Research shows that practicing arm movements related to daily living goals may be more effective at improving arm function than standard exercise. Maximize your post-stroke rehab routine by incorporating task-specific training.

Rehab with Real-World Objects for Improved Hand Use After Stroke

If you've been through stroke rehabilitation, chances are that you're familiar
with the phrase, "use it or lose it". Your therapist likely told you this while
explaining the principle of neuroplasticity
[https://www.neofect.com/us/blog/tips-for-unlocking-neuroplasticity-after-stroke-part-1]
, the brain's potential to reorganize after damage to regain lost functions.
Hopefully "use it or lose it" has helped you remember to engage your weaker arm
throughout the day in order for it to make progress!

Here's another catchy rehab phrase for your repertoire: "you gain what you
train". Research shows that practicing arm movements related to daily living
goals may be more effective at improving arm function than standard,
non-goal-directed arm exercise. Basically, if you want to be able to hold eating
utensils or write with your affected arm, you're better served by putting a fork
or a pen to use than you are by lifting a dumbbell or pinching putty.

"You gain what you train" seems obvious, right? So, why belabor the point? 
Because many stroke survivors are not practicing real-world skills with their
affected arm on their own time. Learning a new skill requires hours of practice
and thousands of repetitions. Stroke survivors must ensure they are dedicating
sufficient time at home to addressing their specific arm use goals in order to
improve.

Think about your current post-stroke home exercise program. Does it go beyond
basic stretching and strengthening? If not, consider incorporating task-specific
training into your routine to maximize arm and hand function.



Task-specific training overview
 * What is task-specific training (TST)?
 * Who can do TST?
 * How can I do TST at home?
 * How much should I do TST?
 * What if I can't do TST?
 * Do I have to do TST after stroke?
 * TST: The Bottom Line

What is task-specific training (TST)?
Task-specific training is a therapy technique focusing on improving function of
a hemiplegic (weakened)
[https://www.neofect.com/us/blog/hemiplegia-vs-hemiparesis] arm through repeated
activity practice. Just like how you learned to tie your shoes or ride a bike, 
TST requires consistent performance of the component steps of a task to help the
brain re-learn the big-picture skill.

Task-specific training activities for the post-stroke hemiplegic arm incorporate
a real-world object and involve the following four steps:

 1. Reaching for the object
 2. Grasping the object
 3. Moving or manipulating the object
 4. Releasing the object

Ideally, a participant will repeat this sequence many times over multiple
sessions to show skill improvement. Research studies generally indicate that
more repetitions and a greater frequency of training are better.

 Who can do TST?
Stroke survivors with sufficient movement to repeatedly reach for an object,
hold on to it, and release it using their affected arm are good candidates for
TST.

Anyone with activity restrictions on their affected side, or those who
experience pain when using their affected side should consult with their medical
team before attempting TST.



How to do task-specific training at home:
First, think about what you would like to be able to do better using your
affected arm and hand. TST goal activities should be centered around a task that
has clear and consistent steps and also involves an object. Although that might
sound complicated, there are countless TST possibilities available in your home
using your everyday belongings. Any of the following ideas make for great TST
goals:

 * Using a cup, fork, or spoon
 * Brushing your hair
 * Pulling your pants up
 * Turning a book page
 * Opening a door handle
 * Writing your signature
 * Putting coins into a piggy bank
 * Hammering a nail
 * Putting laundry into a basket

TST skills can also involve your unaffected hand. Consider using your affected
hand in the dominant role of a two-handed task, while letting your stronger hand
play the role of helper or stabilizer.

 * Fastening buttons or zippers
 * Tying shoelaces
 * Opening containers
 * Pouring liquid from one container into another
 * Putting credit cards into a wallet
 * Wringing out a wet washcloth
 * Putting a stamp on an envelope
 * Folding laundry into halves or quarters

Because TST involves repeating the steps of an activity using your affected arm,
we need to think about how to measure performance. Completing a reach, grasp,
manipulate, release sequence is considered one repetition of a task. The goal of
TST is to complete as many repetitions as possible. View the examples of
measuring one repetition from the TST tasks on our list above:

Using a spoon: Pick up the spoon from the tabletop, bring it up to your mouth,
put it back on the tabletop, return hand to starting position
Writing your signature: Pick up the pen from the tabletop, bring it to paper to
write your full name, put the pen back on the tabletop, return hand to starting
position
Note: The affected arm starts and ends in the same position relative to the task
object/s (e.g. on the tabletop next to the object)

Putting credit cards into a wallet: One repetition = pick up credit card from
tabletop, insert and remove credit card from wallet (held by unaffected hand),
place credit card on tabletop, return hand to starting position
Note: For a two-handed task, you may choose to repeatedly pick up the stabilized
object using your unaffected hand, or hold it throughout the task

After you have defined your activity and what a repetition looks like, you're
ready to go! You may choose to practice one activity in a TST session, or, for a
longer session, you may pick two or three goal areas.



 How much and how often should I do TST?
Studies show that between one and five repetitions of a task per minute may be
ideal to promote improved arm function. Gauge your performance by performing a
15-minute TST test. Have a helper time the number of repetitions you can do
during this period. If you have achieved between 15 and 100 repetitions, you're
in the TST sweet spot: continue practicing the skill! If you are over 100
repetitions, it is time to make the task more difficult by adding more complex
elements (e.g. using heavier objects, attempting the task from standing as
opposed to sitting). If that is not possible, try practicing a different, harder
skill.

Research has also demonstrated that completing 60 minutes of task-specific
training four times per week can produce significant arm function improvements.
This is an amount that you may have to build up to. If one hour seems daunting,
try to ease into TST by attempting increasingly longer intervals, aiming for 5
more minutes of TST each time you practice.

 What if I can't do task-specific training?
Stroke survivors who have some but not all required arm functions to perform TST
may choose to perform a modified version incorporating only the elements within
their capabilities. For instance, TST might consist of repeatedly reaching to
tap an object with the hand as opposed to grasping and releasing it.

If you have minimal to no movement in your affected arm, you will not be able to
perform TST. However, your affected side can still play a role in your daily
living tasks. Use your stronger side to place your affected arm within your
field of vision during tabletop tasks. If you are doing a two-handed task, use
the stronger arm to place the weaker arm to hold or stabilize objects. Even
though doing this is not TST, you are still promoting function of your affected
side while preventing learned non-use.

Do I have to do task-specific training after stroke?
TST is just one tool in your upper extremity stroke rehab toolbox. There are
several other evidence-supported activities
[https://www.neofect.com/us/blog/the-top-5-evidence-based-treatments-for-improving-hand-function-after-stroke] 
that may improve arm and hand function. Some people may not be able to perform
TST without the guidance of a therapist, while others may not be motivated by
the intervention. If you have questions on how to perform TST at home or whether
it is the right option for you, consult with your therapy team.



The bottom line: practice means progress
We'll conclude with one final catchy rehab phrase: "practice means progress".
Needless to say, improving weakened arm function after a stroke can be a long
and sometimes frustrating ordeal. However, additional keys to success are right
in front of you in the forms of your daily tasks and personal belongings. With
practice and repetition, your goals are within reach!

References

French B, Thomas LH, Coupe J, McMahon NE, Connell L, Harrison J, et al..
Repetitive task training for improving functional ability after stroke.Cochrane
Database Syst Rev. 2016; 2016:CD006073. doi: 10.1002/14651858.CD006073.pub3.

Hatem, Samar M et al. “Rehabilitation of Motor Function after Stroke: A Multiple
Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery.”
Frontiers in human neuroscience vol. 10 442. 13 Sep. 2016,
doi:10.3389/fnhum.2016.00442

Lang, Catherine E et al. “Counting repetitions: an observational study of
outpatient therapy for people with hemiparesis post-stroke.” Journal of
neurologic physical therapy : JNPT vol. 31,1 (2007): 3-10.
doi:10.1097/01.npt.0000260568.31746.34

Waddell, Kimberly J et al. “Does Task-Specific Training Improve Upper Limb
Performance in Daily Life Poststroke?.” Neurorehabilitation and neural repair
vol. 31,3 (2017): 290-300. doi:10.1177/1545968316680493

Waddell KJ, Birkenmeier RL, Moore JL, Hornby TG, Lang CE. Feasibility of
high-repetition, task-specific training for individuals with upper-extremity
paresis. Am J Occup Ther. 2014;68(4):444-453. doi:10.5014/ajot.2014.011619


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Call us (888) 623-8984 [tel:+18886238984] or email us at info@neofect.com to 
rehab smarter with Neofect today.


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Hand Rehab

Rehab With Real-World Objects for Improved Hand Use After Stroke

We sifted through the research for you to explain the top 5 medically proven methods for hand rehabilitation: Constraint‐induced movement therapy (CIMT), Mental practice, Mirror therapy, Virtual reality, High dose repetitive task practice.

Hand Rehab after Stroke: The Top 5 Evidenced-Based Methods

After a stroke, it’s challenging enough to navigate the medical system to find
what services you need, let alone the right treatment approach for you. 

You've probably heard a lot of recommendations on how to recover hand function
after stroke, and everyone seems to give different advice. That's why we sifted
through the research for you. We'll explain the top 5 evidence-based methods for
hand rehabilitation, why they work, and who they work for.

The top 5 evidence-based treatments for improving hand function after stroke:
 1. Constraint‐induced movement therapy (CIMT)
 2. Mental practice
 3. Mirror therapy
 4. Virtual reality
 5. High dose repetitive task practice

Constraint-Induced Movement Therapy
You can restrict your unaffected side at home by wearing an oven mitt or placing
it inside your pants or sweatshirt pocket. This will help remind you to rely on
your affected side when completing therapy tasks.
What it is:

Constraint-Induced Movement Therapy (CIMT) is a neuro-rehabilitation method
where the non-affected hand is constrained or restricted in order to force the
brain to use the affected hand, thereby increasing neuroplasticity.

There are two key components: constraint and shaping.

Constraint refers to the way in which the hand is restricted. Therapists have
used casts, splints, and mitts to restrict the use of the non-affected hand.
None of them have been shown to be more effective than the other.

Shaping involves repetitive movements or activities at the patient’s ability
level which become progressively harder. Therapists use shaping techniques to
avoid overwhelming the motor system.

Why it works: 
Our brain automatically completes a task in the easiest way possible. Our brain
is more interested in completing a task than in how it is accomplished.

After a stroke, it’s easier for our brain to do tasks one-handed. This leads to
“learned non-use”.

When we constrain our non-affected hand, suddenly our stronger hand becomes the
weaker, less functional hand and we’re forced to use our affected hand. Our
affected hand might not have much movement, but to our brain any movement is
better than no movement, and the brain is highly motivated to figure out how to
accomplish a task. 

This is where the "shaping" piece is so important. If you are presented with
rehab tasks that overwhelm the motor system or are higher level than your
affected hand can functionally do, you'll be more likely to knock the table over
than to participate in picking up pennies from the table. 

If you knock the table over with your affected hand, your occupational therapist
might actually be excited about it; but in practical life finding that balance
of not being too easy and not being so hard that you give up is an important
lesson for every human being, not just those after stroke.

Who it’s for: 
This approach is used for people who have at least 10 degrees of active wrist
and finger extension, as well as 10 degrees of thumb abduction (the ability of
the thumb to move out of the palm).

It’s been shown to be effective even years after stroke. Lower intensity CIMT is
better than higher intensity in the very early stages after stroke. 

Mental Practice
You might listen to an audio recording describing the sequence of throwing a
ball, imagining yourself doing it. After listening, actually practice throwing
the ball the way you envisioned!


What it is:
Mental practice, sometimes called motor imagery or mental imagery, is a training
method for improving your hand and arm function without moving a muscle!

Mental practice is typically done by listening to pre-recorded audio that
describes in detail the motor movement of a specific task. The listener imagines
their hand and arm moving in a “typical” way, and the instructor provides cues
to extend their arm or open their fingers, as well as the entire sensory
experience of the task.

While it’s true that you can do mental practice on its own, it's best combined
with physical practice immediately following.

Why it works:
Brain scans show that similar parts of the brain are activated whether movement
is actual, observed or imagined.

It’s a separate area of the brain that’s responsible for actually triggering the
muscle movement, but it goes to show that there’s a lot more required of the
brain to complete a task than just sending a signal to the muscle.

Who it’s for:
Mental practice has been shown to improve arm movement and functional use in
patients after stroke of all levels of abilities and as a treatment approach for
people months or years after stroke!

Mirror Therapy
It is critical to stay focused on the reflected image of your hand during mirror
therapy, imagining that it is your affected side performing the target
movements.
What it is:
Mirror therapy is another voodoo-seeming approach that has a lot of scientific
evidence to back it up. It essentially tricks your brain into thinking your
affected hand is moving.

You position a mirror to reflect your non-affected hand, while hiding your
affected hand. Any movement of your non-affected hand will be reflected in the
mirror and make it seem as though you are actually moving your affected hand.

Why it works:
The approach is centered around mirror neurons, which fire in your brain when
you see your arm move. Typically, we think about motor neurons being sent from
the brain to the muscle, but we don’t realize that mirror neurons are connected
to the motor neurons.

After a stroke you lose the ability to access your motor neurons, but not your 
mirror neurons. By accessing your mirror neurons through seeing your movement
(even if the movement is fake), you are tapping into the network between the
neurons. 

It’s like trying to reconnect with an old friend on Facebook by finding the
friends they’re connected with. It might not be the most direct approach in a
real life situation, but in stroke rehab that friend of a friend might be your
strongest connection. 

Who it’s for: 
Mirror therapy can be used for people with no movement of the hand or smaller
movements of the hand and shoulder, but not functional movement of the hand. 

If you have functional movement of your hand, meaning individual finger movement
and wrist movement, you have surpassed the benefit that mirror therapy can
provide.

It can be used early after stroke, as well as in the chronic stages of stroke.

Virtual Reality
The Neofect Smart Board is a non-immersive virtual reality rehabilitation
system.
What it is:
Virtual reality uses a computer interface to simulate a real life objects and
events. It's become an increasingly more prevalent rehabilitation technique to
provide motivation and engagement in therapy.

There are two types:

 1. Immersive: goggles are placed over the eyes and the patient is visually in a
    different environment than their actual physical one 
 2. Non-immersive: sensors are placed on the body and track the movement of the
    body and the movements are shown on a screen 

Why it works:
Virtual reality works best when paired with traditional therapy. It's theorized
to provide more motivation and engagement for the intensity of therapeutic
exercise needed for neuroplasticity. It's been shown to beneficial in high
doses, meaning more than 20 hours.

Another possible factor of why virtual reality works are the same mechanisms
that make mirror therapy effective (tapping into the mirror neurons) could be
similar. 

Virtual reality also creates a biofeedback loop: your brain sends a signal to
the muscle, the brain receives a signal back in the form of visual or auditory
input. Basically, you get rewarded for your effort.

Who it’s for: 
Virtual reality can be used with people who have mild to severe impairments, and
from early after stroke to years out. 

When deciding what's right for you, it's important to look at the adjustability
of the device to meet you where you're at and also to increase in difficulty as
you improve. 

If you have minimal movements, you'll want a virtual reality tool specifically
for stroke rehabilitation. If you have more movement, it's possible to use
gaming systems not specifically designed for rehab, but make sure you have the
support to optimize it for rehab.

High Dose Repetitive Task Practice
There are many ways to do task-specific training at home. Placing coins into a
piggy bank is just one of them!
What it is:
Repetitive Task Practice is when you practice a task or a part of a task over
and over. Task-specific training is a type of repetitive task practice, and
refers to the task we complete that is relevant to our daily life.

"Reach to grasp, transport and release" is a type of task-specific training
because it is one of the common motor requirements for many functional daily
tasks.

The keys for repetitive task practice:

 * Task must be meaningful
 * Participant must be an active problem-solver
 * Real life objects are used
 * Difficulty level is not too high and not too low
 * Repetition is key

Why it works:
Repetitive Task Practice is based on motor learning theory. Our brains are
driven by function. We're able to achieve neuroplasticity with development of
skills, as our brain processes the demands of the task, which have motor and
cognitive components. 

It's often used with other treatments, such as virtual reality, to increase the
15 hour dosage that has been shown to be beneficial.

Who it’s for:
Task-specific practice is generally used and is studied in people who have some
functional ability of their hand. It's been shown to be beneficial throughout
the rehabilitation process.

Even though the research has been focused on "functional ability" of the hand by
practicing reach, grasp, transport, release; there's potential for recovery by
using the same principles of task-specific practice: real life objects,
functional tasks, and problem-solving even without the ability to grasp.

Functionally, we can use our affected upper extremity as a stabilizer, an
assist, or for manipulation. There are lots of ways to get that side involved to
prevent "learned non-use" and to improve your problem-solving skills. 

Now what?
There are two key factors to any hand recovery method: support and meaning.

Neofect [https://shop.neofect.com/] aims to support and inspire you to live your
best life with virtual reality tools that can be used as part of a
constraint-induced movement therapy program or with repetitive task practice. 

Our companion app to create healthy habits for stroke recovery: Rehabit
[https://apps.apple.com/kr/app/rehabit-your-recovery-habits/id1473561369] and
our YouTube Channel: Find What Works
[https://www.youtube.com/channel/UCuawDKIiCA26zF0JB_YALkQ] are based on the
principles of repetitive task practice and aim to give you the tools to live
your best life. 

Now the only question is, what are you waiting for?



Pollock  A, Farmer  SE, Brady  MC, Langhorne  P, Mead  GE, Mehrholz  J, van
Wijck  F. Interventions for improving upper limb function after stroke.
Cochrane
Database of Systematic Reviews
[https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010820.pub2/full?highlightAbstract=limb%7Cstroke%7Cstrok%7Cupper] 
2014, Issue 11. Art. No.: CD010820. DOI: 10.1002/14651858.CD010820.pub2.




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Call us (888) 623-8984 or email us at info@neofect.com to rehab smarter with
Neofect today.


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