CASE REPORT

T
hiS case repon describes a task-oriented approach
to the rehabilitation of a 34-year-old woman with
left hemiplegia. The task-oriented aprroach is
based on a systems model of motor control and contem-
A Task-Oriented porary mowr learning theories. Systems models propose
that occupational or functional performance emerge,s
Approach to the from the interaction and cooperation of many systems,
and that no one system has a logical priority for control-
Treatment of a Client Jing or organizing the system (Kamm, Thelen, & Jensen,
1990; Mathiowetz & Haugen, 1994). The idea behind this
With Hemiplegia approach is that, at different times, various systems can
control the behavior that emerges from the interaction of
systems, The application of this model in rehabilitation
Nancy Flinn emphasizes that effective therapeutic intervention de-
pends on identification of the system that is critical to
controlling the occupational rerformance at a specific
Key Words: hemiplegia. motor control. time.
systems theory In the task-oriented approach, Mathiowetz and Hau-
gen (1994) have used uniform terminology to propose
that occupational performance emerges from the interac-
tion of systems (see Figure 1). These systems are grouped
into those relating to the person (sensorimotor, psycho-
social, and cognitive systems) and those relating to the
total environment (cultural, socioeconomic, and physical
environment systems), Mathiowetz and Haugen pro-
posed that intervention to alter occupational perfor-
mance can occur through any or all of these systems, For
example, for a person with a physical limitation, occupa-
tional performance could be enhanced either by altering
the environment or altering the client's ahilities by mini-
miZing the physical limitation. The selection of one of
these interventions would be determined collaborativel)'
by the client and the therapist.
The treatment in this case report is based on the
hypothesis that the sensorimotor system was the critical
system limiting this client's occupational performance
and that addl'essing this system with concepts from a
task-oriented approach would result in improvement in
the client's occupational performance. The sensorimotor
system includes strength, endurance, range of motion,
coordination, sensory awareness, postural COntrol. and
perceptual skills (Mathiowetz & Haugen, 1994), Although
these components are familiar concerns in rehahilitation,
the task-oriented approach focuses on the interactions
between these component:-; and uses the concepts of
degrees ofFeedom and control parameters,

Degrees of Freedom
Bernstein (1967) first identified degrees of freedom as he
Nancy Flinn, OTH, is a Staff Therapist, Occupational ThcrarY explored how the central nervous system could effiCiently
Department 12213, Abbott Northwestern Hospital/Sister Ken-
control the many variables in movement, including the
ny Institute, 800 East 28th Street, Minneapolis, Minnesota
number of joints, motions within each joint, muscles thar
55407, and a graduate student in educational psychology at
the University of Minnesota in Minneapolis. control each joint, and single motor units within each
muscle, in order to achieve a single movement goal. The
7his article was accepted for publica/ion December 18. 1994
challenge of controlling this large number of variables, or

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 ROLE PERFORMANCE

OCCUPATIONAL PERFORMANCE
t
I \

PERSON ENVIRONMENT
(pERSONAL CHARACfERISTICS) (pERFORMANCECONTI8CO

Figure 1. The task-oriented approach uses the systems model of motor control to illustrate that occupational performance
emerges from the interaction of mUltiple systems, including those related to the person and those related to the environ-
ment. Reprinted with permission from Mathiowetz, V., & Haugen, J. B. (1994). Motor behavior research: Implications for
therapeutic approaches to central nervous system dysfunction, American Journal of Occupational Therapy, 48, 733-745.
Copyright 1994 by American Occupational Therapy Association.

multiple degrees of freedom, is met in a vJrietv ofwJys at in the presence of adcquate strength within component
different times. When J gymnast is attempting new ma- muscle groups may t'eAecr the client's attempts to contml
neuvers, he or she may limit the multiple degrees of the multiple degrees of freedom in the limb (Horak,
freedom in the task bv holding some joints rigid while 1991). In an effort to achieve the functional goal, rhe
focusing on other pans of the task such as hand or foOt client may attempt to increase the control of some joints
placement. Although the initial effect is a stiff appearance by stabilizing them. Therefore, increased tone in clients
to the movement. as the gymnast becomes able to control with hemiplegia mJ\' actuallY be the result of their efforts
more degrees of freedom, the stiffness disappears and a at functional movement (Horak, 1991).
relaxed movement results. In fact. a relaxed appearance
indicates that the gvmnast has become more skilled at
Control Parameters
performing the maneuver.
Thc degrees-of-freedom concept m~l\' help to ex- A control parameter is a variable that shifts a person's
ria in the incoordination and difficult\' that clients with behavior from one form to another (Heriza, 1991). A
hemiplegia have in using rheir impaired upper extrem- component of a system, such as ,strength. could be a
ities. For example, when asked to move a single joint in a control parameter. If muscle strength is decreased due to
specific plane of mOtion, a client with hemiplegia ma\' a stroke or disuse, the result may be abnormal movement
have sufficicnt muscle strength to pel'form this move- ranerns or no movemcnt at all. If muscle strength is
ment wirhout a major change in muscle tone or an al-mor- increased through therapy, the result mal' be enhanced
mal movement pattern. However, when asked to perform functional performance. Several control parameters rna)'
a task with more than onc joint or to combine the avail- influence a person's hehavior. For example, in treating a
able movements intO a functional task, the client rna\' be client who has shoulder pain and weakness, a therapist
unable to coordinate these isolated movements into a may hvporhesilc that the client does nOt lise the limb
functional unit and may exhibit increasecJ tone. or stiff- because of weakness If strength is increased in the limb,
ness, in some muscle groups. From a systems persrec- but the client does not use the limb because it is painful, a
tive, this emergence of ineffective functional movement shift in the c1ient's patterns of use will not occur because

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 the critical control parameter (pain) was not addressed in subjects without hemiplegia (Shea & Morgan, 1979; Win-
treatment. The concept of a critical control parameter is stein & Schmidt, 1990).
particularly important because although a systems model The task-oriented approach described by Math-
identifies many opportunities for intervention, only iowetz and Haugen (1994) comr"lrises the systems model
changes in the critical control parameter will result in of motor control and irs concepr.) of degree.) of freedom
changes in behavior or performance. A control parameter and control parameters, information on muscle function
is considered critical if changes to it result in changes to in hemiplegic upper extremities, and use of techniques
the client's occupational performance. that maximize motor learning. This case report describes
The concept of control parameters can be seen in the use of this approach as applied to a client with
the hypothetical case of a male adolescent with a spinal hemiplegia
cord injury who is returning to school. If the therapeutic
interventions or adaptive equipment used in rehabilita-
Client History
tion are not deemed acceptable to the client within his
peer group, there will be little carryover of treatment to The client is a 34-year-old woman who had a CVA 6 weeks
the school setting. In this case, the psychosocial system earlier with resultant left-sided weakness. The CVA oc-
may be the critical control parameter; therefore, interven- curred in her right middle cerebral artery as a result of an
tion would be appropriately focused on the client's psy- emboli from an atrial septal defect. She began receiving
chological adjustment to his disability. Although the cli- inpatient rehabilitation services 4 days after her CVA and
ent has other problems that need to be addressed, continued inpatient therapy for 2\12 weeks. She then at-
permanent change in his occupational performance will tended a day hospital program for another 3 weeks. At
not occur without effective intervention in this critical the time of this referral, she was making a transition from
control parameter. the day hospital program to outpatient services within
the same facility for continued therapy to improve her
activities of daily living and left upper extremity function.
Sensorimotor System
Before her CVA, the client worked 4 days per week as
Ideas from systems theory, along with information re- a registered nurse on a high-risk antepartum unit. She
garding muscle function after central nervous system had been married for 10 years and had two children, aged
damage, have led to changing approaches to the sensori- 3 years and 7 years. She engaged in a variety of handi-
motor system. Studies have confirmed that strength in crafts. She and her family enjoyed a variety of outdoor
clients with hemiplegia is decreased; clients are unable to activities, such as camping and cross-country skiing. At
generate adequate force in impaired muscles (Bourbon- the time of her CVA, she was 2 weeks pregnant with her
nais & Noven, 1989; Duncan & Badke, 1987) Clients with third child and, at admission to outpatient therapy, the
hemiplegia also are slow to contract and relax muscles pregnancy was proceeding normally. After the client's
(Sahrman & Norton, 1977). In other words, when the CVA, her husband and her mother managed the child
client attempts to initiate a movement, it takes much care and homemaking responsibilities that she had pre-
longer to generate force than it did before the cerebrovas- viously performed.
cular accident (CVA); once force is generated, the muscle The client continued to have limited skills in occupa-
is slower to return to its original state of relaxation. Thus, tional performance at the time of her tranSition to outpa-
longer lengths of time must be allotted for the client to tient therapy. She was independent in dressing and feed-
obtain muscle contractions in the hemiplegic limb. This ing and was able to prepare a light meal from her
delayed relaxation of the muscle may explain the in- wheelchair if given ample time. With minimal assistance,
creased tone that occurs after muscle contractions, par- a Wide-based quad cane, and an articulated ankle-foot
ticularly with repeated or reciprocal muscle contractions. orthOSiS, the client was able to walk 300 feet to 400 feet
Recent literature on motor learning has offered new and was able to climb staircases that had railings. She
definitions of learning and performance. Schmidt (1988) needed supervision with transfers and required stand-by
has made a distinction between motor per(onnance, the assistance for bathing when using a tub bench. Her tol-
performance that is evident during practice or during a erance for activities was diminished, due in part to dif-
thcrap~' session, and motor learning, the skill that is ficulties with Iightheadedness and nausea related to her
evident at some time after the practice has been discon- pregnancy and fatigue related to her pregnancy and
tinued. In fact, techniques that improve motor perform- hemiplegia.
ance, such as constant feedback and blocked practice An evaluation was made of the c1ient's environment,
(practice in which there is repetition of a single task) may induding phYSical, socioeconomic, anel cultural compo-
actually interfere with motor learning. Research has nents. Her home was accessible to her in relation to her
shown that motor learning is enhanced through intermit- mobility status and did not require major adaptations.
tent feedback and random practice (practice in which a The client was not driving at this time and, because of
number of tasks are repeated in a variable fashion) for both her inability to operate the car's manual trans mis-

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 sion and financial pressures resulting from her inability to Table 1
work, she and her family decided to sell her car. She had Client's Manual Muscle Test Scores' for Major Motions
During Outpatient Treatment and at Follow-up
health and disability insurance that covered her contin-
ued therapy and assisted with finances during this period. Time Since (VA
Upper
Within the client's culture there was a strong motivation Extremity 1'12 3'12 ')'/2 7'1, 11
lv!otions Months Months Months Months Months
to work and, from her first day in outpatient therapy, she
Shoulder 2+ with mild- 3+ 4+ 4+
talked of returning to work. She and her husband had a
nexion II' increa,ed
supportive network of family and friends who were able lOne
to help with child care and transportation for therapy. Shoulder 2 + with mild- 4 4+ 4+ 4+
Assessment of her personal characteristics, which abduction II' increased
lOne
included the cognitive, psychosocial, and sensorimotor Shoulder 2+ with mild- 3+ 4 4
areas, indicated strong interaction between her cognitive external I)' increased
,'oration tone
and psychosocial systems. While the client had been an
Shoulder 2+ with mild- 4 4+ 5- 5-
inpatient, cognitive problems were identified, including internal Iv increased
impulsivity, decreased visual memory, and increased dis- roration tone
tractibility. However, after her discharge, these problems Elbow nexion 2+ with mild, 3+ 4 4 5
Iv increased
were no longer present. The client reported that she was tone
"uncomfortable" being an inpatient in the hospital in Elbow eXlen- 2 + with mild, 3+ 4 4+ ')
sion I)' I ncrease<.l
which she worked and that thiS anxiety decreased when
tone
she went home, which in turn resulted in her improved Supination 2- 3+ 4 4+ ')
cognitive function. She also was relieved to be at home Pronation 2- ,'3+ 4+ 4+ ')
Wrist exten· 2- 3+ 4+ 4+ ')
with her children for pan of the day and to be able to
sion
supervise their care. When the client was seen in outpa- W,-jSl nexion 2- 3+ 4+ 4+ ')
tient therapy, she was alert, motivated to make improve- Finger nexion 2- 3 .'3+ 4+ 4+
Finger eXlen- 2- 3- 3 4 4+
ments, and outspoken about her intention to return to
sion
work as soon as possible. She was very interested in the Thumb muscles 2- 3 3+ 4 ')
therapy process and followed through on instructions for 'Daniels, L. & Wonhingham, C. ( 1980). Muscfe testing. Techniques oj'
home activities and exercises. Initially, she had hoped to manual examination (4th eli). Philadelphia: Saunuer,.
return to work within several months and work until the bUnable to test client due '0 her pain.

birth of her third child. A5 her rehabilitation continued,

she deCided to delay her return to work until after her
maternity leave. of use of the arm in funerional activities, hand function
The client's sensorimotor system was seriously im- testing, and grip strength evaluation. The presence of
paired. AJthough sensation in her impaired (left upper) increased tone in the arm during testing was recorded
extremity was intact, the extremity was weak throughout, along with the MMT score.
with mildly increased muscle tone evident with proximal
motions (see Table 1). She did not spontaneously incor-
Treatment Program
porate her impaired arm into functional activities, but was
able to use it as a gross stabilizing assist when cued She The client received l-hr out[1atient occupational therapy
described use of her arm as "contrived." She was unahle sessions over a 6-month period, with the frequency of the
to perform either the ]ebsen-Taylor Test of Hand Func- sessions decreasing over time from three treatments per
tion Oehsen, Taylor, Trieschmann, Trotter & Howard, week to one treatmenr per monrh. The client'S long-term
1969) or grip strength tests (Mathiowetz et a!. 1985). goal was the resumption of her social and professional
AJthough rhe validity of manual muscle resting roles. The client selected the focus of treatment and was
(MMT) (Daniels & Worthingham, 1980) in cases of central very anxious to resume her roles within her home. For
nervous system deficit has been questioned in the pres- this reason, treatment was initially directed toward child
ence of abnormal tone (Bohath, 1990; Daniels & Worth- care and homemaking tasks and later toward specific
ingham, 1980; Davies, 1985), there is support for using anricipated work tasks. Her rehabilitation program was
iVIMT as one component of evaluation for clients with frequently revised, with the determining factor for change
cenrral nervous system dysfunction (Bohannon, 1989). being progress or lack of progress in occupational per-
MMT was used in this case because weakness was hypoth- formance. Various components in the systems model of
esized to be the critical control parameter for this client's motor control were reviewed periodically to determine
function. Therefore, some measurement of that critical their effects on the client's function. However, the treat-
conrrol parameter was essential. ment program focused primarily on the sensorimotor
In addition to MMT (Daniels & Worthingham, 1980), system hecause rhe resumption of her work as a nurse
evaluation of the client included ohservation and report was highly unlikely without improved use of her impaired

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 arm. Although adaptation of the environment and com- Treafment Months 1 and 2
pensatory techniques were possible interventions, the
wide range of tasks required in her job made these strate- During the first 2 months of outpatient occupational ther-
gies complex. In addition, these strategies were not the apy, the client was seen two to three times per week.
client's first choice of treatment. Treatment focused on the weakness throughoUL her left
Although a variety of assessment tools, including arm and on maximizing the use of the arm in spite of this
hand function testing, activities of daily living evaluations, weakness. Her primary problem was an inability to con-
grip strength, and MMT, wel-e used during the course of trol more than one muscle group at a time without expe-
treatment, treatment planning was based on the improve- riencing increased tone in her arm. Her treatment plan
ment that the client made in the functional use of her was based on the hypothesis that the problems with her
impaired arm, as measured by direct observation in the motor performance were caused by a combination of
clinic and by the client's own report. These forms of weakness and difficulty controlling the multiple degrees
evaluation were used to define critical control param- of freedom of her arm. On the basis of this hypothesis, a
eters. If an identified critical control parameter changed treatment program was initiated that included the
but functional performance did not, then the hypoth- strengthening of her arm and hand muscles along with
esized critical parameter was not supported and a new the incorporation of her left arm into a variety of function-
critical control parameter was identified. On the basis of al activities. Close attention was paid to limiting [he de-
the new hypothesized critical control parameter, a re- grees of freedom required for the tasks.
vised treatment plan was designed. The process of select- Early in the treatment program, the client was in-
ing critical control parameters was challenging and re- structed to actively move her left upper extremity rather
qUired careful observation and evaluation. than passively move it with her right upper extremity.
Because the control parameters for upper extremity This active management of the arm, even if only to place
movement in clients with hemiplegia have not been iden- her arm in her lap, was the initial stage of functional use.
tified, it was important to observe the client's perform- This early functional use was encouraged to minimize the
ance of functional tasks from an open-minded perspec- disuse of the impaired arm and overuse of the sound arm
tive, disregarding previous therapeutic assumptions. For [hat sometimes occurs after the loss of function in a hemi-
example, at one point in treatment, the client was haVing plegic upper extremity (Taub et al., 1993). To encourage
difficulty with hand grasp and release in many different successful integration of the impaired arm into function
types of tasks. She could grasp objects with some difficul- and to provide further opportunities to increase strength
ty, but as she attempted to hold the object, her wrist in the impaired arm, a variety of functional tasks were
would move into wrist flexion and she would lose her grip initiated in which the degrees of freedom were carefully
on the ohject. Although her grip strength was limited, it controlled. The degrees of freedom required for a task
seemed that weakness in her finger flexors did not ex- were limited in a variety of ways, including decreasing the
plain the problem. Practitioners of traditional neurode- number of joints involved in the task by stabilizing or
velopment<d approaches would identify the problem as eliminating some joints, often by placing the elbow or
increased tone in the finger flexors and recommend forearm on a surface or by substituting flat hand stabiliza-
inhibition techniques in the arm to control the abnormal tion for hand grasp. The degrees of freedom were also
tone (Bobath, 1990). However, with the use of the infor- limited by decreasing the amount of movement of the
mation on hemiplegic muscle function included in the limb against gravity, either by having the client stand
task-oriented model (Mathiowetz & Haugen, 1994), I sug- rather than sit or by moving the task to a lower surface.
gested that the problem was a lack of wrist stability when For example, the client used her impaired arm to
using finger flexors. lock her wheelchair brakes, dust tables, and provide sta-
As the client's wrist extensors fatigued, her wrist bility and assist with balance while standing at counters,
moved from wrist extension into wrist flexion because of sinks, or tables. As with most clients with hemiplegia,
the contractions of the long finger flexors that also flex performing functional activities such as laundry or kitch-
the wrist. With her wrist in flexion, her long finger flexors en work while sitting was awkward for the client, but she
were placed at a biomechanical disadvantage for grasp- reqUired her sound arm to steady herself when standing.
ing. An intervention that was used was to increase the Therefore, the client's ability to use her impaired arm to
strength and endurance in the wrist extensors, particular- help stabilize herself in standing allowed her to perform
ly through resisted isometric contractions during hand many tasks more efficiently, including washing her face
use. This approach was effective in improving the func- and brushing her teeth, preparing food in the kitchen.
tional use of her hand. This need to observe movement in washing and putting away dishes, and putting away gro-
new ways was a challenge that required an awareness of ceries. The use of her impaired arm to assist with trunk
previous assumptions about hemiplegic arm function and balance incorporated the ann into functional activities,
conscious efforts to consider alternative explanations and allowed her to perform tasks in her home more
when evaluating the client'S performance. efficiently. As a result. the client realized that her im-

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 paired arm could help her resume her roles in the home At the end of this period, some changes had oc-
even at its limited level of functioning. cmred in the client's envimnmental systems. As the client
The client's strengthening progt'am consisted of ac- began assuming more responsibility in the home, she
tive assistive range-of-motion exercises in straight plane reqUired less outside assistance. Emotionally, she was
movements followed by isometric contractions at the end dealing with her atrial septal defeCt and the required
of the range. Her arm was supported as necessary during injections of heparin. A variety of drug delivery systems
eccentric contractions as she lowered her arm. Care was was tried with little success until she learned to stabilize
taken to prevent muscle substitutions during these exer- the bottle with her left (impaired) hand, draw up the
cises, such as substitution of the middle deltoid for the syringe with her right hand, and give herself the injcction.
,Interior deltoid during shoulder flexion. As the client The prohlems of pregnancy-related nausea continued to
gained strength and active movement in concentric con- interfere with her ability to fully participate in activities at
tractions, resistance was added through the addition of home and in therapy.
Thera-Band l exercises graded to the maximum resistance
at which the client cuuld achieve full active range of mo-
Trecllnzenl Y/011.lh5 3 and 4
tion without muscle substitutions. Within this exercise
program, degrees of freedom wel'e limited to those that During the third and fourth months of treatment, the
could be controlled without evidence of abnormal tone. frequencv of her therapy sessions was deueased to two
During these exercises, the client's trunk was posi- times per week. The client did her strengthening exer-
tiuned to activate her trunk muscles. lhe client was seat- cises independently at home, and her program was peri-
ed on an elevated surface with her sound fOOl on a foot- odically reviewed and revised in therapy. Most of the
stool and her impaired foot on the floor. In activities therapy sessions focused on the client's performance of
involving large movements of the upper extremity in functional tasks or on solving problems that the client had
standing or Sitting, initial muscle activitv occms in the encountered at home. Tasks addressed during this peri-
lower extremities and then in the trunk as preparation od included turning light switches on and off, moving
for upper extremity movement (Belen'kii, Gurfinkel, & household items, stabilizing bottles while they were
Pal'tsev, 1967; Horak, Esselman, Anderson, & Lynch, opened with the right hand, closing doors, and handling
1984); therefore, during the session, the client leaned dishes. The client was given the aSSignment of incorporat-
forward so that her weight was over her feet and her ing her impaired arm into one new task per day, and this
trunk. For most clients with hemiplegia, activation of the assignment created many opponunities to solve specific
impaired side of the trunk is more difficult: therefore, the problems during therapy sessions. These problems were
client was positioned so that her entire trunk and im- simulated in the clinic and solutions were suggested. The
paired leg were activated to mimic the activitv pattern client then practiced these suggestions at home and re-
that preceded upper extremity movement in an undam- turned to the next session with a report. The suggestions
aged svstem and maximize the opporrunit\· to elicit con- for improved function were usually related to decreasing
tractions in muscle groups of the upper extremity. the degrees offreedom involved in the task, and the client
At the cnd of the second month of treatment (3 11z eventually generated these solutions herself. The client
months after her stroke), the client had made major im- had inueased strength and movement throughout the
provements in occupational performance, resuming impaired arm and developed the ability to grasp, release,
some specific task:> and activities that she had done pre- and manipulate objects, as long as neither repeated iso-
vious!v. She consistently incorporated her impaired arm lared movements of the thumb nor power grasp were
into specific functional tasks that she had practiced in cequired.
therap\', such as assisting with balance \vhen standing and As the client's ahility to move her left arm improved,
managing the brakes on her wheelchair. She was able to the degrees of freedom in her exercises and activities
carry light objects shorr distances bv holding them against were increased hv requiring her control of increasing
her bodv with her impaired arm, and although use of the numhers of joints simultaneously. For example, as the
arm continued to be ver\' consciously planned, she did client's impaired wrist and fingers became stronger, the
incorporate it into daily actiVities. At home, she assumed Thera-Band exercises were altered to require static hand
responsibility for cooking some meals and assisted with grasp and wrist positioning during elhow exercises,
other home management tasks. At this time, he,' hand thereby increasing the number of joints that needed to be
function was limited and she was unable to perform for- controlled. The degrees of freedom were further in-
mal hand function testing or generate: measurable grip creased by the client's early use of objects, initially
strength (sec Table 1 for changes in the client's MiVlT through simply pushing items such as silverware from a
scores). counter into a drawer, and then by incorporating wrist
position and hand grasp with this shouJder and elbow
IlvlallufaClurcti hI' HI'gCllic Cor"!Joralioll. 12~'i Homc ,\VCllue. Akrnn, movement to grasp objects and place them on a variety of
Ohio 44310 surfaces. The client's development of minimal hand grasp

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 was incorporated into her functional tasks, such as stack- stant!y changing practice was used to help the client de-
ing the unbreakable glasses from the dish rack with her velop a variety of efficient strategies for achieving func-
affected hand and holding her medication bottles with tional use of her limb (Higgins, 1991). For example, after
the left hand while opening them with the right, the client was able to grasp various grocery items and
During this period, problems in the client's function- place them on shelves, she began packing and unpacking
al tasks also revolved around her difficulty with muscle grocery sacks, a task that required varied upper extremity
strength in isometric, eccentric, and concentric contrac- movements with constantly changing hand and wrist ori-
tions, The most problematic movements for the client entations. The client then incorporated these tasks into
were those that required a concentric or eccentric con- her daily routine at home. This use of varying functional
traction of a prime mover (i.e" biceps) combined with an activities as modalities to improve function has been sug-
isometric contraction of an antagonist for a secondary gested in occupational therapy literature as an alternative
function for that prime mover (i.e" pronators) , to traditional drill tasks Oarus, 1994; Neistadt, 1994;
For example, when reaching forward to handle an Poole, 1991; Sabari, 1991).
object at shoulder height with the forearm in pronation, At this point (5 J/2 months after her stroke), the client
as in placing a plate on a shelf, the client had great difficul- had made gains both in muscle strength and grip strength
ty keeping her shoulder in flexion rather than abduction, (see Tables 1 and 2). She had a grip strength of 12lb but
After several sessions of observation and some trial-and- fatigued qUickly. She was using her impaired arm in most
error treatment, the source of the problem was deter- tasks at home and was able to perform limited grasp and
mined to be in the forearm: The client was haVing difficul- release tasks, but she was unable to perform in-hand
ty maintaining isometric pronation during active elbow manipulation tasks. At this point, the client could have
movement, either eccentric or concentric, presumably performed some of the subtests of the Jebsen-Taylor Test
because of the biceps' secondary function as a supinator, of Hand Function (manipulation of light objects, manipu-
She was compensating for thiS inability to maintain pron- lation of heavy objects) Oebsen et aI., 1969), but because
ation in the forearm by abducting her shoulder until the of her rapid fatigue in grasp and release tasks, her times
plate was in position to be placed on the shelf. This would have been prolonged and of limited value in defin-
example demonstrates the difficulty involved in identify- ing her functional level. Consequently, the tests were not
ing a critical control parameter. To help counteract thiS administered.
problem, the client was instructed to pronate her forearm Some slow but important changes were occurring
before activating her elbow flexors during functional ac- within the client's personal environment. Because she
tivities in an effort to preposition her forearm and coun- had resumed most of her responsibilities as mother and
teract the effect of the biceps, In addition, the client prac- homemaker, she required less assistance from others.
ticed Thera-Band exercises that required pronation The assistance that she reqUired was primarily for driving
during elbow flexion eccentric and concentric contrac- and for carrying bulky or heavy objects, such as laundly.
tions as well as resisted isometric contractions at the
extreme of pronation. After several days of practicing Table 2
these movements and strengthening exercises, the client Client's Outpatient Treatment and Follow-up Subtest
no longer had difficulty with tasks that incorporated this Scores From the Jebsen-Taylor Test of Hand Function"
and Grip Strength Tests b
pattern of movement,
With this improved control in forearm rotation, the Time Since eVA

client's arm use was more efficient because objects could Hand Function Sublests 5'1, Monlhs 7'1, Ivlonlh, 11 Months
now be approached in shoulder flexion without her use Time (sec)
Manipulation of light objects Unable 7.1 4,8
of shoulder abduction to compensate for improper posi-
SD -63 -25
tion of the forearm. She was also able to perform rotation- Manipulation of heavy objects Unable 92 Hi
al tasks such as turning doorknobs, placing and removing SD -!l,R -3
Simulated feeding Unable 142 119
lids on jars (providing they were not sealed tightly), and -2,4
:,D -39
turning on faucets. At this time, she made a major shift in Card lurning Unable 91 6,4
the effective use of her arm in occupational performance SD -39 - 15
activities. Strength (lb)
Attempts were made in all of these activities to vary Grip slrenglh
Left (impaireu) hand 12 17 25
the functional tasks constantly in order to have "repeti- :,D -32 -29 -2,4
tion without repetition" (Bernstein, 1967, p. 134), JUSt as
Note. eVA = cerebrovascular <lcciuenl.
tasks vary in the real world or natural environment. "Jebsen, R. H" Taylor, N., Trieschmann, R, B., Troller, M, .I., & Howard.
Therefore, the client's tasks in the clinic included manip- LA, (1969). An objective and stJnuaJ'dized test of hand functiun, AI'-
cbiL'es uf Pbysical iVledici17e and Rehabilitatiun, 50. 311-319,
ulation of a large variety of real-life objects that required
bMathiowclz, V" Kashman, N., Vollanu. G, Weber, K., Davc, M. &
varying upper extremity approaches to the objects in Rogcrs, S. (1985) Grip and pinch strength: Normative uata for auults,
varying postures including sitting and standing. This con- Archil'es of Physical Medicine and Nebahilitatiun, Go. 69-7·4

566 June /995. Volume 49, NUll/bel' 6

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 She began to discuss resuming driving and was referred bottle held in her hand, unscrewing the bottle top with
to a driving evaluation program at a local facility. Impor- her index finger and thumb while holding the bottle with
tant changes also were occurring within the client's psy- her other fingers, and removing a nut from a bolt held in
chosocial area. She began reading biographies of persons her hanclln an effort to control the degrees of freedom,
who had met similar challenges, including those of per- these tasks were initially performed with the client's arm
sons who had spinal cord injury and stroke. She brought supported on a surface so that only her forearm, wrist,
the books to therapy and read sections of the stories and hand needed to be controlled. She was also instruct-
aloud, particularly enjoying the use of humor as a coping ed in manual resistance thumb exercises to build strength
mechanism. She also reestablished contact with the nms- in thumb muscles. Over a period of several weeks, her
ing station on which she had worked, bringing treats to ability to isolate thumb and finger movements improved,
staff members and catching up on station news. and she was able to isolate thumb function from the
function of the other fingers.
At the end of6 months (7Y2 months after her stroke),
Treatment iVlontbs 5 and 6
therapy was discontinued because the client had re-
During the fifth and sixth month of treatment, the client sumed her previous roles in her home and was able to
was seen in therapy sessions a total of five times. As the independently modify aerivities when necessary. She con-
client began to anticipate returning to work, the treat- tinued upper extremity strengthening as a home program
ment focus shifted to work-related tasks, such as breaking and was able to modify the program independently as she
glass ampules of medication and drmving up syringes. gained strength and endurance She was followed peri-
With practice, the client was able to do these tasks With- odically by a physiatrist and encouraged to contacr her
out difficulty and within a reasonable period of time. The occupational therapist or physician if she began having
client continued to practice a home program of resistive difficulty with tasks she could currently do or if she devel-
strengthening exercises oped any pain in her impaired arm. Tentative plans were
At the beginning of this period, the client had prob- made for her to participate in a work-hardening program
lems with functional tasks in which she needed to hold after the birth of her child and before her return to work.
more than one object in her hand at a time or perform Because she was interested in any suggestions about
other in-hand manipulation tasks, such as isolating a key e4uipment and organization of the nursery that were
on a key ring or releasing one object from her hand while related to energy conservation or work simplification, she
maintaining a grasp on another objeer Upon further eval- was referred [0 a program at a nearby facility that focused
uation, it was noted that she was not able to isolate the on child care for persons with disabilities. The client
intrinsic and extrinsic finger flexors, although she could thought that she would be able to physically handle and
use them together to make a full fist. Operating on my care for the baby without any difficulty, but she was con-
hypothesis that weakness in these individual muscle cerned about her decreased endurance.
groups was preventing her from performing these tasks,
the focus was shifted to strengthening intrinsic and ex-
Results
trinsic finger flexors Initially, the client was asked to
maintain a static position of either an intrinsic or an ex- After 6 months of outpatient therapy (33 sessions), the
trinsic finger flexor muscle contraCtion after her hand had client had substantially improved her level of occupation-
been placed in that pOSition Later, she was asked to al performance. She was independent in all self-care and
perform this motion actively, and then against resistance. was able to care for her family, taking on cooking and
After 2 weeks of work on these muscle groups, she was housekeeping duties without outside help. She ambulat-
able to isolate them, and the 4uaJity cll1d speed of her ed community distances independently without any assis-
hand movements improved substantially. Again, thiS tive devices. She had resumed driving. She had nUl re-
pmblem area was identified through its inrerference with turned to work but was planning to do so after her
occupational performance as she resumed her occupa- maternity leave.
tional roles. Her arm funcrion had also improved substantially.
Treatment also focused on her left thumb. Although Performance of some tasks had become automatic, with
she was able to isolate the muscles of the thumb during a no conscious planning of arm or hand movement. She
functional task, with repeated motion or prolonged iso- had no abnormal tone in her left arm, either during use or
metric contraerions the thumb tended to flex into the at rest (Her manual muscle test scores after 6 months of
palm, particularly when she was holding an object stati- treatment [7112 months after her stroke] are listed in Table
callv with her other fingers This problem appeared to be 1)
ont: of controlling multiple degrees of freedom To coun- On four subtests selected from the jebsen-Taylor
teract this problem, the client was given a variety of home Test of Hand Function Oebsen et aI., 1969), the client
assignments that required static finger grasp along with scored between 39 and 11.8 standard deviations below
thumb movt'menr, such as pushing the lid off a medicine the mean, which although indicating significant deficit,

The American Juurnal oJ Occupatiu'lc'; Therapr 567

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 did allow her to perform functional tasks with her im- Identification of critical control parameters remains
paired hand 0ebsen et aI., 1969) Her grip strength was a complex task that at this point relies on close observa-
17 Ib, 2.9 standarcl deviations below the mean (Math- tion and frequent reevaluation of function. Further re-
iowctz et al., 1985). (Grip strength and hand function search is needed to cJari~r methods and techniques to
scores are listed in Table 2.) She continued to have some iden(ify cri(ical parame(ers so (ha( (herapeu(ic imerven-
diftlculty \vith rapid or repetitive fine motor tasks but was tions will result more frequently in changes in functional
incorporating her arm into activities as a nondominant performance. Until then, therapists can only generate hy-
limb. She continued to require concentration on tasks potheses regarding critical parameters and then evaluate
that included in-hand manipulation or isolated finger changes in occupational performance to determine the
movements. accuracy of their assumptions. AJthough the outcome for
Three and one-half months after therapy ended (11 this particular client was excellent, the length of treat-
months after her stroke), she returned for a brief evalua- ment was protracted. With practice in the identification of
tion. (Her MMT [Daniels & Worthingham, 1980] scores at the critical control parameters, the treatment process
that time are indicated in Table 1.) The client's shoulder could become more efficient.
external rotation strength could not be evaluated because Another area of concern is the use of the information
she experienced an increase in shoulder pain after immo- regarding moror performance and motor learning. Re-
bilization of her shoulder because of placement of a cardi- search in this area has primarily involved subjects with
ac pacemaker. She had a major decrease in passive shoul- intact central nervous systems (Shea & Morgan, 1979;
der external rotation and was referred to a physiatrist Schmidt, 1988; Winstein & Schmidt, 1990). AJthough
who diagnosed adhesive capsulitiS in the shoulder. Grip some of the findings apply to populations with hemiple-
strength (Mathiowetz, et aI., 1985) had improved to 251b, gia (Winstein, Gardner, McNeal, Bartos, & Nicholson,
2.4 standard deviations below the mean. On four subtests 1989), there is currently little research on this population
selected from the ]ebsen-Taylor Test of Hand Function and such research needs to be carried out with subjects
Oebsen et aI., 1969), she scored between 1.5 ancl 3 stan- with hemiplegia
dard deviations below the mean (see Table 2). AJthough The use of resistive exercise in treatment of clients
her scores for strength and hand function fell in a range who have had CVA and increased tone indicates an im-
from within normal limits to mild deficit, the client portant shift in practice from previous techniques that
thought that she was able to perform tasks within reason- focused on controlling tone through inhibition tech-
able periods of time and that she was able to plan ahead niques. In this client's case, the resistive exercises were
and modify activities to compensate for her decreased done with great care to avoid substitutions or abnormal
grip strength. She had upgraded her strengthening pro- patterns of movement. The client's improvements in
gram to include exercise on weight lifting machines three muscle strength were integrated with the incorporation
to five times per week at a local exercise facility. After 6 of her impaired ann into functional tasks. The exact
weeks of physical therapy for adhesive capsulitis and re- mechanisms of the increase in strength is not clear. There
sumption of strengthening exercises, her shoulder exter- is also no information available regarding which specific
nal rotation returned to an MMT score of 4 + . clients would henefit from this treatment.
Three months after the birth of her child, the client The effectiveness of the task-oriented approach
returned to work at her previoUS job. She deCided that needs to be evaluated in terms of the overall goal of
the work-hardening program was unnecessary, and she therapy: improved occupational performance. Currently,
was successful in returning to work. exploration of this approach and these concepts is only
beginning to be reponed in occupational therapy litera-
ture (Haugen & Mathiowetz, 199'5; Mathiowetz & Hau-
Conclusion
gen, 1994), although many of these ideas have been dis-
The use of the task-oriented approach in this case pro- cussed in physical therapy literature (Lister, 1991;
vided a valuable framework for treatment planning. The Rothstein, 1991). A.s more exploration and discussion oc-
concepts of degrees of freedom and control parameters curs, concepts such as control parameters and degrees of
were integral in determining treatment. The hypothesis freedom will be more clearly defined within the context of
that weakness and inability to control excess degrees of occupational performance and occupational therapy. This
freedom were critical control parameters for various tasks case report provides beginning evidence in support of a
was valuable in identifying treatment foci. Treatment that task-oriented approach. However, outcome stuclies and
addressed these areas was effective in improving thiS cli- controlled studies that use Single-case or group experi-
ent's function so that she could achieve her goal of re- mental designs are needed to evaluate this approach .•
turning to the family and work roles that she had held
previously. Her outcome was excellent, particularly in Acknowledgments
view of her limited functional status at admission to out- I thank Virgil Mathiowetz. PhD O!K for hi.) many helpful com-
patient occupational therapy. ments on a rrevious draft of this article. I also thank Judv Mor-

568 june 1995. \fulume "19. Number 6

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 ton, PI. I annette Washko. ,\IS. Pl. ancljulie Bass Haugen. PhD.OIR & HO\\arcl, L. A. (1969). An ohJective and standardized test of
for their assistance in the arplication of rhese conceprs to clini- hand function. Arcbiees of Pbysical .Vledicine and ReIJabilila-
cal treatment. I ion. 50. 311-319.
Kamm, K.. Thelen, E. & jensen, j. L. (1990). A dynamical
svstems approach to moror development. Pbysical Tberapy, 70,
References 76:3-77.:;
Lister. ]'v!. j. (Eel.). (1991). Conlemporarl' management of
Belen'kii, v., Gurfinkel, v., & Pal'rsev, Y (1967) Elemenrs molar conlrol problems. Proceedings ofIbe II Slep Con!e/-ence.
of control of volunwlY movements. BiOpbl'sics. 1.2. 1:3':;-14 l. Alexandria. VA: Foundation for Phvsical Therapv.
Bernstein, . (1967). Tbe coordinalion and regulation o( Mathiowetz. V.. & Haugen. J. B. (1994). Motor hehavior
mooemenls. Elmsford. NY. Pergamon. research: Implications for therapeutic approaches to central
Bobath. B. (990). Adull bemiplegia: Emlualion and nervous system dvsfuncrion. Amen'cClnjournal o{OccuPCltiol1'
trealment (:3rd ed.). London: William Heinemann. al Therapy 48. 73.3-74')
Bohannon, R. \Y/. (1989). Js rhe measurement or muscle Mathiowetz, V, Kashman. N.. Volland, G. Weher. K,
strength appropriate in parienrs with brain lesions': A sreci:ll Dowe. M., & Rogers. S. (198'). Grip and pinch strengrh: Norma-
communicarion. Pb)'sical Themp,l'. 69. 22':;-2.36. rive da ta for ad uJrs. ArcfJir'es qfPbysical/Vledicine and Rehahili-
Bourbonnais. D., &. Noven. S V (989). Weakness in pa- lation. 66. 69-74
rienrs wirh hemiparesis. American ./olll'l/al o( Occupalional Neistadr. M. E. (l994). Effeers of different treatmenr acrivi·
ThE' 1apl' , 43. 513-3 J9 rics on funcrional fine m()[or coordinarion in adulrs wirh brain
D:lniels, L., & Worrhingham. C. n9HO) . .\,fllse/e lesling' injury American joul'/wl of Occupalional Therup)'. 48. 877-
Tecbniques o( I1lC1/'1l1al e.YCllili/,wlioll (-irh eel) Philadelphia: rl82
Saunders. Poole,.! L. (1991). Application ofrnotor learning principles
Davies, P. '\'1. (198')). Sleps lofolloll'.· A guide 10 Ibe Ireol- in occupmional rheral)\' American journal of Occupa/ional
mel'll o( adull bemiplegia. re\\' YOI'k: Springel·-Vel'!ag. Tbempy "J5. ').31-')5'
Duncan. P \XI.. & Badke. :\'1. B. (19H'). 5/1'01..'<' rehahililtl- Rorhsrcin . .1. M. (Ed.). (1991) . .Ho/'emenl s('ience Alexan·
lion: Tbe reco/'eIY o( mOlar COlltrol. ChicJgo: YeJr Book. dria. VA: American Plwsical Therap\' Association.
IIaugen. ). 8.. & :"!arhio\\'cu, V (199')). COTl(emporalY Salxll·i. J S (1991) ,v!orOl' Ical'ning concepts arplied to
wsk-orienred arproach. In C. A. Trombh' (Eel.). Occupational aeri\'itv-based inrervenrion wirh adulrs \\ irh hemiplegia Ameri-
Iherapl'./ol' phl'sical dl'sj"uliCiion (-Hh ed .. pp. 1'5--18,)). B,lln- can FJI/rnal q/Ocwpalional Thelap\' 45, ')2:3-5:30
more: Williams & \,(/ilkins. Sahrman. S. &. Norrun. B (1977) The n:larionshi[l of
Heriza. C. (1991). Moror de\'elopmenr: Tradirional ami \'olunran JllOVeJllcnr ro spasricit\· in rhe upper Jlloror ncuron
conremporalY rhcol·ies. In M. .J I.isrel· (Ed). Cuulell/jJur{//l' s\'J)(lroJ1lc. "111/(/ls 0/ Ne7lrolux\', 1. 460-46':;.
management o(motol' conlrol problems: Proceedillgs o(lbe II Schmidr. R A. (1988) ,Holol' conlrol ami lE'aming: A bE"
5>TEP Cun(erence (pp. 99-126). Alexandria. VA: Foundarion for hurioral eJ71pbasis (2nd eu ) Champaign. [L. Human Kinerics.
Plwsical Therap\' Shea ..! B.. & Mmgan. R. L. (19 79) Con[ex[ual interference
Higgins, S. (1991). Moror skill acquisirion. Ph,l'sical The!'- dfens on rhe acquisi(ion. rerenrion. and rransfer of a moror
apl'. 71, 12:3-1:39 ~kill '/ollrl7al or F.\'/Jeril7lenlal PSl'cholo,[!"l'. f-/rr/71an I.earnil'll<
Horak, F. B. (1991) Assumprions underlving moror contra] alld .Hemor)' 5. 17 9-18 7
for neurologic rehabilirarion. In M. J Lisrer (Eel.), CUnlel17pO- Taub. E. Miller. N. E.. Novack. T A, Cook Ill. E W., Flem-
ran' management of malar C0111rol proi?lems Proceedings of ing. \Xi C.. Nepomuceno. C. S. Connell. J So, & Crago. J E.
IbE' /I Slep Conference (pp. 11-27). Alcxamlria. VA Foundation (1<)9:3) JeLhnique to improve chl'Onic motor deficir afrer
for Phvsical Therapv s[['oke An'bires or Pbl'sical .Hedicil'le and Nehahililaliol'l. 74.
I Iorak. F. B., Esselman. P., Amlerson, M. E.. &. Lvnch, M. K. :3r-.3')J
(1984). The effecrs of movemenr velocirv, m;lSS displaced. and Winsrein. C.! . Gardner. E. R . McNc,JI. f) R . Barros, P. S, &.
[ask cerra inn' on associared postural adjusrmenrs made by nor· Nicholson. D E (J9B9) Standing balance rraining: Effect on
mal ami hemi[llegic individuab. j()//I'rwl ofNeurologl'. Neuro- balance and locoJlloriun in hel1lipal-eril' adults Archit'es o/Phl's-
surgery and Ps)'cbial1y, 47,1020-1028. iat! .\tedidne and Nehubililalion. 71l 7')')-762
.!al·us. l' (1994). i'v!orol'leaming and occuparional rherapy: Winsrt'in. C.J . &. Slhmidt, R. A. (1990). Reduced frequency
The organizarion of praerice. Americanjournal ofOccupalion- of kno\\ ledge of resulrs cnhall(e.s J1l()[or skill learning. Journal
al Tberap)'. 48. 81O-H16 OJ'hyperimeilial PSl'cbolof!,,1' I.earning ,\.1el7lor)' and Cugnition
jebsen, R Ii., Tavlor, N.. Trieschmann. R B.. Trorrer, M . .1 .. J(i. 6':--6s>l

The IImerican Journal (!f Occlipalional n'E'ltIpl' 569

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