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[ case report ]

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ALLYN M. BOVE, DPT1 • NANCY BAKER, ScD, MPH, OTR/L2 • HEATHER LIVENGOOD, PhD, OTR/L3 • VISNJA KING, DPT, MTC, OCS1
JOSEPH MANCINO, PT, OCS1 • ADAM POPCHAK, PT, PhD, SCS1  •  G. KELLEY FITZGERALD, PT, PhD, FAPTA1

Task-Specific Training for Adults With


Chronic Knee Pain: A Case Series

E
xercise therapy is an important element in the management Recent evidence suggests that reduc-
of knee osteoarthritis (OA) and chronic knee pain. Several tions in impairments may not correlate
evidence-based guidelines advocate exercise to improve pain with functional improvement, and im-
pairment-based exercise therapy appears
and function in people with knee OA.16,21,27,38 Exercise therapy
to have limited positive effects on perfor-
recommendations include strength training, joint mobility and mance of specific tasks.12,35 It appears
flexibility exercises, and aerobic exercise to overcome impairments that a standard exercise approach that
believed to contribute to knee OA–re- fects may be explained, in part, by the targets muscle strength, joint mobility,
lated functional limitation and disabil- impairment-based approach to knee balance, or aerobic capacity may not be
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ity.16,21,27,38 Although there is agreement OA rehabilitation. While impairments sufficient to influence the performance of
that exercise reduces pain and improves such as limited joint motion, muscle even basic functional tasks, such as walk-
function in knee OA, recent systematic weakness, and reduced aerobic capacity ing.35 Optimal performance of daily tasks
reviews indicate modest benefits, with may improve with exercise, these im- requires adequate strength; joint motion
effect sizes of 0.29 to 0.49 (pooled Co- provements may not translate into di- and endurance; and the integration of
hen’s d) and 0.31 to 0.52 (standardized rect amelioration of activity limitations cognitive, perceptual, and motor skills.
mean difference) for pain and func- and participation restrictions associated Impairment-based exercise approaches
tion, respectively.13,19 These limited ef- with knee OA. do not address all factors involved in
daily function. Consequently, we must
Journal of Orthopaedic & Sports Physical Therapy®

UUSTUDY DESIGN: Case series. both patient-rated outcomes (Knee injury and develop alternative training strategies to
enhance the effect of therapeutic exercise
UUBACKGROUND: Recent evidence suggests that Osteoarthritis Outcome Score, numeric pain-rating
traditional impairment-based rehabilitation ap- scale, modified Arthritis Self-Efficacy Scale) and on task performance.
proaches for patients with knee pain may not result performance-based outcomes (30-second chair- Task-specific training in rehabilitation
in improved function or reduced disability. This case rise test, timed stair-climb test, floor transfer test, improves task performance through goal-
series describes a novel task-specific training ap- Performance Assessment of Self-Care Skills). directed practice and repetition, using a
proach to exercise therapy for patients with chronic UUDISCUSSION: A task-specific training approach specific task as the medium in which to
knee pain and reports changes in measures of clini- for patients with chronic knee pain was described address impairments and activity limita-
cal outcome (pain and physical function) following
and yielded considerable improvement in pain and tions.18 Patients are taught to perform a
participation in the training program.
function for most of the individuals in this case
UUCASE DESCRIPTION: Seven patients with
problematic or painful task under vary-
series. Larger studies are needed to determine
chronic knee pain aged 40 years or older were in- ing practice conditions, with the goal of
how task-specific training compares with more
cluded. Each reported at least “moderate” difficulty traditional impairment-based exercise approaches learning how to perform the task in a
with sit-to-stand transfers, floor transfers, and/or for chronic knee pain. safe, independent, and pain-free man-
stair negotiation at baseline. Experienced physical
UULEVEL OF EVIDENCE: Therapy, level 5.
ner.18 Currently, evidence supporting the
therapists provided between 8 and 16 treatment
J Orthop Sports Phys Ther 2017;47(8):548-556. use of task-specific training in humans
sessions focusing on improving performance of
difficult or painful tasks. doi:10.2519/jospt.2017.7349 involves populations with neurological
UUOUTCOMES: A majority of patients demon- UUKEY WORDS: knee, motor control/learning,
disorders.18 Limited evidence suggests
strated clinically important improvements in therapeutic exercise that a task-specific approach improves
task performance in older adults who

Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA. 2Department of Occupational Therapy, University of Pittsburgh, Pittsburgh, PA. 3Department of
1

Ophthalmology, NYU Langone Medical Center, New York, NY. The study protocol was approved by the University of Pittsburgh Institutional Review Board. The study was supported
by the University of Pittsburgh Research Development Fund. The authors certify that they have no affiliations with or financial involvement in any organization or entity with
a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Allyn Bove, Department of Physical Therapy, University of
Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219. E-mail: Ams453@pitt.edu t Copyright ©2017 Journal of Orthopaedic & Sports Physical Therapy®

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require assistance with activities of daily function) following participation in the if not on medication or greater than
living (ADL), as well as in community- training program in a series of 7 patients 160/100 mmHg if taking medication).
dwelling older adults.1,9,18 While this ap- with chronic knee pain.
proach seems appropriate for individuals Physical Therapists
with chronic knee pain, no studies have CASE DESCRIPTION Each patient was treated by 1 of 3 physical
examined the effects of task-specific therapists at the University of Pittsburgh.
training on improvements in specific task Patients One physical therapist was a board-certi-

P
performance or general function in this atients were recruited from the fied sports clinical specialist with 10 years’
population. Further research is needed to University of Pittsburgh Clinical and experience; the other 2 were board-cer-
determine whether task-specific training Translational Science Institute Re- tified orthopaedic clinical specialists who
enhances the effectiveness of exercise search Participant Registry. All patients each had more than 30 years’ experience.
therapy for those with chronic knee pain provided informed consent, and the pro- The physical therapists received training
and/or knee OA. tocol was approved by the University of in the task-specific approach from 1 of the
Given the lack of evidence regarding Pittsburgh Institutional Review Board. authors (G.K.F.) and were encouraged to
the effects of task-specific training in pa- Patients included in this case series seek additional guidance at any time. The
tients with chronic knee pain, it is impor- were aged 40 years or older and reported training session included reviewing com-
tant to establish proof of concept that this chronic knee pain, defined as self-report- ponents of each task, systematic methods
approach may improve pain and physical ed knee pain “most days of the week for to assess each component, and how to
function in this population. The first step the past 6 months.” Patients were included identify deficits in task performance due
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

is to identify tasks that are commonly dif- if they reported at least moderate difficul- to lack of mobility, strength, or postural
ficult, and then to develop the task-specif- ty with the following activities from the control. It also included review and dis-
ic training program to target these tasks. Knee injury and Osteoarthritis Outcome cussion of ways to alter each task to re-
Prior research has investigated which spe- Score (KOOS): sit-to-stand transfers, ne- duce pain, reduce assistance needed, and/
cific daily tasks are commonly problem- gotiating stairs, and floor transfers. Al- or improve safety. Progressions for each
atic for individuals with knee pain and/or though a diagnosis of knee OA was not task’s level of difficulty were reviewed.
knee OA and found that the most com- required for inclusion, all patients self-
monly problematic tasks are sit-to-stand reported previously being diagnosed with Outcome Measures
transfers, ascending and descending knee OA by a physician. Patients were Patient characteristics were measured at
Journal of Orthopaedic & Sports Physical Therapy®

stairs, and floor transfers.10,15 Therefore, not included if they had received physi- baseline (TABLE 1). The Charlson Comor-
we focused on these 3 tasks. The aims of cal therapy within the past 6 months or bidity Index was used to collect informa-
this case series were to (1) describe the recent intra-articular knee injections, or tion regarding medical comorbidities.5
task-specific training approach to exercise had a history of myocardial infarction or Clinical outcome measures were as-
therapy for patients with chronic knee neurological disorder. In addition, none sessed at baseline and after 8, 12, and
pain, and (2) report changes in measures of the patients exhibited uncontrolled hy- 16 treatment sessions. The interim as-
of clinical outcome (pain and physical pertension (greater than 140/90 mmHg sessments helped determine the dose-

TABLE 1 Patient Characteristics

Patient ID
A B C D E F G
Age, y 60 54 75 72 64 77 60
Sex Female Female Female Female Male Male Female
Duration of knee pain, y 3-5 ≥10 3-5 ≥10 ≥10 1-2 ≥10
Charlson Comorbidity Index score13 3 5 4 10 3 4 2
Body mass index, kg/m2 46.3 35.9 21.7 26.8 34.3 30.3 17.9
ROM/joint mobility deficit* Yes No No Yes Yes Yes Yes
Balance deficit* No No Yes Yes No Yes No
Treatment sessions, n 16 8 16 15 16 16 16
Abbreviation: ROM, range of motion.
*Deficits in ROM, joint mobility, and balance were treated by the physical therapist if they were determined to limit task performance.

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[ case report ]
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response trajectory over time. At each scales.6 The PASS rates 3 functional per- evaluated each patient on each of the 3
assessment time point, physical func- formance constructs: (1) independence, tasks to determine which portion(s) of
tion and pain were assessed via the gen- which is the ability to initiate, continue, each task should be a focus of treatment.
eral and task-specific self-reported and and complete tasks without the assis- For example, if a patient seated in a chair
performance-based measures described tance of another; (2) adequacy, which ex- was successful in scooting to the edge of
in TABLE 2. The KOOS and numeric amines the efficiency of the performance the chair and correctly positioning his or
knee pain rating were selected because and the quality of the product; and (3) her feet but was unable to transfer weight
they are often used in clinical settings. safety.6,30 The PASS has been used previ- to the feet to continue the sit-to-stand
A modified Arthritis Self-Efficacy Scale ously to assess task performance in com- transfer, then the therapist would focus
was used to capture potential changes munity-dwelling older adults with OA.30 on improving the weight-transfer portion
in patients’ confidence when performing To minimize bias, all outcome measures of the task during treatment. During a
tasks that are commonly difficult for in- were assessed by a physical therapist and floor transfer, if a patient attempting to
dividuals with knee pain. Three perfor- an occupational therapist who were not stand from the floor was able to get into
mance-based outcome measures were involved in treating the patients. The oc- a kneeling position but was unable to in-
chosen; each represents 1 of the 3 tasks cupational therapist administered the dependently raise himself or herself to
studied. The Performance Assessment PASS and the physical therapist admin- standing, then the therapist would begin
of Self-Care Skills (PASS) was added be- istered the remaining outcomes. by training the patient on strategies to
cause it is a reliable and valid measure move from kneeling to standing.
that assesses the actual performance of Evaluation Procedures In addition, the treating physical
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

functional tasks, such as tub transfers, Following baseline assessment (on a sep- therapist also assessed knee range of mo-
using task-specific criterion-based rating arate visit), the treating physical therapist tion and joint mobility. Lower extremity

TABLE 2 Outcome Measures

Outcome Instructions Scoring Psychometrics


Patient-reported outcomes
KOOS Patient-reported scales related to pain, stiffness, 5 subscales, each scored separately; lower MCIDs7: pain subscale, 13.4 points;
Journal of Orthopaedic & Sports Physical Therapy®

difficulty with ADL, sports and recreation, and scores indicate higher disability symtpoms subscale, 15.5 points; ADL
quality of life subscale, 15.4 points
Target task item difficulty rating Specific KOOS items related to the 3 relevant tasks 5-point Likert scale ranging from “none” to NA
were used to assess each patient’s perception of “extreme” difficulty
change in difficulty on the tasks
Numeric knee pain rating 11-point numeric scale for current pain, worst pain Rating from 0 to 10, with 0 indicating “no 2-point change considered clinically
in past 24 hours, and pain during each of the 3 pain” and 10 indicating “worst pain important11
relevant tasks imaginable”
Modified Arthritis Self-Efficacy Patient reports confidence in ability to routinely and Each item rated on a 0-to-100 scale, with NA
Scale independently perform a variety of daily tasks that higher numbers indicating greater confi-
may be difficult for those with knee pain dence in ability to perform task
Performance-based outcomes
30-second chair rise Patient seated with arms across chest; patient per- Number of successful transfers in 30 Test-retest reliability good in older adults
forms as many sit-to-stand transfers as possible seconds is recorded (ICC = 0.84-0.92)14,25
in 30 seconds MCID: increase of 3 or more rises37
Timed stair-climb test Patient ascends and descends full flight of stairs with Number of seconds needed to ascend and MCID: reduction of 2.51 seconds2
bilateral hand rails as quickly as possible descend full flight of stairs is recorded
Floor transfer test Patient begins in standing and is asked to sit down 0-to-5 scale for each phase of the task (low- NA (test modified from the version
and then rise from the floor, using the minimum ering and rising); higher scores indicate described by de Brito et al8)
amount of support necessary to complete the task less support needed to complete task
Performance Assessment of Items related to functional mobility were tested: bed Each task rated from 0 to 3: independence, Test-retest reliability, r = 0.96; interob-
Self-Care Skills mobility, toileting, tub/shower transfers, dressing, safety, and adequacy; higher scores server reliability, 0.89-0.98; validity
taking out trash, sweeping the floor, and stair indicate better performance is referenced to common ADL/IADL
negotiation instruments28-30
Abbreviations: ADL, activities of daily living; IADL, instrumental activities of daily living; ICC, intraclass correlation coefficient; KOOS, Knee injury and
Osteoarthritis Outcome Score; MCID, minimum clinically important difference; NA, not applicable.

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strength was assessed either with manual or changing conditions of the task (eg, example, if the physical therapist noted
muscle testing or through observation of height of the chair, type of floor surface, limited knee range of motion upon physi-
functional activities at the discretion of movement speed). During this stage, the cal examination and observed that climb-
the physical therapist. Consistent with physical therapist provided feedback less ing stairs was difficult due to a lack of knee
common clinical practice, balance was frequently, allowing the patient to problem flexion range of motion, which limited
also formally tested at the physical thera- solve. Eventually, the patient began to con- step clearance, exercise and manual ther-
pist’s discretion if a potential impairment sistently perform the task independently apy techniques were applied to increase
was observed. Similarly, other measures, without errors. At this stage, the thera- knee flexion and thus allow for optimal
such as ankle or hip range of motion and pist continued to pro­gress the difficulty task performance. As another example, a
accessory mobility, were assessed if the of the task and suggested ways in which patient who presented with reduced ankle
physical therapist felt it was indicated. the patient could vary movement options dorsiflexion range of motion and then had
when encountering the task in real-world difficulty with sit-to-stand transfers due
Intervention situations. to an inability to slide the feet under the
Patients underwent up to 16 sessions of The following example illustrates the chair was treated with posterior talocrural
task-specific training at a frequency of 2 use of motor learning principles in train- mobilizations to improve ankle dorsiflex-
visits per week. The 16-session cap was ing a patient who reports pain and dif- ion range of motion. Mobilizations were
placed on the number of physical therapy ficulty during stair negotiation. Because continued until adequate ankle motion
sessions because this would likely be near the pain/difficulty was observed while the was achieved to allow proper foot place-
the maximum number of visits permitted patient attempted to descend the stairs in ment under the chair in preparation for
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

in real clinic environments under most a traditional reciprocal pattern, the physi- standing. In most cases, impairments may
third-party payer systems. All 7 patients cal therapist first taught the patient to de- be treated within the context of the task:
were trained on all 3 tasks (sit-to-stand scend in a nonreciprocal pattern and use for example, poor balance during stair ne-
transfers, floor transfers, and stair nego- the hand rail for support. As the patient gotiation may be treated by performing
tiation) because they all reported at least began to learn the new method, the physi- balance activities on a step; weakness in
“moderate” difficulty on the KOOS items cal therapist placed the patient in a closed the quadriceps muscles may be treated by
relevant to each task. stairwell with no one nearby. The physical performing sit-to-stand transfers with a
When designing training sessions, we therapist consistently provided feedback, weighted vest or backpack. By focusing on
used basic principles of motor learning re- reminding the patient of the nonrecipro- training a specific task rather than treating
Journal of Orthopaedic & Sports Physical Therapy®

garding types of practice and feedback.22 At cal pattern and to use the hand rail for bal- impairments in isolation, this approach
the beginning of training, all patients were ance and/or weight bearing. The patient maximizes relevance of the prescribed
assumed to be in the cognitive stage of mo- was asked to perform many repetitions. exercises.
tor learning, in which the patient needs to As the patient mastered each new task
focus on correctly performing the task but variation, the physical therapist gradually Data Analysis
frequently makes errors requiring external reduced frequency of feedback, as the pa- Data from 7 patients were summarized
feedback to correct. During this stage, the tient was able to perform the task without using descriptive statistics. Changes in
patient was asked to perform the task re- constant reminders. The physical thera- outcomes from patients in the present
peatedly (blocked practice), with no inter- pist also began altering the task by asking study were compared with those found in
trial variability (eg, using the same chair to the patient to perform the task compo- previously published studies of standard
repeatedly practice sit-to-stand transfers), nents in random order and by creating exercise programs in those with chronic
in an environment that was quiet. The an open environment with more potential knee pain that used outcome measures
therapist provided manual guidance if nec- distractions (eg, other people moving up/ similar to ours. We used SPSS Version 23
essary. Feedback was provided during or down the stairs), to ensure that the patient for Windows (IBM Corporation, Armonk,
immediately following task performance. could remember to perform the task cor- NY) for data management and analysis.
As the patients’ abilities to correctly per- rectly and safely in a real-world environ-
form the task improved and they began to ment. Please see the APPENDIX (available at OUTCOMES
fine tune motor performance, the therapist www.jospt.org) for a more detailed out-

S
began to make the task more complex. line of the task-specific training program even patients completed full
Methods used to increase task complex- employed for sit-to-stand transfers, floor episodes of care (completed all 16
ity included asking the patient to perform transfers, and stair negotiation. visits or reached a peak in func-
task components in random order, adding While the focus of this training is on tion in less than 16 visits). Demographic
potential distractions to the environment task performance, task-limiting impair- and clinical information is presented in
such as noise or other moving people, and/ ments were treated as necessary. For TABLE 1.

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Patient-Reported Outcome Measures 16.6% (range, 2.2%-46.7%) from baseline the quality of task performance. Deficits
The KOOS baseline and follow-up scores to end of care across the 9 items on the in adequacy were common at baseline,
for 3 subscales are presented in TABLE 3. scale, representing an average improve- particularly with the tasks of tub/shower
The proportions of patients exceeding ment of 1.8 points per item on a 10-point transfers and stair negotiation. At follow-
the minimum clinically important differ- scale. Mean change from baseline to up, deficits in tub/shower transfers per-
ences (MCIDs) for the pain (MCID, 13.4 follow-up score was a 19% improvement sisted, but adequacy of most other tasks
points), symptoms (MCID, 15.5 points), in patients’ confidence while performing improved. Finally, 5 patients demon-
and ADL (MCID, 15.4 points) subscales daily activities. strated deficits in independence of tub/
were 4 of 7, 1 of 7, and 4 of 7, respectively.7 shower transfers at baseline; by follow-
Target tasks on the KOOS were calcu- Performance-Based Outcome Measures up, 2 of those patients had become fully
lated as the average difficulty reported by Charts demonstrating performance- independent in the transfer.17
the patient for items related to each of the based outcome measures over time are
3 tasks. For both sit-to-stand transfers and depicted in the FIGURE. From baseline DISCUSSION
floor transfers, 4 of 7 patients improved by to end of care, 5 of 7 patients improved

R
at least 1 full point on the scale (eg, mov- beyond the MCID (increase of 3 or more esults indicate that a task-
ing from “moderate” to “mild” difficulty rises) on the 30-second chair-rise test.37 specific training program effectively
or from “mild” difficulty to “none”). Only Three patients demonstrated clinically improved performance of specific
1 patient improved by more than 1 point important improvement (reduction of tasks and scores on more general outcome
when rating difficulty of climbing stairs. at least 2.51 seconds) on the stair-climb measures for most patients. For 2 of 3
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Four of 7 patients improved by at least test.2 There is no published MCID for the tasks (sit-to-stand and floor transfers),
2 points when rating “worst knee pain in floor transfer test, but 5 of 7 patients im- 4 or 5 of the 7 patients demonstrated
the past 24 hours,” “knee pain during sit- proved at least 2 points on the 10-point clinically important improvements in
to-stand transfer,” and “knee pain dur- scale. pain, substantial improvement in perfor-
ing floor transfer” on the more painful The PASS measurements at baseline mance-based task assessment, and less
side; 5 of 7 patients improved at least 2 and follow-up are presented in TABLE 4. difficulty performing the task.
points when rating “knee pain during Outcomes for each task were dichoto- Improvements in stair climbing were
stair climbing.” An absolute improvement mized into a deficit being present (score less consistent; while 5 of 7 patients re-
of 2.0 points on an 11-point pain-rating of 0, 1, or 2) or absent (maximum score of ported clinically important pain reduc-
Journal of Orthopaedic & Sports Physical Therapy®

scale is considered clinically important.9 3). Safety deficits were not common, but tion, only 3 of 7 improved beyond the
The median increase on the modified most deficits present at baseline were re- MCID on a timed stair-climb test, and
Arthritis Self-Efficacy Scale scores was solved by follow-up. Adequacy measures only 1 of 7 reported less difficulty ne-

TABLE 3 Baseline and Follow-up Scores on 3 Subscales of the KOOS*

Patient ID
A B C D E F G
Pain subscale
Baseline 11.1 25.0 69.4 52.8 44.4 69.4 77.8
Follow-up 38.9 58.3 63.9 50.0 75.0 83.3 83.3
Change 27.8 33.3 –5.6 –2.8 30.6 13.9 5.6
Symptom subscale
Baseline 35.7 14.3 71.4 57.1 53.6 50.0 64.3
Follow-up 42.9 57.1 53.6 64.3 64.3 64.3 71.4
Change 7.2 42.9 –17.9 7.2 10.7 14.3 7.1
ADL subscale
Baseline 25.0 33.8 64.7 66.2 55.9 66.2 89.7
Follow-up 47.1 75.0 66.2 60.3 92.7 85.3 88.2
Change 22.1 41.2 1.5 –5.9 36.8 19.1 –1.5
Abbreviations: ADL, activities of daily living; KOOS, Knee injury and Osteoarthritis Outcome Score.
*For each KOOS subscale, possible scores range from 0 to 100, with 0 representing extreme problems and 100 representing no problems.

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A B C
20 12.0 45.00
18 40.00
16 10.0
35.00

Floor Transfer Test Score


30-Second Chair Rise, n

14

Stair-Climb Test, s
8.0 30.00
12
25.00
10 6.0
20.00
8
6 4.0 15.00
4 10.00
2.0
2 5.00
0 0.0 0.00
Baseline 8 visits 12 visits 16 visits Baseline 8 visits 12 visits 16 visits Baseline 8 visits 12 visits 16 visits

A B C D E F G

FIGURE. (A) The number of sit-to-stand transfers completed in 30 seconds, (B) the floor transfer test score, with higher numbers indicating better performance of the task, and
(C) the stair-climb test score, reported as seconds required to complete the task.

gotiating stairs. It is possible that the 8-week program used in the Villadsen contrast to these 3 studies, improvements
alternative techniques allowed patients et al36 study noted small improvements in our study were noticeably higher, with
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

to negotiate stairs with less pain due to (KOOS pain mean improvement, 3.0 ± a median improvement of 14 points on
changes in joint mechanics, but at the 1.6 points; KOOS ADL mean improve- the KOOS pain subscale and 19 points
cost of increasing time or physical effort ment, 2.5 ± 1.9 points).36 The 12-week on the ADL subscale. While our results
needed. program used in the Skou et al32 study should be interpreted with caution due
resulted in greater mean improvements to the small sample size, the magnitude
Comparison to Recent Literature (KOOS pain mean improvement, 9.0 of improvement on various outcomes
Several recent studies investigating exer- points; 95% confidence interval [CI]: 3, is comparable to or exceeds the upper
cise for knee pain and knee OA have also 15 and KOOS ADL mean improvement, bound of the 95% CIs of the other recent
used the KOOS as a primary outcome 11.2 points; 95% CI: 5.4, 17.1), which may studies of impairment-based exercise
Journal of Orthopaedic & Sports Physical Therapy®

measure.31,32,36 Rosedale and colleagues31 be partially attributable to nonexercise approaches. This suggests that further
employed a 3-month McKenzie-based ex- components of their intervention, in- investigation directly comparing task-
ercise program and noted a modest aver- cluding prescription of pain medication specific training with impairment-based
age improvement of 7 points and 5 points as needed, dietary advice, and use of shoe exercise approaches is warranted.
on the KOOS pain and ADL subscales, inserts.32 However, the CIs in this study While the effects of our intervention
respectively. Two other studies, by Vil- were still wide enough that it is unclear were greater than those reported in re-
ladsen et al36 and Skou et al,32 employed whether the program’s effects reached cent individual studies, our results are
neuromuscular exercise programs. The the threshold of clinical importance.7,32 In comparable to those found in a recent

Patients Showing Deficits on PASS Outcomes for Safety,
TABLE 4
Adequacy/Quality, and Independence of Each Measured Task*

Safety Adequacy/Quality Independence


Baseline Follow-up Baseline Follow-up Baseline Follow-up
Bed mobility 0 0 2 0 1 0
Tub/shower transfer 4 2 6 6 5 3
Dressing 3 3 2 2 2 0
Taking out trash 0 0 3 1 1 1
Sweeping the floor 2 0 4 1 0 0
Stair negotiation 1 0 6 3 1 0
Toileting 0 0 4 1 2 0
Abbreviation: PASS, Performance Assessment of Self-Care Skills.
*Values are n.

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Cochrane review.13 This meta-analysis13 improvements in independence and qual- Limitations


of land-based exercise programs for knee ity when performing tasks that simulated While we designed our treatment sessions
OA noted a mean relative improvement the application of techniques learned in to adhere to principles of motor learning,
of 27% (95% CI: 21%, 32%) on pain therapy, as represented with the PASS. we did not specifically assess whether mo-
scales and 26% (95% CI: 20%, 32%) For example, toilet transfer requires the tor learning occurred following treatment.
on physical function scales. Patients in patient to get on and off a toilet, which Learning would require a permanent
our study achieved an average of 29% requires a high level of sit-to-stand trans- change in behavior. Given that our follow-
relative improvement on the KOOS pain fers. Three out of 4 patients improved up assessments were conducted within 1
subscale and 28% relative improvement their adequacy, and 2 out of 2 improved week following the end of care, it would
on the KOOS ADL subscale. Direct com- independence in this task. These results not be possible for us to conclude that a
parison between our intervention and suggest that patients who learn strategies permanent change in behavior occurred.
the interventions used by the studies to do a task, rather than simply remediat- However, we believe the results suggest
in the meta-analysis is difficult due to ing impairments, may have better overall that the training program may have in-
the use of many different outcome mea- function in the real world. duced improvements in motor learning
sures, and the meta-analysis did not in- Considering the sum of the recent lit- and control. Direct performance-based
clude any performance-based outcome erature regarding exercise-based inter- assessment of the 3 tasks improved for
measures. ventions for individuals with knee pain most patients at follow-up. All 7 patients’
Another recent meta-analysis of 17 and/or knee OA, it appears that our task- floor transfer scores improved, indicating
randomized clinical trials investigated specific training approach may be at least the ability to perform the task with less as-
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

the effects of resistance training for indi- comparable to other land-based exercise sistance and/or improved safety. The ex-
viduals with knee OA.23 Results indicated interventions. Randomized controlled aminer does not provide cues during this
fairly large standardized mean differenc- trials with larger sample sizes are needed task, so patients’ improved performance
es for both pain (–0.43; 95% CI: –0.57, to directly compare impairment-based to may indicate improved motor planning
–0.29) and function (–0.53; 95% CI: task-specific rehabilitation approaches and execution of a safer and more efficient
–0.7, –0.37) for individuals receiving re- and to determine how the 2 approaches motor plan. Similar results were observed
sistance training compared to controls.23 may best be combined to maximize clini- with the timed chair-rise test; faster per-
However, the authors noted large vari- cal outcome for individuals with chronic formance of sit-to-stand transfers may
ability in the dosage of exercise and level knee pain. indicate that altering the existing motor
Journal of Orthopaedic & Sports Physical Therapy®

of supervision across studies, making it Evidence suggests that individuals with plan allows for more efficient and/or less
difficult to argue in favor of any particular knee OA and/or chronic knee pain likely painful transfer. In addition, scores from
exercise program design. experience changes in the central nervous baseline to follow-up on the PASS for in-
Median improvement on the modified system that contribute to their pain, and dependence and adequacy/quality metrics
Arthritis Self-Efficacy Scale was 16.6% that exercise may help to reduce central both improved after training, indicating
(range, 2.2%-46.7%), indicating that pa- sensitization.4,20,24,26,33,34 While several that patients were able to demonstrate
tients were considerably more confident studies have attempted to directly impact tasks more competently, with fewer cues
in their ability to perform various daily these centrally mediated pain experiences, needed from the assessor.
tasks. Some items on the scale directly few interventions have been provided di- Overall, both actual performance and
query patients regarding their confi- rectly by physical therapists.3 In the pres- self-reported ability to perform tasks sub-
dence when performing the tasks being ent study, we did not conduct any clinical stantially improved in most patients. The
trained (stair negotiation, sit-to-stand examination to determine whether the fact that patients became more indepen-
transfers), but others are more indirectly pain experienced by the patients in our dent and faster with task performance
related (using the shower, overground case series had a central nervous system may indicate improved motor planning
walking). Increased confidence in these component, nor did we train the physical and problem solving during painful
indirectly related tasks may be due to a therapists to specifically address centrally activities.
transfer of training effect from the tasks or peripherally mediated pain. Future The small sample size utilized in this
being trained to similar tasks. research should consider evaluating the case series design does not allow accu-
As indicated by PASS improvement, sources and mechanisms of pain in this rate comparison of our results to a con-
patients’ skills in sit-to-stand transfers, population and whether task-specific trol group or a group receiving a different
floor transfers, and stair negotiation treatment approaches may be more effec- type of exercise intervention. Future in-
practiced during physical therapy inter- tive when provided in combination with vestigation is warranted to compare out-
ventions did generalize to novel applica- pain-coping skills training or a similar comes between a task-specific approach
tions of the skills. Patients demonstrated type of approach. and traditional impairment-based exer-

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cise approaches in a larger sample with a A new method of classifying prognostic comor- functional limitations of elders in the Framing-
randomized trial design. bidity in longitudinal studies: development and ham Study. Am J Public Health. 1994;84:351-358.
By limiting visit numbers and fre- validation. J Chronic Dis. 1987;40:373-383. 16. Hochberg MC, Altman RD, April KT, et al.
6. C
 hisholm D, Toto P, Raina K, Holm M, Rogers American College of Rheumatology 2012 recom-
quently reassessing outcomes, we at-
J. Evaluating capacity to live independently mendations for the use of nonpharmacologic and
tempted to create a realistic episode of and safely in the community: Performance As- pharmacologic therapies in osteoarthritis of the
physical therapy care. However, it is pos- sessment of Self-care Skills. Br J Occup Ther. hand, hip, and knee. Arthritis Care Res (Hobo-
sible that third-party payers may have 2014;77:59-63. https://doi.org/10.4276/0308022 ken). 2012;64:465-474. https://doi.org/10.1002/
14X13916969447038 acr.21596
further restricted visits to a number less
7. C
 ollins NJ, Misra D, Felson DT, Crossley KM, Roos 17. Holm M, Rogers J. Performance Assessment of
than the maximum of 16 offered in this EM. Measures of knee function: International Self-Care Skills. In: Hemphill-Pearson BJ, ed.
study. In this study, 6 of the 7 patients re- Knee Documentation Committee (IKDC) Sub- Assessments in Occupational Therapy Mental
ceived 15 or 16 visits, but they achieved jective Knee Evaluation Form, Knee Injury and Health: An Integrative Approach. Thorofare, NJ:
Osteoarthritis Outcome Score (KOOS), Knee SLACK; 1999:ch 8.
the majority of improvement within the
Injury and Osteoarthritis Outcome Score Physical 18. Hubbard IJ, Parsons MW, Neilson C, Carey
first 8 visits. Continued but smaller im- Function Short Form (KOOS-PS), Knee Outcome LM. Task-specific training: evidence for and
provements were observed at visits 12 Survey Activities of Daily Living Scale (KOS-ADL), translation to clinical practice. Occup Ther Int.
and 16. Lysholm Knee Scoring Scale, Oxford Knee Score 2009;16:175-189. https://doi.org/10.1002/oti.275
(OKS), Western Ontario and McMaster Universi- 19. Jamtvedt G, Dahm KT, Christie A, et al. Physical
ties Osteoarthritis Index (WOMAC), Activity Rat- therapy interventions for patients with osteo-
CONCLUSION ing Scale (ARS), and Tegner Activity Score (TAS). arthritis of the knee: an overview of systematic
Arthritis Care Res (Hoboken). 2011;63 suppl reviews. Phys Ther. 2008;88:123-136. https://doi.

A
task-specific training approach 11:S208-S228. https://doi.org/10.1002/acr.20632 org/10.2522/ptj.20070043
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8. d e Brito LB, Ricardo DR, de Araújo DS, Ramos 20. Joergensen TS, Henriksen M, Danneskiold-
for patients with chronic knee pain
PS, Myers J, de Araújo CG. Ability to sit and rise Samsoee B, Bliddal H, Graven-Nielsen T. Experi-
yielded considerable improvement from the floor as a predictor of all-cause mortal- mental knee pain evoke spreading hyperalgesia
in pain and function for most individu- ity. Eur J Prev Cardiol. 2014;21:892-898. https:// and facilitated temporal summation of pain. Pain
als in this case series. Larger studies are doi.org/10.1177/2047487312471759 Med. 2013;14:874-883. https://doi.org/10.1111/
9. d e Vreede PL, Samson MM, van Meeteren NL, pme.12093
needed to determine how task-specific
van der Bom JG, Duursma SA, Verhaar HJ. 21. Jordan KM, Arden NK, Doherty M, et al. EULAR
training compares with more traditional Functional tasks exercise versus resistance ex- recommendations 2003: an evidence based
impairment-based exercise approaches ercise to improve daily function in older women: approach to the management of knee osteo-
for chronic knee pain. t a feasibility study. Arch Phys Med Rehabil. arthritis: report of a Task Force of the Standing
2004;85:1952-1961. https://doi.org/10.1016/j. Committee for International Clinical Studies In-
apmr.2004.05.006 cluding Therapeutic Trials (ESCISIT). Ann Rheum
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10. D
 illon CF, Rasch EK, Gu Q, Hirsch R. Prevalence Dis. 2003;62:1145-1155.
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in vivo pathomechanics of osteoarthritis at the 11. F arrar JT, Young JP, Jr., LaMoreaux L, Werth exercise in patients with knee osteoarthri-
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2. Bennell K, Dobson F, Hinman R. Measures of in chronic pain intensity measured on an Clin Rehabil. 2016;30:947-959. https://doi.
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Walk Test (SPWT), Stair Climb Test (SCT), Six- 2001;94:149-158. https://doi.org/10.1016/ 24. Lluch Girbés E, Nijs J, Torres-Cueco R, López
Minute Walk Test (6MWT), Chair Stand Test S0304-3959(01)00349-9 Cubas C. Pain treatment for patients with
(CST), Timed Up & Go (TUG), Sock Test, Lift and 12. F itzgerald GK, White DK, Piva SR. Associations osteoarthritis and central sensitization. Phys
Carry Test (LCT), and Car Task. Arthritis Care Res for change in physical and psychological factors Ther. 2013;93:842-851. https://doi.org/10.2522/
(Hoboken). 2011;63 suppl 11:S350-S370. https:// and treatment response following exercise in ptj.20120253
doi.org/10.1002/acr.20538 knee osteoarthritis: an exploratory study. Arthritis 25. McCarthy EK, Horvat MA, Holtsberg PA, Wisen-
3. Bennell KL, Ahamed Y, Jull G, et al. Physical Care Res (Hoboken). 2012;64:1673-1680. https:// baker JM. Repeated chair stands as a measure
therapist–delivered pain coping skills training doi.org/10.1002/acr.21751 of lower limb strength in sexagenarian women. J
and exercise for knee osteoarthritis: randomized 13. F ransen M, McConnell S, Harmer AR, Van der Gerontol A Biol Sci Med Sci. 2004;59:1207-1212.
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2016;68:590-602. https://doi.org/10.1002/ osteoarthritis of the knee. Cochrane Database 26. Moss P, Knight E, Wright A. Subjects with knee
acr.22744 Syst Rev. 2015;1:CD004376. https://doi. osteoarthritis exhibit widespread hyperalgesia to
4. Brosseau L, Wells GA, Kenny GP, et al. The org/10.1002/14651858.CD004376.pub3 pressure and cold. PLoS One. 2016;11:e0147526.
implementation of a community-based aerobic 14. G illespie LD, Gillespie WJ, Robertson MC, Lamb https://doi.org/10.1371/journal.pone.0147526
walking program for mild to moderate knee SE, Cumming RG, Rowe BH. Interventions for 27. Richmond J, Hunter D, Irrgang J, et al. Treatment
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5. Charlson ME, Pompei P, Ales KL, MacKenzie CR. effects of specific medical conditions on the Particip Health. 2000;20:68S-85S. https://doi.

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method. Arthritis Rheum. 2003;49:640-647. exercise reverses sensory hypersensitivity in a rat Abbott JH. A comparison of 3 methodological
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30. Rogers JC, Holm MB, Beach S, Schulz R, oids. Anesthesiology. 2011;114:940-948. https:// tant improvement of 4 performance measures
Starz TW. Task independence, safety, and doi.org/10.1097/ALN.0b013e318210f880 in patients with hip osteoarthritis. J Orthop
adequacy among nondisabled and osteoar- 34. S usko AM, Fitzgerald GK. The pain-relieving Sports Phys Ther. 2011;41:319-327. https://doi.
thritis-disabled older women. Arthritis Rheum. qualities of exercise in knee osteoarthritis. Open org/10.2519/jospt.2011.3515
2001;45:410-418. https://doi.org/10.1002/1529- Access Rheumatol. 2013;5:81-91. https://doi. 38. Zhang W, Moskowitz RW, Nuki G, et al. OARSI
0131(200110)45:5<410::AID-ART359>3.0.CO;2-Y org/10.2147/OARRR.S53974 recommendations for the management of hip
31. Rosedale R, Rastogi R, May S, et al. Efficacy of ex- 35. T eixeira PE, Piva SR, Fitzgerald GK. Effects of im- and knee osteoarthritis, part II: OARSI evidence-
ercise intervention as determined by the McKen- pairment-based exercise on performance of spe- based, expert consensus guidelines. Osteoar-
zie system of Mechanical Diagnosis and Therapy cific self-reported functional tasks in individuals thritis Cartilage. 2008;16:137-162. https://doi.
for knee osteoarthritis: a randomized controlled with knee osteoarthritis. Phys Ther. 2011;91:1752- org/10.1016/j.joca.2007.12.013
trial. J Orthop Sports Phys Ther. 2014;44:173-181. 1765. https://doi.org/10.2522/ptj.20100269
https://doi.org/10.2519/jospt.2014.4791 36. V illadsen A, Overgaard S, Holsgaard-Larsen A,

@ MORE INFORMATION
32. Skou ST, Rasmussen S, Laursen MB, et al. The Christensen R, Roos EM. Immediate efficacy of
efficacy of 12 weeks non-surgical treatment for neuromuscular exercise in patients with severe
patients not eligible for total knee replacement: osteoarthritis of the hip or knee: a secondary WWW.JOSPT.ORG
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APPENDIX

DESCRIPTION OF TASK-SPECIFIC TRAINING INTERVENTION


Task-Specific Intervention Program
Depending on the patient’s report of difficulty in performing the target tasks, patients may have received training for any or all of the target tasks. As
described below, each task was broken down into phases and subtasks. In order to follow proper motor learning and skill acquisition principles, pro-
gression from blocked to random order of practice of each phase/subtask and from continuous to summary feedback was incorporated as each patient
progressed through the phases of motor learning. Please see the supplementary videos for demonstrations of task-specific treatment approaches for
each task.
Sit-to-Stand Training
Phases
1. Scoot
• Scoot to edge of chair with feet placed behind knees
• Emphasis on trunk and pelvis rotation and weight shifting to achieve adequate positioning toward the edge of the chair
2. Flexion momentum
• Flex trunk forward to position center of gravity over the feet in preparation for momentum
• Emphasis on weight shifting and achievement of adequate hip and knee flexion and ankle dorsiflexion range of motion
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

• If patients have difficulty with this phase, they can use the same activities as an exercise program. To progress, provide manual or elastic resis-
tance to the trunk or pelvis
3. Momentum transfer
• Transfer body weight to feet and lift buttocks off the chair until a semi-squat position is achieved
• Emphasis on weight transfer, adequate hip and knee flexion and ankle dorsiflexion range of motion, adequate lower extremity strength to assume
and hold the semi-squat position, and adequate balance in the semi-squat position
• If patients have difficulty with this phase, they may begin with the use of arm support and progress to no arm support. They may also begin with
a higher seat height and gradually lower the seat height to increase level of difficulty. This activity may be used as a progressive resistance exercise
by using manual or elastic resistance, or a weighted vest or backpack
4. Vertical extension
• Move from the semi-squat position to an erect standing position
Journal of Orthopaedic & Sports Physical Therapy®

• Emphasis on adequate lower extremity strength to extend the hips and knees and bring the ankles to neutral dorsiflexion. Balance during the
activity is also emphasized
• If patients have difficulty with this phase, they may begin with arm support (or support from therapist) and progress to no support. Activity may
be progressed by adding resistance through a weighted vest or backpack
5. Stability
• Maintain balance in the erect position while repositioning the feet for an adequate base of support
• Emphasis on standing balance activities
• Activity may be progressed from even to uneven surfaces or by adding mild perturbation forces from the therapist to the patient’s shoulders or
pelvis
Training to emphasize the stand-to-sit transfer occurs in the same phases, with the movements being reversed in direction (eg, vertical flexion to move
from erect to semi-squat, momentum transfer from semi-squat to sitting on the edge of the chair, extension momentum for placing the feet in front of
the knees, then shifting the pelvis back to scoot backward into the chair). See the video at https://www.youtube.com/watch?v=pknme9TU0pQ.
Floor Transfer Training
The lowering and rising components were further subdivided into 4 phases, including straddle stance, partial kneeling, full kneeling, and side sitting on
the floor. A brief description of each training phase is as follows.
Phases
1. Straddle stance
• Beginning in a standing position on a floor mat, assume a diagonal stance, with one foot placed forward and the other back
• Emphasis on assuming as wide a stance as comfortably possible to get the center of gravity lower to the floor, to improve stability and ultimately
require less knee motion to eventually lower the body to the ground
• The patient can also practice performing partial squatting motions in this stance to strengthen the lower extremity muscles for this task. In addition,
the patient may practice weight shifting from the back foot to the forward foot
2. Partial kneeling
• The patient moves from the straddle stance to kneeling on one knee, with the trunk maintained in the upright position

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APPENDIX

• If the patient has difficulty with this task, the physical therapist may provide manual assistance or external support, such as a chair or assistive
device. As patients improve, they may progress to using their own hands for support and eventually to performing the movement without support
3. Full kneeling
• The patient moves from kneeling on one knee to a 4-point kneeling position (all-fours position)
• If the patient has difficulty with this task, the physical therapist may provide manual assistance or external support, such as a chair or assistive
device. As patients improve, they may progress to using their own hands for support and eventually to performing the movement without support
4. Side sitting
• The patient moves from the 4-point kneeling position to a side-sitting position on the floor
• Emphasis is on moving one knee toward the opposite hand while simultaneously rotating the trunk and pelvis toward the side of the moving
lower limb to gradually rest the hip on the ground
• If the patient has difficulty with this task, he or she may progress from manual assistance from the therapist to eventual performance without
assistance
Training in moving from side sitting on the floor up to the standing position would occur in the same phases, with the movements being reversed in
direction (eg, moving from side sitting to the 4-point position, followed by moving from the 4-point position to partial kneeling, followed by movement
from partial kneeling to the straddle stance, then finally moving from straddle stance to full upright standing). As the patient progresses in the ability
to perform floor transfers, the training intensity can be increased by adding resistance through a weighted vest or backpack during the activity. See the
video at https://www.youtube.com/watch?v=X1bXcHSOGq8.
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Ascending and Descending Stairs Training


Phases
1. Foot placement
• Shift weight to support limb while placing the other foot up (or down) onto the next step
• When ascending, emphasis is on weight shifting, balance, hip and knee range of motion, and hip flexor strength needed to complete the phase
• When descending, emphasis is on adequate hip and knee flexion and ankle dorsiflexion range of motion of the support limb, as well as adequate
strength and control of hip and knee extensors and ankle plantar flexors to sustain a controlled lowering of body weight onto the stepping limb.
In addition, support-limb alignment is important (keeping the knee in position over the second toe and not allowing the pelvis to drop too far
toward the opposite limb during descent). On the stepping limb, emphasis is on adequate hip flexor control to move the limb forward, then
adequate knee and ankle stability in preparation for weight acceptance
Journal of Orthopaedic & Sports Physical Therapy®

2. Weight transfer
• Shift weight from the support limb to the stepping limb that is now placed on the next step
• Emphasis is on adequate weight transfer to the limb to allow unloading of the support limb for raising or lowering the body to the next step
3. Raising (or lowering)
• Raise (or lower) body weight up (or down) to the next step and bring the trailing limb (previous support limb) onto the step
• During raising, emphasis is on adequate strength of hip and knee extensors and ankle plantar flexors to lift body weight to the next step in
a controlled manner, and adequate support from hip abductors and external rotators to control lower extremity alignment during the task
• During lowering, emphasis is on weight acceptance onto the new support limb as well as adequate hip flexion, knee extension, and ankle
dorsiflexion range of motion and control to move the limbs in a controlled fashion
To adjust the degree of difficulty of negotiating stairs:
• Use a side-stepping technique rather than forward stepping: the patient turns at a 45° angle to ascend and descend stairs. This may reduce
knee flexion moments and thus reduce the quadriceps force required to complete the task
• Use shorter step heights and progress to taller step heights
• Progress from 2 hand rails to 1 to 0 for balance and weight bearing
• Use a step-to-gait pattern at first and advance to a step-through pattern to increase difficulty
See the video at https://www.youtube.com/watch?v=iVZ97orPbU0.
Additional Impairment-Based Training Activities
If during the task-specific training the therapist determines that there is a specific impairment (eg, limited motion at a specific joint and/or muscle
weakness in a specific muscle group) that is affecting performance of the task, then the therapist may use other impairment-based procedures that
specifically address the impairment (eg, specific muscle flexibility or strengthening exercise, joint mobilization techniques) to supplement the task-
specific training program.

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