
•Practice specific to goals, increase
challenge and variability
Summary
• Task specific training of sufficient
intensity and repetition is important
following neurological injury/disease in
order to optimize neuroplasticity and
motor learning.
• Tasks trained need to share general
characteristics with desired task
References
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