Task-Oriented Training – lower extremity / mobility

Evidence Reviewed as of before: 01-09-2016
Author(s): Tatiana Ogourtsova, MSc BSc OT; Adam Kagan, B.Sc.; Dr. Nicol Korner-Bitensky PhD OT
Expert Reviewer: Nancy Salbach, PhD PT
Table of contents

Introduction

Task-oriented training involves practicing real-life tasks (such as walking or answering a telephone), with the intention of acquiring or reacquiring a skill (defined by consistency, flexibility and efficiency). The tasks should be challenging and progressively adapted and should involve active participation (Wolf & Winstein, 2009). It is important to note that it differs from repetitive training, where a task is usually divided into component parts and then reassembled into an overall task once each component is learned. Repetitive training is usually considered a bottom-up approach, and is missing the end-goal of acquiring a skill. Task-oriented training can involve the use of a technological aid as long as the technology allows the patient to be actively involved. Task-oriented training is also sometimes called task-specific training, goal-directed training, and functional task practice. This particular module focuses on task-oriented training intended specifically to improve lower extremity function and mobility.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

*Studies may not have been sufficiently powered to find between groups differences, while important within group differences indicated a possible effect of treatment.

To date, 20 publications were reviewed in this module where 13 are high quality RCTs (one is a secondary analysis of a high quality RCT), 6 are fair quality RCT, and 1 is a quasi-experimental study. All the included studies meet the inclusion criteria described below.

Note: Studies were excluded if the intervention did not involve: 1) practicing a salient, real-life task, 2) progressively adapting the task to the patient’s progress over time, or 3) active participation by the patient. As well, studies that mixed task-oriented training with other types of exercise (e.g. aerobic, strength), or that compared one type of task-oriented training to another type of task-oriented training (e.g. different types of feedback, or different types of gait training) without varying the intensity were excluded.

Results Table

View results table

Outcomes

Acute Phase

Balance
Not Effective
1a

Two high quality RCTs (Richards et al., 1993; Langhammer & Stanghelle, 2000) and 1 quasi-experimental study (Rose et al., 2011) investigated the effect of lower extremity task-oriented training on balance in patients with acute stroke.

The high quality RCT (Richards et al., 1993) randomized patients to receive (i) early, intensive gait-focused task-oriented physical therapy, (ii) early, high-intensity conventional rehabilitation, or (iii) conventional rehabilitation. Balance was measured by the Berg Balance Scale and Fugl Meyer Assessment (balance subscale) at post-treatment (6 weeks) and at follow-up (3 and 6 months post-stroke). No significant between-group differences were found on either balance measure at any time points.

The second high quality RCT (Langhammer & Stanghelle, 2000) randomized patients to receive lower extremity task-oriented training using a Motor Relearning Programme or Bobath-based treatment for the duration of hospitalization. Balance was measured by the Sødring Motor Evaluation Scale (balance/trunk control score) at 2 weeks and at 3 months post-stroke. No significant between-group difference was found at any time point.

The quasi-experimental study (Rose et al., 2011) assigned patients to receive lower extremity task-oriented mobility training or conventional rehabilitation. Balance was measured by the Berg Balance Scale at post-treatment (discharge from hospital, average length of stay of 20 days). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from 2 high quality RCTs and 1 quasi-experimental study that lower extremity task-oriented training is not more effective than comparison interventions (conventional rehabilitation, Bobath-based treatment) for improving balance in patients with acute stroke.

Functional independence
Not Effective
1A

Three high quality RCTs (Richards et al., 1993; Langhammer & Stanghelle, 2000; van Vliet et al., 2005) and one quasi-experimental study (Rose et al., 2011) investigated the effect of lower extremity task-oriented training on functional independence in patients with acute stroke.

The high quality RCT (Richards et al., 1993) randomized patients to receive (i) early, intensive gait-focused task-oriented physical therapy, (ii) early, high-intensity conventional rehabilitation, or (iii) conventional rehabilitation. Functional independence was measured by the Barthel Index (BI) at post-treatment (6 weeks) and at follow-up (3 and 6 months post-stroke). No significant between-group differences were found at any time points.

The second high quality RCT (Langhammer & Stanghelle, 2000) randomized patients to receive lower extremity task-oriented training using a Motor Relearning Programme or Bobath-based treatment for the duration of hospitalization. Functional independence was measured by the BI (feeding, transferring from wheelchair to bed and back, personal hygiene, getting on and off toilet, bathing, walking on level surface/propelling wheelchair, ascending and descending stairs, dressing, controlling bowels, controlling bladder) at baseline and at 3 months post-stroke. On three measures of functional independence (BI toilet, bowel, bladder scores), there was a significant between-group difference at 3 months post-stroke, and a significant between-group difference in the change in score from baseline to 3 months, favoring task-oriented training vs. Bobath-based treatment. There were no significant differences on other BI subscores.

The third high quality RCT (van Vliet et al., 2005) randomized patients to receive lower extremity task-oriented training using a Motor Relearning Programme or Bobath-based treatment. Functional independence was measured by the BI at 1 month, 3 months and 6 months. There was a significant between-group difference in only one measure of functional independence (BI bathing score) at 1 month follow-up, favoring task-oriented training vs. Bobath-based treatment. There were no significant differences on other BI subscores at any time points.
Note: The treatment did not have a specific ‘end-point’ and continued as long as was needed.

The quasi-experimental study (Rose et al., 2011) assigned patients to receive lower extremity task-oriented mobility training or conventional rehabilitation. Functional independence was measured by the Functional Independence Measure (FIM – phone version) at 90 days post-stroke. No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from 3 high quality RCTs and 1 quasi-experimental study that lower extremity task-oriented training is not more effective than comparison interventions (conventional rehabilitation, Bobath-based treatment) in improving functional independence in patients with acute stroke.

Gait
Not Effective
1b

One high quality RCT (Langhammer & Stanghelle, 2000) investigated the effect of lower extremity task-oriented training on gait in patients with acute stroke. This high quality RCT randomized patients to receive task-oriented training using a Motor Relearning Programme or Bobath-based treatment for the duration of hospitalization. Gait was measured by the Sødring Motor Evaluation Scale (gait score) at 2 weeks and at 3 months post-stroke. No significant between-group difference was found at any time point.

Conclusion: There is moderate evidence (Level 1b) from 1 high quality RCT that lower extremity task-oriented training is not more effective than a comparison intervention (Bobath-based treatment) in improving gait in patients with acute stroke.

Health-related quality of life
Not Effective
1B

One high quality RCT (Langhammer & Stanghelle, 2000) and 1 quasi-experimental study (Rose et al., 2011) investigated the effect of lower extremity task-oriented training on health-related quality of life in patients with acute stroke.

The high quality RCT (Langhammer & Stanghelle, 2000) randomized patients to receive lower extremity task-oriented training using a Motor Relearning Programme or Bobath-based treatment for the duration of hospitalization. Health-related quality of life was measured by the Nottingham Health Profile at 3 months post-stroke. No significant between-group difference was found.

The quasi-experimental study (Rose et al., 2011) assigned patients to receive task-oriented mobility training or conventional rehabilitation. Health-related quality of life was measured by the Stroke Impact Scale (SIS) at 90-days post-stroke. No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from 1 high quality RCT and 1 quasi-experimental study that lower extremity task-oriented training is not more effective than comparison interventions (Bobath-based treatment, conventional rehabilitation) in improving health-related quality of life in patients with acute stroke.

Instrumental activities of daily living (IADLs)
Not Effective
1B

One high quality RCT (van Vliet et al., 2005) investigated the effect of lower extremity task-oriented training on instrumental activities of daily living (IADLs) in patients with acute stroke. This high quality RCT randomized patients to receive lower extremity task-oriented training using a Motor Relearning Programme or Bobath-based treatment. IADLs were measured by the 22-item Extended Activities of Daily Living Scale (EADLS) at 1 month, 3 months and 6 months. There was a significant between-group difference on only 1 IADL item (EADLS – Leisure: go out socially) at all time point, in favor of task-oriented training vs. Bobath-based treatment.
Note: The treatment did not have a specific ‘end-point’ and continued as long as needed.

Conclusion: There is moderate evidence (Level 1b) from 1 high quality RCT that lower extremity task-oriented training is not more effective than a comparison intervention (Bobath-based treatment) in improving IADLs in patients with acute stroke.

Lower extremity motor function
Not Effective
1A

Three high quality RCTs (Richards et al., 1993, Langhammer & Stanghelle, 2000; van Vliet et al., 2005) and 1 quasi-experimental study (Rose et al., 2011) investigated the effect of lower extremity task-oriented training on lower extremity motor function in patients with acute stroke.

The first high quality RCT (Richards et al., 1993) randomized patients to receive (i) early, intensive gait-focused task-oriented physical therapy, (ii) early, high-intensity conventional rehabilitation, or (iii) conventional rehabilitation. Lower extremity motor function was measured by the Fugl-Meyer Assessment (FMA; lower extremity scale) at post-treatment (6 weeks) and at follow-up (3 and 6 months post-stroke). No significant between-group differences were found at any time points.

The second high quality RCT (Langhammer & Stanghelle, 2000) randomized patients to receive lower extremity task-oriented training using a Motor Relearning Programme or Bobath-based treatment. Lower extremity motor function was measured by the Sødring Motor Evaluation Scale (SMES; lower extremity, mobility scales) and the Motor Assessment Scale (MAS), at baseline, 2 weeks, and at 3 months post-stroke. No significant between-group differences were found on any measures, at either time point. There was no between-group difference in change from baseline to 2 weeks, or from baseline to 3 months post-stroke, measured using the MAS.

The third high quality RCT (van Vliet et al., 2005) randomized patients to receive lower extremity task-oriented training using a Motor Relearning Programme or Bobath-based treatment. Lower extremity motor function was measured by the Rivermead Motor Assessment and the MAS at 1 month, 3 months and 6 months. No significant between-group differences were found for either measure of lower extremity motor function at any time points.

Note: The treatment did not have a specific ‘end-point’ and continued as long as needed.

The quasi-experimental study (Rose et al., 2011) assigned patients to receive task-oriented mobility training or conventional rehabilitation. Lower extremity motor function was measured by the FMA (lower extremity motor scale) at post-treatment (discharge from hospital, average length of stay of 20 days). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from 3 high quality RCTs and 1 quasi experimental study that lower extremity task-oriented training program is not more effective than comparison interventions (conventional rehabilitation, Bobath-based treatment) for improving lower extremity motor function in patients with acute stroke.

Lower extremity spasticity
Not Effective
1B

One high quality RCT (an Vliet et al., 2005v) investigated the effect of lower extremity task-oriented training on lower extremity spasticity in patients with acute stroke. This high quality RCT randomized patients to receive lower extremity task-oriented training using a Motor Relearning Programme or Bobath-based treatment. Lower extremity spasticity was measured by the Modified Ashworth Scale at 1 month, 3 months and 6 months. No significant between-group difference was found at either time point.
Note: The treatment did not have a specific ‘end-point’ and continued as long as was needed.

Conclusion: There is moderate evidence (Level 1b) from 1 high quality RCT that lower-extremity task-oriented training is not more effective than a comparison intervention (Bobath-based treatment) in improving lower extremity spasticity in patients with acute stroke.

Sensory impairment
Not Effective
1B

One high quality RCT (van Vliet et al., 2005) and 1 quasi-experimental study (Rose et al., 2011) investigated the effect of lower extremity task-oriented training on sensory impairment in patients with acute stroke.

The high quality RCT (van Vliet et al., 2005) randomized patients to receive lower extremity task-oriented training using a Motor Relearning Programme or Bobath-based treatment. Sensory impairment was measured by the Nottingham Sensory Assessment at 1 month, 3 months and 6 months. No significant between-group difference was found at any time point.
Note: The treatment did not have a specific ‘end-point’ and continued as long as was needed.

The quasi-experimental study (Rose et al., 2011) assigned patients to receive task-oriented mobility training or conventional rehabilitation. Sensory impairment was measured by the Fugl-Meyer Assessment (FMA; sensory scale) at post-treatment (discharge from hospital, average length of stay of 20 days). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from 1 high quality RCT and 1 quasi-experimental study that lower extremity task-oriented training is not more effective than a comparison intervention (Bobath-based treatment,conventional rehabilitation) in improving sensory impairment in patients with acute stroke.

Walking speed
Not Effective
1A

Two high quality RCTs (Richards et al., 1993; van Vliet et al., 2005) and 1 quasi-experimental study(Rose et al., 2011) investigated the effect of lower extremity task-oriented training on walking speed in patients with acute stroke.

The first high quality RCT (Richards et al., 1993) randomized patients to receive (i) early, intensive gait-focused task-oriented physical therapy, (ii) early, high-intensity conventional rehabilitation, or (iii) conventional rehabilitation. Walking speed was measured by the 6-Meter Walk Test (6MWT) at post-treatment (6 weeks) and at follow-up (3 and 6 months post-stroke). No significant between-group differences were found at any time points.

The second high quality RCT (van Vliet et al., 2005) randomized patients to receive lower extremity task-oriented training using a Motor Relearning Programme or Bobath-based treatment. Walking speed was measured by the 6MWT at 1 month, 3 months and 6 months. No significant between-group difference was found at any time point.

The quasi-experimental study (Rose et al., 2011) assigned patients to receive task-oriented mobility training or conventional rehabilitation. Walking speed was measured by the 5-Meter Walk Test at post-treatment (discharge from hospital with mean length of stay of 20 days). A significant between-group difference was found favoring task-oriented training vs. conventional rehabilitation.

Conclusion: There is strong evidence (Level 1a) from 2 high quality RCTs that lower extremity task-oriented training is not more effective than comparison interventions (conventional rehabilitation, Bobath-based treatment) for improving walking speed in patients with acute stroke.

Note: However, 1 quasi-experimental study found that lower-extremity task-oriented training is more effective than conventional rehabilitation for improving walking speed in patients with acute stroke.

Chronic Phase

Balance
Conflicting
4

Two high quality RCTs (Marigold et al., 2005; Yang et al., 2006) and three fair quality RCTs (Dean et al., 2000; Kim et al., 2012; Choi & Kang, 2015) investigated the effect of lower extremity task-oriented training on balance in patients with chronic stroke.

The first high quality RCT (Marigold et al., 2005) randomized patients to receive lower extremity task-oriented training or a slow stretching and weight shifting program. Balance was measured by the Berg Balance Scale (BBS), and falls (forced due to platform translation), at post-treatment (10 weeks) and at follow-up (1 month); falls (unforced) were measured using monthly calendars from baseline up to 1 year later. There were no significant between-group differences in balance at any time points.

The second high quality RCT (Yang et al., 2006) randomized patients to receive task-oriented progressive resistant training or no therapy. Standing balance was measured by the Step Test at post-treatment (4 weeks). Significant between-group difference was found favoring task-oriented progressive resistant training vs. no therapy.

The first fair quality RCT (Dean et al., 2000) randomized patients to receive lower extremity task-oriented training or upper extremity task-oriented training. Standing balance was measured by the Step Test at post-treatment (4 weeks) and at follow-up (2 months). A significant between-group difference was found at any time point, favoring the lower extremity task-oriented training vs. upper extremity task-oriented training.

The second fair quality RCT (Kim et al., 2012) randomized patients to receive lower extremity task-oriented training with conventional physical therapy or conventional physical therapy alone. Balance was measured by the BBS at post-treatment (4 weeks). Significant between-group difference was found favoring lower extremity task-oriented training with conventional physical therapy vs. conventional physical therapy alone.

The third fair quality RCT Choi & Kang, 2015) randomized patients to receive either lower extremity task-oriented training or conventional physical therapy. Balance was measured by the BBS at post-treatment (4 weeks). Significant between-group difference was found favoring lower extremity task-oriented training vs. conventional physical therapy.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of lower extremity task oriented training on balance in patients with chronic stroke. One high quality RCT and 3 fair quality RCTs found that lower extremity task-oriented training was more effective than comparison programs (upper extremity task-oriented training, conventional physical therapy) and no therapy for improving balance outcomes (Step Test, BBS). However, a second high quality RCT found no difference in balance (BBS, forced/unforced falls) between lower extremity task-oriented training and another lower extremity training program (slow stretching and weight shifting program).

Balance confidence
Not Effective
1A

Two high quality RCTs (Marigold et al., 2005, Mudge et al., 2009) investigated the effect of lower extremity task-oriented training on balance confidence in patients with chronic stroke.

The first high quality RCT (Marigold et al., 2005) randomized patients to receive lower extremity task-oriented training or a slow stretching and weight shifting program. Balance confidence was measured by the Activities-Specific Balance Confidence (ABC) Scale at post-treatment (10 weeks) and at 1-month follow-up. No significant between-group difference was found at any time point.

The second high quality RCT (Mudge et al., 2009) randomized patients to receive lower extremity task-oriented training or social/educational classes. Balance confidence was measured by the ABC Scale at post-treatment (4 weeks) and at 3-month follow-up. No significant between-group difference was found at any time point.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that lower extremity task-oriented training is not more effective than comparison interventions (slow stretching and weight shifting program, social/educational classes) in improving balance confidence in patients with chronic stroke.

Functional independence/ADLs
Effective
2A

One fair quality RCT (Choi & Kang, 2015) investigated the effect of lower extremity task-oriented training on functional independence/activities of daily living (ADLs) in patients with chronic stroke. This fair quality RCT randomized patients to receive lower extremity task-oriented training or conventional physical therapy. ADLs were measured by the Modified Barthel Index at post-treatment (4 weeks). Significant between-group difference was found favoring lower extremity task-oriented training vs. conventional physical therapy.

Conclusions: There is limited evidence (Level 2a) from one fair quality RCT that lower extremity task-oriented training is more effective than a comparison intervention (conventional physical therapy) in improving functional independence/ADLs in patients with chronic stroke.

Functional mobility
Conflicting
4

Three high quality RCTs (Marigold et al., 2005; Yang et al., 2006; Mudge et al., 2009) and two fair quality RCTs (Dean et al., 2000; Kim et al., 2012) investigated the effect of lower extremity task-oriented training on functional mobility in patients with chronic stroke.

The first high quality RCT (Marigold et al., 2005) randomized patients to lower extremity task-oriented training or a slow stretching and weight shifting program. Functional mobility was measured by the Timed Up-and-Go Test (TUG) at post-treatment (10 weeks) and at follow-up (1 month). No significant between-group difference was found at any time point.

The second high quality RCT (Yang et al., 2006) randomized patients to receive task-oriented progressive resistant training or no therapy. Functional mobility was measured by the TUG at post-treatment (4 weeks). Significant between-group difference was found favoring task-oriented progressive resistant training vs. no therapy.

The third high quality RCT (Mudge et al., 2009) randomized patients to receive lower extremity task-oriented training or social/educational classes. Functional mobility was measured by the Rivermead Mobility Index at post-treatment (4 weeks) and at 3-month follow-up. While there was no significant between-group difference at post-treatment, results were significant at 3-month follow-up in favour of lower extremity task-oriented training vs. social/educational classes.

The first fair quality RCT (Dean et al., 2000) randomized patients to receive lower extremity task-oriented training or upper extremity task-oriented training. Functional mobility was measured by the TUG at post-treatment (4 weeks) and at follow-up (2 months). No significant between-group difference was found at any time point.

The second fair quality RCT (Kim et al., 2012) randomized patients to receive lower extremity task-oriented training with conventional physical therapy or conventional physical therapy alone. Functional mobility was measured by the TUG at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of lower extremity task-oriented training on functional mobility in the chronic stage of stroke recovery. Whereas 1 high quality RCT found that a lower extremity task-oriented training program was more effective than no intervention, 1 high quality RCT and 2 fair quality RCTs found that lower extremity task-oriented training was not more effective than comparison interventions (slow stretching and weight shifting program, upper extremity task-oriented training, conventional physical therapy) for improving functional mobility outcomes (TUG). A third highquality RCT found that lower extremity task-oriented training was not more effective than a comparison intervention (social/education classes) immediately post-treatment, but demonstrated long-term effectiveness.

Note: This study used a different measure of functional mobility (Rivermead Mobility Index).

Gait parameters
Effective
1A

Three high quality RCTs (Marigold et al., 2005; Yang et al., 2006; Jonsdottir et al., 2010) investigated the effect of lower extremity task-oriented training on gait parameters in patients with chronic stroke.

The first high quality RCT (Marigold et al., 2005) randomized patients to receive lower extremity task-oriented training or a slow stretching/weight-shifting program. Gait parameters (step reaction time) were measured at baseline, post-treatment (10 weeks) and follow-up (1 month). Significant between-group differences were found across time points, favoring lower extremity task-oriented training vs. slow stretching and weight shifting program.

The second high quality RCT (Yang et al., 2006) randomized patients to receive task-oriented progressive resistant training or no therapy. Gait parameters (velocity, cadence, stride length) were measured using the GAITRite system at post-treatment (4 weeks). Significant between-group differences were found for all gait parameters, favoring task-oriented progressive resistant training vs. no therapy.

The third high quality RCT (Jonsdottir et al., 2010) randomized patients to receive either lower extremity task-oriented training using biofeedback or conventional rehabilitation. Gait parameters (peak knee flexion during gait swing, peak ankle power, and stride length) were measured at baseline and at post-treatment (7 weeks) and at follow-up (3 months). Significant between-group differences were found for gait parameters (peak ankle power and stride length) across time points, favoring lower extremity task-oriented training using biofeedback vs. conventional rehabilitation.

Conclusion: There is strong evidence (Level 1a) from 3 high quality RCTs that lower extremity task-oriented training is more effective than comparison interventions (slow stretching and weight shifting program or conventional rehabilitation) and no therapy in improving gait parameters in patients with chronic stroke.

Health-related quality of life
Not Effective
1b

One high quality RCT (Marigold et al., 2005) investigated the effect of lower extremity task-oriented training on health-related quality of life in patients with chronic stroke. This high quality randomized patients to receive lower extremity task-oriented training or a slow stretching/weight-shifting program. Health-related quality of life was measured by the Nottingham Health Profile at baseline, at post-treatment (10 weeks) and at follow-up (1 month). No significant between-group differences were found across time points.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity task-oriented training is not more effective than a comparison intervention (slow stretching/weight-shifting program) in improving health-related quality of life in patients with chronic stroke.

Lower extremity strength
Effective
1B

One high quality RCT (Yang et al., 2006) investigated the effect of lower extremity task-oriented training on strength in patients with chronic stroke. This high quality RCT randomized patients to receive task-oriented progressive resistant training or no therapy. Strength of the hip flexors/extensors, knee flexors/extensors and ankle dorsi/plantarflexors was measured by Jamar hand held dynamometer at post-treatment (4 weeks). Significant between-group differences were found across all measures of lower extremity strength, favoring lower extremity task-oriented training vs. no therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity task-oriented training is more effective than no therapy in improving lower extremity strength in patients with chronic stroke.

Physical activity
Not Effective
1B

One high quality RCT (Mudge et al., 2009) investigated the effect of lower extremity task-oriented training on physical activity in patients with chronic stroke. This high quality RCT randomized patients to receive lower extremity task-oriented training or social/educational classes. Physical activity was measured by the Physical Activity & Disability Scale and the StepWatch Activity Monitor (mean steps/day, peak activity index, steps/minute, % time inactive) at post-treatment (4 weeks) and at 3-month follow-up. No significant between-group differences were found at any time points.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity task-oriented training is not more effective than a comparison intervention (social/educational classes) in increasing physical activity in patients with chronic stroke.

Self-efficacy
Effective
2A

One fair quality RCT (Choi & Kang, 2015) investigated the effect of lower extremity task-oriented training on self-efficacy in patients with chronic stroke. This fair quality RCT randomized patients to receive lower extremity task-oriented training or conventional physical therapy. Self-efficacy was measured by the Self-Efficacy Scale at post-treatment (4 weeks). Significant between-group difference was found favoring lower extremity task-oriented training vs. conventional physical therapy.

Conclusions: There is limited evidence (Level 2a) from one fair quality RCT that lower extremity task-oriented training is more effective than a comparison intervention (conventional physical therapy) in improving self-efficacy in patients with chronic stroke.

Sit-to-stand impairment
Effective
2a

One fair quality RCT (Dean et al., 2000) investigated the effect of lower extremity task-oriented training on sit-to-stand impairment in patients with chronic stroke. This fair quality RCT randomized patients to receive lower extremity task-oriented training or upper extremity task-oriented training. Sit-to-stand impairment was measured by the ground reaction AMTI force plate at post-treatment (4 weeks) and at follow-up (2 months). A significant between-group difference was found at any time point, favoring lower extremity task-oriented training vs. upper extremity task-oriented training.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that lower extremity task-oriented training is more effective than a comparison intervention (upper extremity task-oriented training) in improving the sit-to-stand impairment in patients with chronic stroke.

Trunk motor impairment
Effective
2A

One fair quality RCT (Kim et al., 2012) investigated the effect of lower extremity task-oriented training on trunk motor impairment in patients with chronic stroke. This fair quality RCT randomized patients to receive lower extremity task-oriented training with conventional physical therapy or conventional physical therapy alone. Trunk motor impairment was measured by the Trunk Impairment Scale (TIS – static sitting, dynamic sitting, coordination and total scores) at post-treatment (4 weeks). A significant between-group difference in trunk motor impairment (TIS total score only) was found, favoring lower extremity task-oriented training vs. conventional physical therapy alone.

Conclusions: There is limited evidence (Level 2a) from one fair quality RCT that lower extremity task-oriented training is more effective than a comparison intervention (conventional physical therapy alone) in improving trunk motor impairment in patients with chronic stroke.

Walking endurance
Effective
1a

Two high quality RCTs (Yang et al., 2006; Mudge et al., 2009) and 1 fair quality RCT (Dean et al., 2000) investigated the effect of lower extremity task-oriented training on walking endurance in patients with chronic stroke.

The first high quality RCT (Yang et al., 2006) randomized patients to receive task-oriented progressive resistant training or no therapy. Walking endurance was measured by the 6-Minute Walk Test (6MWT) at post-treatment (4 weeks). A significant between-group difference was found favoring lower extremity task-oriented training vs. no therapy.

The second high quality RCT (Mudge et al., 2009) randomized patients to receive lower extremity task-oriented training or social/educational classes. Walking endurance was measured by 6MWT at post-treatment (4 week) and at 3-month follow-up. A significant between-group difference was found at post-treatment, favoring lower extremity task-oriented training vs. social/educational classes; difference did not remain significant at 3-month follow-up.

The fair quality RCT (Dean et al., 2000) randomized patients to receive lower extremity task-oriented raining or upper extremity task-oriented training. Walking endurance was measured by 6MWT at post-treatment (4 weeks) and at follow-up (2 months). A significant between-group difference was found at any time point, favoring lower extremity task-oriented training vs. upper extremity task-oriented training.

Conclusion: There is strong evidence (Level 1a) from 2 high quality RCTs and 1 fair quality RCT that lower extremity task-oriented training is more effective than comparison interventions (no therapy, social/educational classes, upper extremity task-oriented training) in improving walking endurance in patients with chronic stroke.

Walking speed
Effective
1A

Three high quality RCTs (Yang et al., 2006; Mudge et al., 2009; Jonsdottir et al., 2010) and 2 fair quality RCTs (Dean et al., 2000; Kim et al., 2012) investigated the effect of lower extremity task-oriented training on walking speed in patients with chronic stroke.

The first high quality RCT (Yang et al., 2006) randomized patients to receive task-oriented progressive resistant training or no therapy. Walking speed was measured using the GAITRite system at post-treatment (4 weeks). A significant between-group difference was found favoring lower extremity task-oriented training vs. no therapy.

The second high quality RCT (Mudge et al., 2009) randomized patients to receive lower extremity task-oriented training or social/educational classes. Walking speed was measured by the 10-Meter Walk Test (10MWT) at post-treatment (4 weeks) and at 3-month follow-up. While there were no significant between-group differences at post-treatment, differences became significant at 3-month follow-up, favoring lower extremity task-oriented training vs. social/educational classes.

The third high quality RCT (Jonsdottir et al., 2010) randomized patients to receive lower extremity task-oriented training using biofeedback or conventional rehabilitation. Walking speed was measured by the 8-Meter Walk Test (8MWT), without assistive devices, at baseline, post-treatment (7 weeks) and at 3-month follow-up. Significant between-group differences were found across time points, favoring lower extremity task oriented training vs. conventional rehabilitation.

The first fair quality RCT (Dean et al., 2000) randomized patients to receive lower extremity task-oriented training or upper extremity task-oriented training. Walking speed was measured by the 10MWT (with and without assistive device) at post-treatment (4 weeks) and at 2-month follow-up. A significant between-group difference in walking speed (without assistive device only) was found at any time point, favoring lower extremity task-oriented training vs. upper extremity task-oriented training.

The second fair quality RCT (Kim et al., 2012) randomized patients to receive lower extremity task-oriented training with conventional physical therapy or conventional physical therapy alone. Walking speed was measured by the 10MWT at post-treatment (4 weeks). A significant between-group difference was found favoring lower extremity task-oriented training with conventional physical therapy vs. conventional physical therapy alone.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs and two fairquality RCTs that lower extremity task-oriented training is more effective than comparison interventions (social/educational classes, conventional rehabilitation, upper extremity task-oriented training, physical therapy) and no therapy in improving walking speed in patients with chronic stroke.

Phase of stroke recovery not specific to one period

Anxiety and depression
Not Effective
1b

One high quality RCT (van de Port et al., 2012) investigated the effect of lower extremity task-oriented training on anxiety and depression in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive lower extremity task-oriented circuit training or conventional physical therapy. Anxiety and depression was measured by the Hospital Anxiety and Depression Scale (HADS) at post-treatment (12 weeks) and at 3-month follow-up. No significant between-group differences were found at either time points.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity task-oriented training is not more effective than a comparison intervention (conventional physical therapy) in reducing anxiety and depression in patients with stroke.

Balance
Not Effective
1a

Five high quality RCTs (Blennerhassett & Dite 2004; McClellan & Ada, 2004; Salbach et al., 2004; van de Port et al., 2012; Kim et al., 2016) investigated the effect of lower extremity task-oriented training on balance in patients with stroke.

The first high quality RCT (Blennerhassett & Dite 2004) randomized patients with acute/subacute stroke to receive lower extremity task-oriented training or upper-extremity task-oriented training; both groups received conventional rehabilitation. Balance was measured by the Step Test at post-treatment (4 weeks) and at 6-month follow-up. No significant between-group difference was found at either time point.

The second high quality RCT (McClellan & Ada, 2004) randomized patients with subacute/chronic stroke to receive home-based lower extremity task-oriented training or home-based upper extremity training. Balance on reaching was measured by the Functional Reach Test at post-treatment (6 weeks) and at 2-month follow-up. Significant between-group difference was found at any time point, favoring lower extremity task-oriented training vs. upper extremity training.

The third high quality RCT (Salbach et al., 2004) randomized patients with subacute/chronic stroke to receive lower extremity task-oriented training or upper extremity task-oriented training. Balance was measured by the Berg Balance Scale (BBS) at post-treatment (6 weeks). No significant between-group difference was found.

The fourth high quality RCT (van de Port et al., 2012) randomized patients with subacute/chronic stroke to receive lower extremity task-oriented circuit training or conventional physical therapy. Balance was measured by the Timed Balance Test at post-treatment (12 weeks) and at 3-month follow-up. No significant between-group difference was found at either time point.

The fifth high quality RCT (Kim et al., 2016) randomized patients with acute/subacute stroke to receive either task-oriented mobility circuit training or physical therapy based on neurodevelopmental therapy. Balance was measured by the BBS at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from four high quality RCTs that lower extremity task-oriented training is not more effective than comparison interventions (upper-extremity task-oriented training, conventional physical therapy,physical therapy based on neurodevelopmental therapy) in improving balance in patients with stroke.

Note: However, one high quality RCT found that lower extremity task-oriented training is more effective than comparison intervention (upper-extremity task-oriented training) in improving balance on reaching in patients with stroke.

Balance confidence
Effective
1B

One secondary analysis by Salbach et al., 2005 – related to a high quality RCT (Salbach et al., 2004) – investigated the effect of lower extremity task-oriented training on balance confidence in patients with stroke. This secondary analysis revealed a significant between-group difference in average proportional change of balance self-efficacy (Activities-specific Balance Confidence Scale) at post-treatment (6 weeks), favoring lower extremity task-oriented training vs. upper extremity task-oriented training. In addition, the baseline level of depressive symptoms (Geriatric Depression Scale) was found to be an effect modifier on change in balance confidence.

Conclusion: There is moderate evidence (Level 1b) from one secondary analysis of a high quality RCT that lower extremity task-oriented training is more effective than a comparison intervention (upper-extremity task-oriented training) in improving balance confidence in patients with stroke.

Falls
Not Effective
2a

One fair quality RCT (Barreca et al., 2004) investigated the effect of lower extremity task-oriented training on falls in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive task-oriented sit-to-stand training or recreational therapy; both groups received conventional rehabilitation. There was no significant between-group difference in the number of patients who fell during the study, measured from baseline to either the point at which independent sit-to-stand was achieved or discharge.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that lower extremity task-oriented training is not more effective than comparison intervention (recreational therapy) in reducing the incidence of falls in patients with stroke.

Falls efficacy
Not Effective
1B

One high quality RCT (van de Port et al., 2012) investigated the effect of lower extremity task-oriented training on falls efficacy in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive either lower extremity task-oriented circuit training or conventional physical therapy. Falls efficacy was measured by the Falls Efficacy Scale at post-treatment (12 weeks) and at 3-month follow-up. No significant between-group difference was found at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity task-oriented training is not more effective than comparison interventions (conventional physical therapy) in improving falls efficacy in patients with stroke.

Fatigue
Not Effective
1b

One high quality RCT (van de Port et al., 2012) investigated the effect of lower extremity task-oriented training on fatigue (self-report) in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive either lower extremity task-oriented circuit training or conventional physical therapy. Fatigue (self-report) was measured by the Fatigue Severity Scale at post-treatment (12 weeks) and at 3-month follow-up. No significant between-group difference was found at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity task-oriented training is not more effective than a comparison intervention (conventional physical therapy) in reducing fatigue (self-report) in patients with stroke.

Functional independence/ADLs
Not Effective
1B

One high quality RCT Kim et al., 2016) and one fair quality RCT (Kim et al., 2015b) investigated the effect of lower extremity task-oriented training on functional independence/ADLs in patients with stroke.

The high quality RCT (Kim et al., 2016) randomized patients with acute/subacute stroke to receive task-oriented mobility circuit training or physical therapy based on neurodevelopmental therapy. Functional independence/ADLs were measured by the Korean version of the Modified Barthel Index (m-BI) at post-treatment (4 weeks). No significant between-group difference was found.

The fair quality RCT (Kim et al., 2015b) randomized patients with acute/subacute stroke to receive task-oriented training on a tilt table + conventional rehabilitation, standard tilt table training + conventional rehabilitation, or conventional rehabilitation alone. Functional independence/ADLs were measured by the Barthel Index (BI) at post-treatment (3 weeks). Significant between-group differences were found favoring task-oriented tilt table training vs. standard tilt table training; favoring task-oriented tilt table training vs. conventional rehabilitation alone; and favoring standard tilt table training vs. conventional rehabilitation alone.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity task-oriented training is not more effective than a comparison intervention (physical therapy based on neurodevelopmental therapy) in improving functional independence/ADLs in patients with stroke.

Note: However, one fair quality RCT found that task-oriented training on a tilt table is more effective than comparison interventions (standard tilt table training, conventional rehabilitation alone) in improving functional independence/ADLs in patients with stroke.

Functional mobility
Not Effective
1A

Four high quality RCTs (Blennerhassett & Dite 2004; Salbach et al., 2004; McClellan & Ada, 2004; van de Port et al., 2012) investigated the effect of lower extremity task-oriented training on functional mobility in patients with stroke.

The first high quality RCT (Blennerhassett & Dite 2004) randomized patients with acute/subacute stroke to receive lower extremity task-oriented training or upper-extremity task-oriented training; both groups received conventional rehabilitation. Functional mobility was measured by the Timed Up-and-Go Test (TUG) at post-treatment (4 weeks) and at 6-month follow-up. No significant between-group difference was found at either time point.

The second high quality RCT (Salbach et al., 2004) randomized patients with subacute/chronic stroke to receive lower extremity task-oriented training or upper extremity task-oriented training. Functional mobility was measured by the TUG at post-treatment (6 weeks). No significant between-group difference was found.

The third high quality RCT (McClellan & Ada, 2004) randomized patients with subacute/chronic stroke to receive home-based lower extremity task-oriented training or home-based upper extremity training. Functional mobility was measured by the Motor Assessment Scale – walking ability scale (item 5) at post-treatment (6 weeks) and at 2-month follow-up. No significant between-group difference was found at either time point.

The forth high quality RCT (van de Port et al., 2012) randomized patients with subacute/chronic stroke to receive lower extremity task-oriented circuit training or conventional physical therapy. Functional mobility was measured by the Rivermead Mobility Index, the TUG and the Functional Ambulation Classification at post-treatment (12 weeks) and at 3-month follow-up. There were no significant between-group differences in any measure of functional mobility at either time points.

Conclusion: There is strong evidence (Level 1a) from four high quality RCTs that lower extremity task-oriented training is not more effective than comparison interventions (upper-extremity task-oriented training, conventional physical therapy) in improving functional mobility in patients with stroke.

Gait parameters
Effective
2A

One fair quality RCT (im et al., 2015aK) investigated the effect of lower extremity task-oriented training on gait parameters in patients with stroke. This fair quality RCT randomized patients with subacute / chronic stroke to receive task-oriented training on a tilt table, one-leg standing training on a tilt-table or standard tilt table training; all groups received conventional rehabilitation in conjunction with their respective interventions. Gait parameters (velocity, cadence, stride length, gait symmetry ratio, double support percentage) were measured at post-treatment (3 weeks) using the GAITRite system. There were significant between-group differences for all gait parameters, favoring task-oriented tilt table training vs. one-leg standing training, and favoring task-oriented tilt table training vs. standard tilt table training. There were also significant between-group differences for some gait parameters (velocity, cadence), favoring one-leg standing tilt table training vs. standard tilt table training.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that lower extremity task-oriented training with tilt table training is more effective than comparison interventions (one-leg tilt table training, standard tilt table training) in improving gaitparameters in patients with stroke.

Health-related quality of life
Not Effective
1B

One high quality RCT (McClellan & Ada, 2004) and one fair quality RCT (Barreca et al., 2004) investigated the effect of lower extremity task-oriented training on health-related quality of life in patients with stroke.

The high quality RCT (McClellan & Ada, 2004) randomized patients with subacute/chronic stroke to receive home-based lower extremity task-oriented training or home-based upper extremity training. Health-related quality of life was measured by the Stroke Adapted Sickness Impact Profile at post-treatment (6 weeks) and at 2-month follow-up. No significant between-group difference was found at either time point.

The fair quality RCT (Barreca et al., 2004) randomized patients with acute/subacute stroke to receive task-oriented sit-to-stand training or recreational therapy; both groups received conventional rehabilitation. Health-related quality of life was measured by the Global Rating Scale and the Darmouth Primary Care Cooperative Information Project at post-treatment (4 months). There were no significant between-group differences in any measures.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fairquality RCT that lower extremity task-oriented training is not more effective than comparison interventions (upper extremity training, recreational therapy) in improving health-quality of life among patients with stroke.

Instrumental activities of daily living (IADLs)
Not Effective
1B

One high quality RCT (an de Port et al., 2012v) investigated the effect of lower extremity task-oriented training on instrumental activities of daily living (IADLs) in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive lower extremity task-oriented circuit training or conventional physical therapy. IADLs were measured by the Nottingham Extended ADL (NEADL – mobility, kitchen, domestic, leisure scores) at post-treatment (12 weeks) and at 3-month follow-up. There was a significant between-group difference in one measure of IADLs (NEADL – Leisure) at post-treatment, favoring conventional physical therapy vs. task-oriented mobility circuit training. This did not remain significant at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity lower extremity task-oriented training is not more effective than a comparison intervention (conventional physical therapy) in improving IADLs in patients with stroke.

Note: In fact, conventional physical therapy was found to be more effective than lower extremity task-oriented circuit training in improving one domain of IADLs (leisure) in the short-term.

Lower extremity motor function
Not Effective
1A

Two high quality RCTs (van de Port et al., 2012, Kim et al., 2016) and one fair quality RCT (Kim et al., 2015b) investigated the effect of lower extremity task-oriented training on lower extremity motor function in patients with stroke.

The first high quality RCT (van de Port et al., 2012) randomized patients with subacute/chronic to receive lower extremity task-oriented circuit training or conventional physical therapy. Lower extremity motor function was measured by the Motricity Index (MI) – Leg score at post-treatment (12 weeks) and at 3-month follow-up (3 months). No significant between-group difference was found at either time point.

The second high quality RCT (Kim et al., 2016) randomized patients with acute/subacute stroke to receive task-oriented mobility circuit training or physical therapy based on neurodevelopmental therapy. Lower extremity motor function was measured by the Fugl-Meyer Assessment (FMA – lower extremity subscale) at post-treatment (4 weeks). No significant between-group difference was found.

The fair quality RCT (Kim et al., 2015b) randomized patients with acute/subacute stroke to receive task-oriented training on a tilt table + conventional rehabilitation, standard tilt table training + conventional rehabilitation, or conventional rehabilitation alone. Lower extremity motor function was measured by the FMA – lower extremity subscale at post-treatment (3 weeks). Significant between-group differences were found favoring task-oriented tilt table training vs. standard tilt table training; favoring task-oriented tilt table training vs. conventional rehabilitation alone; and favoring standard tilt table training vs. conventional rehabilitation alone.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that lower extremity task-oriented training is not more effective than a comparison intervention (conventional physical therapy,physical therapy based on neurodevelopmental therapy) in improving lower extremity motor function in patients with stroke.

Note: However, one fair quality RCT found that task-oriented training on a tilt table is more effective than comparison interventions (standard tilt table training, conventional rehabilitation alone) in improving lower extremity motor function in patients with stroke.

Muscle activation
Effective
2A

One fair quality RCT (Kim et al., 2015b) investigated the effect of lower extremity task-oriented training on muscle activation in patients with stroke. This fair quality RCT randomized patients with acute / subacute stroke to receive task-oriented training on a tilt table + conventional rehabilitation, standard tilt table training + conventional rehabilitation, or conventional rehabilitation alone. Muscle activations (biceps femoris, medial gastrocnemius, rectus femoris, tibialis anterior of the affected and unaffected lower extremities) were measured by the electromyography (EMG) at post-treatment (3 weeks). Significant between-group differences were found (affected and less affected biceps femoris; affected and less affected medial gastrocnemius; less affected rectus femoris), favoring task-oriented tilt table training vs. standard tilt table training, and favoring task-oriented tilt table training vs. conventional rehabilitation alone.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that lower extremity task-oriented training on a tilt table is more effective than comparison interventions (standard tilt table training, conventional rehabilitation alone) in improving muscle activation in patients with stroke.

Muscle strength
Effective
2A

One fair quality RCT (Kim et al., 2015a) investigated the effect of lower extremity task-oriented training on lower extremity muscle strength in patients with stroke. This fair quality RCT randomized patients with subacute/chronic stroke to receive task-oriented training on a tilt table, one-leg standing training on a tilt table, or standard tilt table training; all groups also received conventional rehabilitation. Lower extremity muscle strength (hip flexors/extensors, knee flexors/extensors, ankle dorsi/plantarflexors) was measured by handheld dynamometer at post-treatment (3 weeks). There were significant between-group differences in lower extremity muscle strength (hip flexors/extensors, knee flexors/extensors, ankle dorsi/plantarflexors), favoring task-oriented tilt table training vs. one-leg standing tilt table training, and favoring task-oriented tilt table training vs. standard tilt table training. There were also significant between-group differences (hip flexors/extensors only), favoring one-leg standing tilt table training vs. standard tilt table training.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that lower extremity task-oriented training on a tilt table is more effective than comparison interventions (one-leg standing training on a tilt table, standard tilt table training) in improving lower extremity muscle strength in patients with stroke.

Sit-to-stand maneuver
Effective
2A

One fair quality RCT (Barreca et al., 2004) investigated the effect of lower extremity task-oriented training on sit-to-stand maneuver in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive task-oriented sit-to-stand training or recreational therapy; both groups received conventional rehabilitation. Sit-to-stand maneuver was measured as the number of participants who were successful in standing up twice, without hands, from a 16-inch mat surface for 2 consecutive days. Sit-to-stand maneuver was also measured as the mean number of daily sit-to-stand repetitions performed until the end of the study defined as either the point at which independent sit-to-stand was achieved or discharge. There were significant between-group differences on both measures of sit-to-stand, favoring task-oriented training vs. recreational therapy.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that task-oriented sit-to-stand training is more effective than a comparison intervention (recreational therapy) in improving the sit-to-stand maneuver in patients with stroke.

Stairs competence
Effective
1B

One high quality RCT (van de Port et al., 2012) investigated the effects of lower extremity task-oriented training on stairs competence in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive lower extremity task-oriented circuit training or conventional physical therapy. Stairs competence was measured by the Modified Stairs Test at post-treatment (12 weeks) and at 3-month follow-up. There was a significant between-group difference at post-treatment, favoring lower extremity task-oriented circuit training vs. conventional physical therapy. This difference did not remain significant at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity task-oriented training is more effective, in short term, than a comparison intervention (conventional physical therapy) in improving stairs competence in patients with stroke.

Stroke outcomes
Not Effective
1B

One high quality RCT (van de Port et al., 2012) investigated the effect of lower extremity task-oriented training on stroke outcomes in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive lower extremity task-oriented circuit training or conventional physical therapy. Stroke outcomes were measured by the Stroke Impact Scale (SIS) – Mobility, Strength, Memory/Thinking, Emotion, Communication, ADLs/IADLs, Hand function, Participation and Stroke recovery scores at post-treatment (12 weeks) and at 3-month follow-up. Significant between-group difference was found in one measure of stroke outcomes (SIS – memory/thinking) at post-treatment only, favoring conventional physical therapy vs. task-oriented mobility training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity task-oriented training is not more effective than a comparison intervention (conventional physical therapy) in improving stroke outcomes of patients with stroke.

Note: In fact, conventional physical therapy was found to be more effective, in short term, than lower extremity task-oriented training on one measure of stroke outcomes (memory/thinking).

Stroke severity
Effective
2A

One fair quality RCT (Kim et al., 2015b) investigated the effect of lower extremity task-oriented training on stroke severity in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive task-oriented training on a tilt table + conventional rehabilitation, standard tilt table training + conventional rehabilitation, or conventional rehabilitation alone. Stroke severity was measured by the National Institutes of Health Stroke Scale (NIHSS) at post-treatment (3 weeks). Significant between-group differences were found favoring task-oriented tilt table training vs. standard tilt table training; favoring task-oriented tilt table training vs. conventional rehabilitation alone; and favoring standard tilt table training vs. conventional rehabilitation alone.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that lower extremity task-oriented training on a tilt table is more effective than comparison interventions (standard tilt table training, conventional rehabilitation alone) in improving stroke severity in patients with stroke.

Walking endurance
Effective
1A

Four high quality RCTs (Blennerhassett & Dite 2004; Salbach et al., 2004; van de Port et al., 2012; Kim et al., 2016) investigated the effect of lower extremity task-oriented training on walking endurance in patients with stroke.

The first high quality RCT (Blennerhassett & Dite 2004) randomized patients with acute/subacute stroke to receive lower extremity task-oriented training or upper-extremity task-oriented training; both groups received conventional rehabilitation. Walking endurance was measured by the 6-Minute Walk Test (6MWT) at post-treatment (4 weeks) and 6-month follow-up. There was a significant between-group difference in walking endurance at post-treatment, favoring lower extremity task-oriented training vs. upper extremity task oriented training. This difference did not remain significant at follow-up.

The second high quality RCT (Salbach et al., 2004) randomized patients with subacute/chronic stroke to receive lower extremity task-oriented training or upper extremity task-oriented training. Walking endurance was measured by the 6MWT at post-treatment (6 weeks). Significant between-group difference was found favoring lower extremity task-oriented training vs. upper extremity task-oriented training.

The third high quality RCT (van de Port et al., 2012) randomized patients with subacute/chronic stroke to receive lower extremity task-oriented circuit training or conventional physical therapy. Walking endurance was measured by the 6MWT at post-treatment (12 weeks) and at 3-month follow-up. Significant between-group difference was found at post-treatment, favoring lower extremity task-oriented circuit training vs. conventional physical therapy. This difference did not remain significant at follow-up.

The fourth high quality RCT (Kim et al., 2016) randomized patients with acute/subacute stroke to receive task-oriented mobility circuit training or physical therapy based on neurodevelopmental therapy. Walking endurance was measured by the 6MWT at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from 3 high quality RCTs that lower extremity task-oriented training is more effective than comparison interventions (upper extremity task-oriented training, conventional physical therapy) in improving walking endurance among patients with stroke.

Note: However, a fourth high quality RCT found no difference in walking endurance between task-oriented mobility circuit training and physical therapy based on neurodevelopmental therapy.

Walking speed
Effective
1A

Two high quality RCTs (Salbach et al., 2004; van de Port et al., 2012) and one fair quality RCT (Kim et al., 2015a) investigated the effect of lower extremity task-oriented training on walking speed in patients with subacute/chronic stroke.

The first high quality RCT (Salbach et al., 2004) randomized patients to receive lower extremity task-oriented training or upper extremity task-oriented training. Walking speed was measured by the 5-Meter Walk Test (5MWT) maximal and comfortable speed scores at post-treatment (6 weeks). Significant between-group differences in both maximal and comfortable walking speeds were found, favoring lower extremity task-oriented training vs. upper extremity task-oriented training.

The second high quality RCT (van de Port et al., 2012) randomized patients to receive lower extremity task-oriented circuit training or conventional physical therapy. Walking speed was measured by the 5-Meter Comfortable Walking Speed Test at post-treatment (12 weeks) and at 3-month follow-up. Significant between-group difference was found at any time point, favoring lower extremity task-oriented circuit training vs. conventional physical therapy.

The fair quality RCT (Kim et al., 2015a) randomized patients with subacute/chronic stroke to receive task-oriented training on a tilt table, one-leg standing training on a tilt-table or standard tilt table training; all groups received conventional rehabilitation in conjunction with their respective interventions. Walking speed was measured at post-treatment (3 weeks) using the GAITRite system. Significant between-group differences were found favoring task-oriented tilt table training vs. one-leg standing training; favoring task-oriented tilt table training vs. standard tilt table training; and favoring one-leg standing tilt table training vs. standard tilt table training.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs and one fairquality RCT that lower extremity task-oriented training is more effective than comparison interventions (upper extremity task-oriented training, conventional physical therapy,one-leg standing training on a tilt-table, standard tilt table training) in improving walking speed in patients with subacute/chronic stroke.

References

Barreca, S., Sigouin, C.S., Lambert, C., & Ansley, B. (2004). Effects of extra training on the ability of stroke survivors to perform an independent sit to stand: a randomized controlled trial. Journal of Geriatric Physical Therapy, 27, 59–64.
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Blennerhassett, J. & Dite, W. (2004). Additional task-related practice improves mobility and upper limb function early after stroke: a randomised controlled trial. Australian Journal of Physiotherapy, 50, 219-224.
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Choi, J.-U. & Kang, S.-H. (2015). The effects of patient-centered task-oriented training on balance activities of daily living and self-efficacy following stroke. Journal of Physical Therapy Science, 27, 2985-8
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Dean, C., Richards, C., & Malouin, F. (2000). Task-related circuit training improves performance of locomotor tasks in chronic stroke: A randomized, controlled pilot trial. Archives of Physical Medicine and Rehabilitation, 81(4), 409-417.
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Jonsdottir, J., Cattaneo, D., Recalcati, M., Regola, A., Rabuffetti, M., Ferrarin, M., & Casiraghi A. (2010). Task-oriented biofeedback to improve gait in individuals with chronic stroke: Motor learning approach. Neurorehabilitation and Neural Repair, 24(5), 478-485.
http://www.ncbi.nlm.nih.gov/pubmed/20053951

Kim, B.H., Lee, S.M., Bae, Y.H., Yu, J.H., & Kim, T.H. (2012).The effect of task-oriented training on trunk control ability, balance and gait of stroke patients. Journal of Physical Therapy Science, 24, 519-22.
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Kim, C.-Y., Lee, J.-S., Kim, H.-D., & Kim, J.-S. (2015a). The effect of progressive task-oriented training on a supplementary tilt table on lower extremity muscle strength and gait recovery in patient with hemiplegic stroke. Gait & Posture, 41, 425-430.
http://www.ncbi.nlm.nih.gov/pubmed/25467171

Kim, C.-Y., Lee, J.-S., Kim, H.-D., Kim, J.-S., Lee, I.-H. (2015b). Lower extremity muscle activation and function in progressive task-oriented training on the supplementary tilt table during stepping-like movements in patients with acute stroke hemiparesis. Journal of Electromyography and Kinesiology, 25, 522-30.
http://www.ncbi.nlm.nih.gov/pubmed/25863464

Kim, S.M., Han, E.Y., Kim B.R., & Hyun, C.W. (2016). Clinical application of circuit training for subacute stroke patients: a preliminary study. The Journal of Physical Therapy Science, 28, 169-74.
https://www.jstage.jst.go.jp/article/jpts/28/1/28_jpts-2015-787/_article

Langhammer, B., & Stanghelle, J.K. (2000). Bobath or motor relearning programme? A comparison of two different approaches of physiotherapy in stroke rehabilitation: a randomized controlled study. Clinical Rehabilitation, 14, 361–69.
http://www.ncbi.nlm.nih.gov/pubmed/10945420

Marigold, D.S., Eng, J.J., Dawson, A.S., Inglis, J.T., Harris, J.E., & Gylfadottir, S. (2005). Exercise leads to faster postural reflexes, improved balance and mobility, and fewer falls in older persons with chronic stroke. Journal of the American Geriatrics Society, 53(3), 416-423.
http://www.ncbi.nlm.nih.gov/pubmed/15743283

McClellan, R., & Ada, L. (2004). A six-week, resource-efficient mobility program after discharge from rehabilitation improves standing in people affected by stroke: Placebo-controlled, randomised trial. Australian Journal of Physiotherapy, 50(3), 163-168.
http://www.ncbi.nlm.nih.gov/pubmed/15482247

Mudge, S., Barber, A., & Scott, S. (2009). Circuit-based rehabilitation improves gait endurance but not usual walking activity in chronic stroke: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 90, 1989-96.
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Richards, C.L., Malouin, F., Wood-Dauphinee, S., Williams, J.I., Bouchard, J.P., & Brunet, D. (1993). Task-specific physical therapy for optimization of gait recovery in acute stroke patients. Archives of Physical Medicine and Rehabilitation, 74, 612-620.
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Salbach, N.M., Mayo, N.E., Wood-Dauphinee, S., Hanley, J.A., Richards, C.L., & Cote, R. (2004). A task-orientated intervention enhances walking distance and speed in the first year post stroke: a randomized controlled trial. Clinical Rehabilitation, 18, 509-519.
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Excluded Studies

Barbeau, H. & Visintin, M. (2003). Optimal outcomes obtained with body-weight support combined with treadmill training in stroke subjects. Archives of Physical Medicine and Rehabilitation, 84(10), 1458-1465.

Reason for exclusion: Both groups received a type of task-oriented mobility training

Bayouk, J.-F., Boucher, J.P., & Leroux, A. (2006). Balance training following stroke: effects of task-oriented exercises with and without altered sensory input. International Journal of Rehabilitation Research, 29(1), 51-9.

Reason for exclusion: Both groups received task-oriented training.

Bourbonnais, D., Bilodeau, S., Lepage, Y., Beaudoin, N., Gravel, D., & Forget, R. (2002).
Effect of force-feedback treatments in patients with chronic motor deficits after a stroke. American Journal of Physical Medicine and Rehabilitation,81, 890-89.

Reason for exclusion: Did not involve a functional salient, real-life task.

Chan, D., Chan, C. & Au, D. (2006). Motor relearning programme for stroke patients: a randomized controlled trial. Clinical Rehabilitation, 20(3), 191.

Reason for exclusion: Both groups received a type of task-oriented mobility training.

Duclos, C., Nadeau, S., Bourgeois, N., Bouyer, L., & Richards, C.L. (2014). Effects of walking with loads above the ankle on gait parameters of persons with hemiparesis after stroke. Clinical Biomechanics, 29, 265-71.

Reason for exclusion: Not RCT.

Husemann, B., Muller, F., Krewer, C., Heller, S. & Koenig, E. (2007). Effects of locomotion training with assistance of a robot-driven gait orthosis in hemiparetic patients after stroke: a randomized controlled pilot study. Stroke, 38(2), 349.

Reason for exclusion: Unclear if patients were actively participating, unclear if the control group did not receive task-oriented training.

Fernandes, B., Ferreira, M.J., Batista, F., Evangelista, I., Prates, L., & Silveira-Sergio, J. (2015). Task-oriented training and lower limb strengthening to improve balance and function after stroke: a pilot study. European Journal of Physiotherapy, 17 (2), 74-80.

Reason for exclusion: Both groups received a form of task-oriented training.

Jeon, B.-J., Kim, W.-H., & Park, E.-Y. (2015). Effect of task-oriented training for people with stroke: a meta-analysis focused on repetitive or circuit training. Topics in Stroke Rehabilitation, 22(1), 34-43.

Reason for exclusion: Review.

Kwakkel, G., Wagenaar, R., Twisk, J., Lankhorst, G., & Koetsuer, J. (1999). Intensity of leg and arm training after primary middle-cerebral- artery stroke: a randomised trial. Lancet, 354, 189-194.

Reason for exclusion: Article is not explicit about intervention being progressively adapted.

Mudie, M.H., Winzeler-Mercay, U., Radwan, S., & Lee, L. (2002). Training symmetry of weight distribution after stroke: a randomized controlled pilot study comparison task-related reach, Bobath and feedback training approaches. Clinical Rehabilitation, 16, 582-92.

Reason for exclusion: Not focusing on mobility or lower-extremities training.

Nadeau, S., Duclos, C., Bouyer, L., & Richards, C.L. (2011). Guiding task-oriented gait training after stroke or spinal cord injury by means of a biomechanical gait analysis. Progress in Brain Research, 192, 161-80.

Reason for exclusion: Review

Nilsson, L., Carlsson, J., Danielsson, A., Fugl-Meyer, A., Hellstrom, K., Kristensen, L., et al. (2001). Walking training of patients with hemiparesis at an early stage after stroke: a comparison of walking training on a treadmill with body weight support and walking training on the ground. Clinical Rehabilitation, 15(5), 515-527.

Reason for exclusion: Both groups received a type of task-oriented mobility training

Outermans, J.C., van Peppen, R.P., Wittink, H., Takken, T. & Kwakkel, G. (2010). Effects of a high-intensity task-oriented training on gait performance early after stroke: a pilot study. Clinical Rehabilitation, 24(11), 979-87.

Reason for exclusion: Both groups received a form of task-oriented training with varying intensities.

Richards, C.L., Malouin, F., Bravo, G., Dumas, F., & Wood-Dauphinee, S. (2004). The role of technology in task-oriented training in persons with subacute stroke: a randomized controlled trial. Neurorehabilitation and Neural Repair, 18, 199-211.

Reason for exclusion: Both groups received a type of task-oriented mobility training.

Sunnerhagen, K.T. (2007). Circuit training in community-living “younger” men after stroke. Journal of Stroke and Cerebrovascular Diseases, 16(3), 122-9.

Reason for exclusion: Not an RCT.

Verma, R, Arya, K.N., & Singh, T. (2011). Task-oriented circuit class training program with motor imagery for gait-rehabilitation in poststroke patients: a randomized controlled trial. Topics in Stroke Rehabilitation, 18, 620-32.

Reason for exclusion: Experimental group also received mental imagery.

Visintin, M., Barbeau, H., Korner-Bitensky, N. & Mayo, N.E. (1998). A new approach to retrain gait in stroke patients through body weight support and treadmill stimulation. Stroke, 29(6), 1122-1128.

Reason for exclusion: Both groups received a type of task-oriented mobility training

Wang, R.-Y., Tseng, H.-T., Liao, K-K., Wang, C.-J., Lai, K.-L., & Yang, Y.-R. (2012) rTMS combined with task-roeinted training to improve symmetry of interhemispheric corticomotor excitability and gait performance after stroke: a randomized trial. Neurorehabilitation and Neural Repair, 26(3), 222-30.

Reason for exclusion: both groups got task-oriented training

Yang, Y.R., Yen, J.G., Wang, R.Y., Yen, L.L., & Lieu, F.K. (2005). Gait outcomes after additional backward walking training in patients with stroke: a randomized controlled trial. Clinical Rehabilitation, 19, 264-273.

Reason for exclusion: Did not involve a functional salient, real-life task (backwards walking).

Yen, C.-L., Wang, R.-Y., Lioa, K.-K. Huang, C.-C., & Yang, Y.-R. (2008). Gait training-induced change in cotricomotor excitability in patients with chronic stroke. Neurorehabilitation and Neural Repair, 22, 22-30.

Reason for exclusion: Treadmill training

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