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Background. Stroke commonly affects upper extremity motor abilities, yet there has been very limited success in developing effective rehabilitation interventions to remediate motor impairments, particularly for the upper extremity. Objective. To determine if task-oriented practice administered soon after stroke is more effective than usual care in improving poststroke upper extremity motor recovery and to explore the optimal amount of practice. Methods. A systematic review of the literature was performed from 1950 to November 2012, to identify randomized controlled trials of task-oriented practice compared to usual care, or to different amounts of task-oriented practice to improve motor impairment and activity. Studies were excluded if specific types of interventions were used as comparators or if they were of poor methodological quality. Results. Six studies met the review criteria. Three of the six studies demonstrated a statistically significant effect of task-oriented practice. Study results could not be pooled because of a lack of homogeneity in populations and intervention. Conclusions. The results demonstrate that an increase in the amount of task-oriented practice after stroke may result in less upper extremity impairment; further research on both effect and required dosage is needed as results are inconsistent.

Introduction Post-stroke activity limitation secondary to upper-extremity motor impairment is common, and increasing. We do not currently have effective, globally applicable interventions to improve activity limitation. The burden of post-stroke disability is rising in low and middle-income countries, resulting in an immediate need for effective interventions that can be implemented throughout the world. Purpose This program of research was structured to address three important questions, 1) In all parts of the world, do people with stroke experience similar degrees of activity limitation secondary to upper extremity motor impairment? 2) Are there simple interventions that can be initiated by health care workers, but autonomously sustained by people with stroke, that can improve activity limitation secondary to upper extremity motor impairment? and 3) Are these interventions effective? Methods To address the first question, data from an international stroke study were used to quantify the amount of post-stroke upper extremity weakness and characterize the people. For the second question, a systematic review was conducted to identify current evidence on the effectiveness of simple, task-based practice. To address the third question a protocol was developed for an outcome study. Results Post-stroke upper extremity weakness is common throughout the world, ranging from 67.3% of those with stroke in high-income countries to 97.3% in low-income countries. There is inconclusive, but promising evidence on the effectiveness of simple, task-based practice to improve upper-extremity motor impairment. It is likely that multiple interventions are needed to address the problem and a two-by-two factorial design trial, evaluating simple, task-based practice or a motor enhancing pharmacological agent, implemented in all regions of the world, would be a novel and efficient means of addressing the question. Conclusions The answers to these questions have provided novel information that is a required next step to providing effective, globally applicable interventions for people with stroke. Thesis Doctor of Philosophy (PhD) After having a stroke, more than half the people have difficulty moving their arm. This difficulty often results in difficulties doing every day tasks. Most of the information on what happens after stroke comes from developed countries and we do not know if these problems exist to the same extent in developed countries. We also do not know the most effective interventions to help improve arm function after stroke. Possible interventions could include rehabilitation strategies, drugs or a combination of both. This thesis describes the amount of arm weakness after stroke throughout the world, looks at the evidence for a simple intervention that could be used throughout the world, and describes the design of study that could look at the effectiveness of both rehabilitation and drug interventions throughout the world. This work provides information on the globally applicable interventions to improve arm function after stroke, which has not been considered in the literature to date.

Background: Walking dysfunction is one of the most disabling and persistent of stroke-related sequela. Theory- and research-derived motor learning principles (MLPs) offer an ideal theoretical framework for the development and evaluation of walking-skill focused interventions. Purpose: To: 1) appraise the degree of adherence to motor learning principles (MLPs) in current post-stroke walking-skill training research; 2) describe the Motor Learning Walking Program (MLWP), a novel, MLPs-framed walking training program; and 3) compare the MLWP to an alternate theory-framed walking-focused intervention in community-dwelling individuals within one year of stroke. Methods: A scoping review methodology was used to identify the prevalent theoretical frameworks in current post-stroke walking training literature, and to appraise the adherence to selected MLPs in walking-focused interventions. A randomized controlled trial (n=71) was conducted to compare the MLWP to a body-weight-supported treadmill training (BWSTT) intervention. Results: In the scoping review of 27 walking-focused studies, a minority of investigators explicitly stated a theoretical-framework. Application of MLPs was inconsistent across interventions. In the randomized controlled trial, both intervention groups improved walking function after 5 weeks of training however, there were no significant between-group differences in the primary and secondary outcomes. Conclusions: To date, there has been limited integration of MLPs into post-stroke walking-skill training literature. This randomized controlled trial is unique in its comparison of two theoretically divergent, yet equally intense, walking-training interventions. While the results were equivocal, future research should continue to explore the impact of application of MLPs on walking-skill recovery after stroke. Doctor of Philosophy (PhD)

Two studies were conducted to examine the effects of learner-adapted practice on the self-efficacy beliefs, acquisition and retention of a motor task. Through a discovery process all participants learned to perform several keypress patterns, with the goal of completing each sequence as fast and accurate as possible. The first experiment had learners practice the keypress sequences in one of two adaptive schedules, which utilized either a ‘WinSwitch’ or ‘WinRepeat’ task switching algorithm, or follow a pre-determined order of tasks (two yoked-control groups). The purpose of this experiment was to determine if adaptive schedules were effective because they were tailored to a learner’s performance characteristics or due to the nature of the contextual interference employed by the switching algorithm when the 'winning' criterion was satisfied. To examine the psychological factors involved in adaptive practice, the second experiment had all groups practice in a ‘WinSwitch Adaptive’ schedule and manipulated the social-comparative feedback that was provided (positive, negative or control). Together these studies revealed that the effectiveness of adaptive schedules may not necessarily be due to the fact that they are tailored to a learner's performance characteristics. They also suggest that learning is facilitated by a switching algorithm that involves some blocked practice towards the beginning and mostly random practice towards the end of acquisition (WinRepeat schedule). However, providing positive social-comparative feedback can override the negative effects of the opposite schedule (WinSwitch) and result in more effective learning and increases in self-efficacy beliefs. These findings are discussed in reference to contextual interference effects and the self-efficacy framework. Master of Science in Kinesiology