Chapter 1: Introduction
1.1 Background
Neurological disorders are usually associated with balance problems and decreased independency in daily life, since balance plays a major role in everyday activities. Balance and postural stability can be described as the ability of the human body to return to a point of equilibrium when it is exposed to external disturbance (Karlsson, 2000). Postural stability and balance are maintained through a postural control or balance system (Guskiewiz, 1996). The balance system reflects the functions of the sensory, motor and nervous systems (Duarte, 2010). The sensory system, which includes visual, vestibular and somatosensory inputs, provides feedback about body-segment position in relation to other systems as well as to the environment (Duarte, 2010). The motor system corrects and provides appropriate muscle activation in order to determine adequate movement. The nervous system processes the information received from the sensory system and sends a nervous impulse to ensure neuromuscular response generation (Duarte, 2010). Indeed, the neuromuscular response is considered to be an important factor in maintaining balance during different activities (Duarte, 2010). Accordingly, the postural control system acts as a link between the brain and multiple body systems (Guskiewiz, 1996). Any brain damage may lead to postural control system disorder, which will result in postural instability and balance problems.
As indicated, many components contribute to the postural control system, such as biomechanical, motor, sensory and cognition (Horak, 2006). Consequently, appropriate understanding of all of these components will lead to proper assessment and treatment of balance disorder (Horak, 2006). Several interventions have been used to improve balance disorder, such as strengthening training, balance training based on manipulating sensory input, feedback therapy and bobath therapy. The majority of interventions concentrate on the disability itself and seek to regain a normal pattern of movement (Rensik, 2009). The concept of neurorehabilitation, however, is based on using different ways to re-learn previously known tasks (Rensik, 2009). These ways may involve compensatory strategies as well as recruitment of different alternative pathways. In fact, it is suggested that functional improvement depends on impairment restoration as well as adaptation strategies, since it compensates for the impairment. To provide appropriate and comprehensive interventions, management should not be limited to the disability since other components will contribute to intervention outcomes, such as activity level and participation level (Novak, 2013). Additionally, a goal-based approach may be used to select the best interventions, which will be determined according to patient and family goals (Novak, 2013).
A new intervention known as “task-oriented training” has been introduced into the rehabilitation field to improve functional ability through a goal-directed approach and repetition (Hubbard, 2009). Task-oriented training is based on movement science and motor learning (Hubbard, 2009). Since motor learning suggests that greater improvement occurs when the task is specific to the desired result, the rehabilitation technique has shifted from a facilitation/inhibition approach toward a dynamic, task-specific approach (Salem, 2009). Movement arises from different systems in the brain, which are directed to the intended goal and restricted by the environment (Rensink, 2009). Accordingly, individual, task and environmental demands will affect movement organisation (Shumway-Cook et al., 2012). Thus, the task-oriented training approach seems to focus on the task and the patient rather than on the therapist (Rensink, 2009). Moreover, task-oriented training relies on the performance of functional tasks instead of specific movement patterns (Shumway-Cook et al., 2012). According to the task-oriented training concept, the learning process will take place as a result of active solving of problems during a functional task rather than repetition of a precise normal pattern of movement (Shumway-Cook et al., 2012). In addition, the variety of exercises performed during task-oriented training will result in reduced compensatory movement (Kim, 2012).
Introducing task-oriented training in clinical practice requires a focus on five guidelines to ensure the training’s effectiveness (Hubbard, 2009). First, the training must be relevant, which can be achieved through meaningful tasks as well as tasks that rely on “real world” activities. Second, randomisation is important since it improves retention and transfer. Using different task contexts, settings, demands and sequences ensures randomisation (Hubbard, 2009). Third, repetition has a role to play because the more a task is practised the better functional performance will be; although it should be added that specificity of task is considered to be just as important as repetition (Hubbard, 2009). Fourth, reconstruction, which is determined through performing the component part of the task, then progressing to the whole task; and fifth, reinforcement, which involves providing positive feedback to the participant at an early stage of training, decreasing this over time to avoid dependency (Hubbard, 2009).
Unfortunately, while many studies have assessed the efficiency of task-oriented training, these studies are disparate in nature. Although the literature supports the use of task-oriented training, the effectiveness of the training is still uncertain. This study will review the literature with the aim of developing a rigorous methodology to determine the effectiveness of task-oriented training.
1.2 Study’s objectives
The objective of this study is to determine the effect of task-oriented training on balance performance.
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