Would you choose different parameters of exercise training, including frequency (number of training sessions in a given period), intensity (within session attributes for training goal and progression), and duration (total number of sessions or hours), if the goals were specific for: (1) muscle strengthening; (2) cardiovascular endurance; (3) reversal of "learned-non-use"; or (4) motor skill acquisition? We ask this rhetorical question to emphasize the point that without explicit discussion of the goals of exercise training for individuals with neurologic impairments, the selection of precise parameters will have undefined rationale. Perhaps, more importantly, without a sound theoretical framework for exercise parameter selection, future clinical trials in this field will be limited to a purely empirical approach, an approach that will not survive the rigors of scientific review (Verville and DeLisa, 2003). Future advances in rehabilitation science will depend on the development of hypothesis-driven clinical trials that are designed to test relevant and innovative ideas about exercise training (Dobkin, 2004).
For these reasons, we distinguish between exercise and task-specific training in neurorehabilita-tion. The term "exercise training" in the classical sense refers to cardiovascular fitness training (aerobic and anaerobic) or muscle strength training. The goal for these exercise training protocols is either cardiovascular conditioning as evidenced by various performance-based tests including VO2 peak in the former or targeted levels of voluntary muscle force (e.g., maximum torque) or muscle endurance (e.g., sub-maximal torque levels for a given duration) in the latter. There is an extensive literature in both of these areas that can be used to develop appropriate exercise parameters for the desired goal, including in individuals with neurologic impairments. The reader is referred to Chapter 21 by MacKay-Lyons in this volume for an excellent discussion of cardiovascular fitness and training in neurorehabilitation and Chapter 18 by Blanton and Wolf for a review of UE muscle weakness following stroke.
Task-specific training, in contrast to a generic exercise program, focuses on improving the performance of functional tasks through repetition and goal-oriented practice. A task-specific training program and a generic exercise program, therefore, have fundamentally different goals. Further, task-specific training can be quite limited without a foundation grounded in the rubric of skill learning. For purposes of this chapter, we define a motor skill as one in which the task is performed effectively, efficiently, and within a variety of environmental contexts (Gordon, 2000). When the goal of rehabilitation is to enhance skilled task performance, the appropriate resources such as strength, endurance, motor control, and coordination provide the foundation that supports task practice. Given this specific therapeutic goal, the purpose of this chapter is to provide a scientific rationale for choosing the conditions of practice that best promote skill learning in the context of task-specific training for diminished functional ability in the neurologically impaired patient. First, we define skill and motor learning within the context of neurorehabilitation. Next, we discuss the differences between "use" and "skill" as these terms apply to UE and manual actions. We argue that this distinction becomes important for choosing the appropriate conditions of practice for individuals post-stroke. Next, we review the literature pertaining to two important conditions of practice known to be critical for motor skill learning: (1) augmented feedback and explicit information and (2) task scheduling. For each we outline how these conditions might be manipulated to promote recovery of functional skills in the neu-rologically impaired patient.
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