Lessons learned and functional outcomes following multifaceted team training in a cognitive strategy-based approach to stroke rehabilitation.

AIM: To estimate the impact of a multifaceted knowledge translation intervention on patient rehabilitation outcomes in an inpatient stroke setting. METHODS: Interprofessional stroke rehabilitation teams were trained in Cognitive Orientation to daily Occupational Performance as part of the larger knowledge translation study. This study describes a two group (historical control vs. post knowledge translation intervention) nonrandomized study. Patient participants with stroke and cognitive impairment were recruited from five rehabilitation hospitals and completed an assessment battery upon admission to and discharge from rehabilitation and at three follow-up times. Data were analyzed using a two-way ANOVA. RESULTS: Seventeen historical controls and eight postintervention participants were recruited. The effect for time was significant (P ≤ 0.05) for the majority of outcomes, but there were no significant group × time effects. Small effect sizes for the group × time interaction were noted on several indicators. CONCLUSION: Few studies report on patient outcomes following a knowledge translation intervention. Small effect sizes were detected on several patient outcomes, despite study limitations. Lessons learned for future patient-level studies within knowledge translation interventions include the importance of monitoring therapist adherence to implementation protocols and ensuring research designs consider the impact on patient recruitment and retention.

Implementing a shared decision-making and cognitive strategy-based intervention: Knowledge user perspectives and recommendations.

The aim of this study was to employ knowledge user perspectives to develop recommendations that facilitate implementation of a complex, shared decision-making (SDM)-based intervention in an interprofessional setting. This study was part of a larger knowledge translation (KT) study in which interprofessional teams from five freestanding, academically affiliated, rehabilitation hospitals were tasked with implementing a cognitive strategy-based intervention approach that incorporates SDM known as Cognitive Orientation to daily Occupational Performance (CO-OP) to treat survivors of stroke. At the end of the 4-month CO-OP KT implementation support period, 10 clinicians, two from each site, volunteered as CO-OP site champions. A semi-structured focus group was conducted with 10 site champions 3 months following the implementation support period. To meet the study objective, an exploratory qualitative research design was used. The focus group session was audio-recorded, transcribed verbatim and analyzed through the lens of the integrated promoting action on research implementation in health services (iPARIHS) framework. The focus group participants (n = 8) consisted of occupational therapists, physical therapists, and speech language pathologists. Ten recommendations for CO-OP implementation were extracted and co-constructed from the focus group transcript. The recommendations reflected all four iPARHIS constructs: Facilitation, Context, Innovation, and Recipients. Implementation recommendations, from the knowledge user perspective, highlight that context-specific facilitation is key to integrating a novel, complex intervention into interprofessional practice. Facilitators should lay out a framework for training, communication and implementation that is structured but still provides flexibility for iterative learning and active problem-solving within the relevant practice context.

Minimal Clinically Important Differences in Functional Independence After a Knowledge Translation Intervention in Stroke Rehabilitation.

OBJECTIVE: To examine the odds of persons with stroke achieving minimal clinically important difference (MCID) in functional independence during inpatient rehabilitation relative to cognitive impairment (CI) severity, site, and rehabilitation teams' exposure to a Cognitive Orientation to daily Occupational Performance (CO-OP) knowledge translation (KT) intervention. DESIGN: A pre-post observational study was conducted using data from a centralized referral system. Our research team implemented a CO-OP KT intervention as part of a larger study aimed at training teams to use the CO-OP approach. SETTING: Five inpatient rehabilitation units. PARTICIPANTS: Cases extracted from a centralized referral system from the 5 participating units. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The FIM instrument data from 12 months preintervention and 6 months postintervention were analyzed. A logistic regression was performed to determine the odds ratios (ORs) for achieving MCID based on sample cohort (historical control not exposed to CO-OP KT vs post-CO-OP KT intervention), controlling for site and severity of CI. RESULTS: A model that considered the intervention, admission score, CI severity, and site was the best fit for the cases analyzed. Those with severe CI were less likely to achieve FIM total MCID compared to those with no CI (P=<.001; OR=.18; 95% confidence interval, .09-.39). Taking site and CI into account, cases post CO-OP KT intervention were significantly more likely to achieve MCID on FIM motor (P=.048; OR=1.4; 95% confidence interval, 1.00-1.98) than historical controls. CONCLUSION: The CO-OP KT intervention is associated with increased odds of achieving MCID in the FIM motor subscale in inpatient stroke rehabilitation.

Implementing a function-based cognitive strategy intervention within inter-professional stroke rehabilitation teams: Changes in provider knowledge, self-efficacy and practice.

BACKGROUND: The Cognitive Orientation to daily Occupational Performance (CO-OP) approach is a complex rehabilitation intervention in which clients are taught to use problem-solving cognitive strategies to acquire personally-meaningful functional skills, and health care providers are required to shift control regarding treatment goals and intervention strategies to their clients. A multi-faceted, supported, knowledge translation (KT) initiative was targeted at the implementation of CO-OP in inpatient stroke rehabilitation teams at five freestanding rehabilitation hospitals. The study objective was to estimate changes in rehabilitation clinicians' knowledge, self-efficacy, and practice related to implementing CO-OP. METHODS: A single arm pre-post and 6-month follow up study was conducted. CO-OP KT consisted of a 2-day workshop, 4 months of implementation support, a consolidation session, and infrastructure support. In addition, a sustainability plan was implemented. Consistent with CO-OP principles, teams were given control over specific implementation goals and strategies. Multiple choice questions (MCQ) were used to assess knowledge. A self-efficacy questionnaire with 3 subscales (Promoting Cognitive Strategy Use, PCSU; Client-Focused Therapy, CFT; Top-Down Assessment and Treatment, TDAT) was developed for the study. Medical record audits were used to investigate practice change. Data analysis for knowledge and self-efficacy utilized mixed effects models. Medical record audits were analyzed with frequency counts and chi-squares. RESULTS: Sixty-five health care providers consisting mainly of occupational and physical therapists entered the study. Mixed effects models revealed intervention effects for MCQs, CFT, and PCSU at post intervention and follow-up, but no effect on TDAT. No charts showed any evidence of CO-OP use at baseline, compared to 8/40 (20%) post intervention. Post intervention there was a trend towards reduction in impairment goals and significantly more component goals were set (z = 2.7, p = .007).

Evaluation of a rehabilitation planning consult for survivors of head and neck cancer.

BACKGROUND: The rehabilitation planning consult (RPC) is a novel, transdisciplinary rehabilitation intervention for survivors of head and neck cancer. The study aimed to: (1) estimate recruitment and withdrawal rates, and adverse events; and (2) estimate the effect on rehabilitation indicators in survivors of head and neck cancer. METHODS: A single group pre-post study with follow-up was conducted with survivors of head and neck cancer who had completed treatment within 18 months. Outcome measures included goal attainment and quality of life indicators. RESULTS: Thirty participants (30) completed the RPC, and 20 completed follow-up. The average age was 59.8 years (SD 13.3), 23 were men, and 23 set rehabilitation goals. At follow-up, there was a large effect on goal performance (d = 1.5) and satisfaction (d = 1.5), and on the Short Form Health Survey-36 (SF-36) physical role and social functioning subscales (d = 1.0 and 0.8). There was a small to moderate effect on most other outcomes. CONCLUSION: The RPC is a promising transdisciplinary rehabilitation intervention warranting further study with a controlled trial.

The Cognitive Orientation to Daily Occupational Performance Approach and Transfer: A Scoping Review.

Transferring learning from therapy to everyday life skills is a necessary step for successful therapy outcomes, yet rarely addressed and achieved. However, a cognitive approach to skill acquisition, and the Cognitive Orientation to daily Occupational Performance (CO-OP), explicitly identifies transfer as an objective and incorporates elements into the intervention to support transfer. A scoping review was undertaken to explore the nature and extent of the research regarding CO-OP and transfer. An online search of 10 databases was conducted to identify and examine research studies reporting on CO-OP and transfer. The search yielded 25 documents that addressed CO-OP and transfer. The studies used a variety of approaches to evaluate transfer; all reported transfer on at least one and, in many cases, multiple transfer outcome variables. The CO-OP literature addresses transfer across a variety of populations and settings using a variety of approaches. Further work is required to establish a common approach to examining transfer in the CO-OP literature and the literature in general.

A multi-faceted knowledge translation approach to support persons with stroke and cognitive impairment: evaluation protocol.

BACKGROUND: Patients with cognitive impairments following a stroke are often denied access to inpatient rehabilitation. The few patients with cognitive impairment admitted to rehabilitation generally receive services based on outdated impairment-reduction models, rather than recommended function-based approaches. Both reduced access to rehabilitation and the knowledge-to-practice gap stem from a reported lack of skills and knowledge regarding cognitive rehabilitation on the part of inpatient rehabilitation team members. To address these issues, a multi-faceted knowledge translation (KT) initiative will be implemented and evaluated. It will be targeted specifically at the inter-professional application of the cognitive orientation to daily occupational performance (CO-OP). CO-OP training combined with KT support is called CO-OP KT. The long-term objective of CO-OP KT is to optimize functional outcomes for individuals with stroke and cognitive impairments. Three research questions are posed: 1. Is the implementation of CO-OP KT associated with a change in the proportion of patients with cognitive impairment following a stroke accepted to inpatient rehabilitation? 2. Is the implementation of CO-OP KT associated with a change in rehabilitation clinicians' practice, knowledge, and self-efficacy related to implementing the CO-OP approach, immediately following and 1 year later? 3. Is CO-OP KT associated with changes in activity, participation, and self-efficacy to perform daily activities in patients with cognitive impairment following stroke at discharge from inpatient rehabilitation and at 1-, 3-, and 6-month follow-ups? METHODS/DESIGN: Three interrelated studies will be conducted. Study 1 will be a quasi-experimental, interrupted time series design measuring monthly summaries of stroke unit level data. Study 2, which relates to changes in health care professional practice and self-efficacy, will be a single group pre-post evaluation design incorporating chart audits and a self-report survey. Study 3 will assess patient functional outcomes using a non-randomized design with historical controls. Assessments will occur during admission and discharge from rehabilitation and at 1, 3, and 6 months following discharge from rehabilitation. DISCUSSION: This project will advance knowledge about the degree to which the implementation of a supported KT initiative can sustainably change health system, knowledge, and patient outcomes.

Development and preliminary evaluation of a rehabilitation consult for survivors of head and neck cancer: an intervention mapping protocol.

BACKGROUND: Evidence suggests that rehabilitation interventions can improve function and quality of life in survivors of head and neck cancer (HNC), but there is a lack of coordinated, integrated services, and those offered are inconsistent. To address these gaps, we will develop and conduct preliminary evaluation of a rehabilitation consult, built on the theoretical foundations of goal setting and self-management, and composed of a brief functional evaluation, a resource compendium, and collaborative goal-setting and action planning processes. METHODS/DESIGN: The development of the rehabilitation consult will be guided by intervention mapping, which consists of six steps: 1. Needs assessment; 2. Definition of program objectives; 3. Selection of theory-based intervention methods; 4. Production and pretesting; 5. Adoption, implementation and sustainability planning; 6. Process and effect evaluation. Within the intervention mapping framework, an iterative process of constructing drafts and mini-evaluations with consumers and experts will be used, modifying the rehabilitation consult intervention until a version suitable for formal evaluation is established. The rehabilitation consult will then be evaluated using a prospective, mixed method, single group design with 30 survivors of head and neck cancer. Outcomes will be assessed pre- and post-intervention and at 6-month follow-up. DISCUSSION: Survivors of head and neck cancer have among the most complex rehabilitation needs of all cancer patients. The rehabilitation consult is expected to improve knowledge and uptake of rehabilitation resources and strategies in survivors of head and neck cancer and thereby improve long-term function and quality of life. If the rehabilitation consult is effective in cancer patients with such high and diverse needs, this project will produce a toolkit that will be adaptable for other types of cancer in other jurisdictions.

Occupational performance coaching for stroke survivors: a pilot randomized controlled trial protocol.

BACKGROUND: Many stroke survivors report participation challenges. Occupational Performance Coaching for stroke survivors (OPC-Stroke) is designed to assist stroke survivors to develop the ability to plan and manage engagement in occupation. This approach combines emotional support, individualized education, and goal-focused problem solving to promote occupational engagement. PURPOSE: This study will explore the potential efficacy of OPC-Stroke and the feasibility of the research methods for use in a larger trial. METHOD: A pilot randomized controlled trial will be undertaken. Participants will be randomly assigned to receive 10 sessions of OPC-Stroke or usual care. Participation, perceived goal performance, satisfaction and self-efficacy, emotional well-being, and cognition will be measured at three time points. IMPLICATIONS: This research will test the potential usefulness of OPC-Stroke as well as the study methods, and thereby inform the continuing development of OPC-Stroke and further studies to measure its effectiveness.

Pilot randomized controlled trial investigating cognitive strategy use to improve goal performance after stroke.

OBJECTIVE: The authors compared changes in client performance on three goals poststroke after the Cognitive Orientation to daily Occupational Performance (CO-OP) intervention or standard occupational therapy (SOT) to determine the magnitude and direction of change. METHOD: Eight people living in the community following a stroke were randomly assigned to receive CO-OP (n = 4) or SOT (n = 4). CO-OP is a 10-session, cognitive-oriented approach to improving performance that uses client-driven cognitive strategies. SOT was therapist driven and combined task-specific and component-based training. Goal performance was measured by the therapist-rated Performance Quality Rating Scale (PQRS) and the participant-rated Canadian Occupational Performance Measure (COPM). RESULTS: Using Mann-Whitney U test, we found that CO-OP participants showed significantly greater improvement in performance (PQRS, p = .02; COPM Performance, p = .02) compared with SOT but no improvement in satisfaction (COPM Satisfaction, p = .38). CONCLUSION: The CO-OP group demonstrated larger performance improvements than the SOT group. Because of the promising results, an investigation using a larger sample is warranted.

Inpatient oncology rehabilitation in Toronto: a descriptive 18-month retrospective record review.

PURPOSE: The purpose was twofold: (1) to develop a comprehensive profile of patients discharged from an inpatient oncology rehabilitation unit and (2) to explore the relationships between patient characteristics and functional status. METHODS: A retrospective review of electronic data from all patients discharged from oncology rehabilitation between November 1, 2008, and March 31, 2010, was conducted. Data elements included age, sex, primary language, living arrangements, cancer diagnosis, comorbidities, and admission and discharge Functional Independence Measure (FIM(™)) scores. Descriptive statistics were compiled for all data elements. General linear regression was conducted to determine the descriptors independently associated with FIM(™) discharge and FIM(™) change scores. RESULTS: There were 153 eligible records. The patients' age ranged from 38 to 97 years (M = 72.6, SD = 12.9); 59.5% were women, and 39.3% lived alone prior to hospitalization. The most common diagnoses were colorectal cancer (n = 45, 28.8%), metastatic disease (n = 24, 15.7%), and cancer of the urinary organs (n = 14, 9.2%). Service goals were met for 77.1%. Patients improved an average of 17.1 (SD = 8.8) points on the FIM(™). Being older and having a diagnosis of brain or uterine cancer were associated with lower FIM™ change scores. CONCLUSIONS: In this sample, the majority of patients were older women, and many lived alone. While the group as a whole made significant functional gains, those who were younger improved more. Having a diagnosis of uterine or brain cancer was associated with lower functional change scores. This study was limited by a small sample size and the retrospective design; however, the results provide a foundation for future prospective research.

Inter-task transfer of meaningful, functional skills following a cognitive-based treatment: Results of three multiple baseline design experiments in adults with chronic stroke.

The transfer of skills learned in rehabilitation to new skills in the home has hitherto been notoriously difficult to achieve. The Cognitive Orientation to daily Occupational Performance (CO-OP) treatment approach has been associated with improved performance in people living with stroke, but the specific impact on transfer to untrained skills has not been investigated. The objective of the study was to investigate the capacity of CO-OP treatment to improve performance in both trained and untrained self-selected skills in adults living with stroke. A single case experiment with multiple baselines across skills was conducted, with two replications. The participants self-selected four skills; three were trained using CO-OP; the fourth was not. Using video recording, data points were collected at multiple baselines, during intervention, post-intervention, and at follow-up. The Performance Quality Rating Scale (PQRS) was used by an independent rater to score performances. The two-standard deviation band method was used to determine the significance of improvements. At follow-up, significant performance improvements were seen in all three single case experiments in all trained and untrained skills. A cognitive-based approach was associated with improved performance in trained and untrained skills in three adults with chronic stroke; further controlled research is warranted.

'There's a real plan here, and I am responsible for that plan': participant experiences with a novel cognitive-based treatment approach for adults living with chronic stroke.

PURPOSE: This study was part of a larger mixed methods project aimed at adapting the Cognitive Orientation to daily Occupational Performance (CO-OP) treatment approach, originally designed for children with performance problems, for use with adults with stroke. In CO-OP, the client focuses on learning strategies and skills, rather than on remediating impairments. Therapists use guided discovery to teach cognitive strategy use. The purpose of this study was to explore participants' experiences with the approach. METHOD: Semistructured interviews were conducted with five participants. Transcriptions were coded by two members of the research team. Data analysis was conducted in two distinct phases: Directed content analysis was conducted to apply codes to predetermined categories; Thematic analysis was conducted to allow themes grounded in the data to emerge. RESULTS: Participants reported learning and transferring the strategies taught, and made suggestions for modifications to the approach, such as increasing the number of sessions. One theme emerged, Balancing the need for autonomy with the need for support. CONCLUSIONS: The findings suggest the cognitive strategies were well learned and effectively used. CO-OP was able to provide participants with increased decision-making autonomy, but may require modifications to better support their transition to higher levels of independence.

Exploring a cognitive-based treatment approach to improve motor-based skill performance in chronic stroke: Results of three single case experiments.

PRIMARY OBJECTIVE: Early evidence suggests the use of cognitive strategies has potential to improve skill performance in people living with the effects of stroke, but no specific protocol has been identified. This study aimed to explore the potential of using the Cognitive Orientation to daily Occupational Performance (CO-OP) protocol to improve the functional performance of adults with chronic stroke. RESEARCH DESIGN AND METHODS: A single case experimental design study with two replications was conducted. Three community-dwelling participants were recruited. Each selected three functional goals for the focus of the CO-OP intervention. Multiple video recorded data points were collected at baseline, during intervention, post-intervention and at 1-month follow-up. RESULTS: The nine goals selected varied widely, e.g. using a computer mouse, bicycling and yoga. An independent observer used the observational Performance Quality Rating Scale (PQRS) to rate performances throughout. Using the 2 SD band method to analyse the data, each participant showed significant performance improvements in at least two goals during the course of the intervention and at follow-up. Two participants had an additional goal show significant improvement at follow-up. CONCLUSION: Results provide preliminary evidence that CO-OP is associated with significant performance improvements in self-selected functional goals.

Standardization of the continuing care activity measure: a multicenter study to assess reliability, validity, and ability to measure change.

BACKGROUND: There is a lack of standardized mobility measures specific to the long-term care (LTC) population. Therefore, the Continuing Care Activity Measure (CCAM) was developed. OBJECTIVE: This study determined levels of reliability, validity for clinical utilization, and sensitivity to change of this measure. DESIGN: This was a prospective longitudinal cohort study among elderly people with primarily physical or medical impairments who were residing in LTC institutions that provide nursing home and more-complex care, with access to physical therapy services. METHOD: The CCAM, the Clinical Outcome Variables Scale (COVS), the Social Engagement Scale (SES) of the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0 instrument, and the Resource Utilization Groups, version 3, (RUG-III) were administered by clinical and research physical therapists, with timing dictated by the study purpose. RESULTS: The participants were 136 residents of LTC institutions and 21 physical therapists. The CCAM interrater reliability (intraclass correlation coefficient [ICC]) was .97 (95% confidence interval=.91-1.00), and test-retest reliability (ICC) over a period of 1 week was .99 (95% confidence interval=.93-1.00). Over 6 months, the absolute change in total score was 5.88 for the CCAM and 4.26 for the COVS; the CCAM was 28% more responsive across all participants (n=105) and 68% more responsive for those scoring in the lower half (n=49). The minimal detectable difference of the CCAM was 8.6 across all participants. The CCAM correlated with the COVS, nursing care hours inferred from the RUG-III, and the SES. LIMITATIONS: Some participants were lost to follow-up. CONCLUSIONS: The CCAM is a reliable and valid tool to measure gross motor function and physical mobility for elderly people in LTC institutions. It discriminates among functional levels, measures individual functional change, and can contribute to clinical decision making.

Cognitive strategy use to enhance motor skill acquisition post-stroke: a critical review.

OBJECTIVE: The objective of this critical review was to examine the literature regarding the use of cognitive strategies to acquire motor skills in people who have had a stroke, to determine which strategies are in use and to compile evidence of their effectiveness. SEARCH TERMS: A computerized search of a range of databases was conducted using the following search terms: stroke, cerebrovascular accident; combined with strategy training, learning strateg*, cognitive strateg*, metacognitive strateg*, goal setting, goal planning, goal attainment, goal direct*, goal orient*, self talk, imagery, mental practice, self evaluat*, ready*, attentional focus*, problem solv*, goal management; combined with motor, mobility, activit*, skill, task, function, ADL. RESULTS: Twenty-six articles were reviewed. Seven studies investigated general cognitive strategies and 19 investigated task-specific strategies. The most commonly studied task-specific strategy was motor imagery. Findings suggest that general strategy training improves performance in both trained and untrained activities compared to traditional therapy; and that a specific motor imagery protocol can improve mobility and recovery in the affected upper extremity in people living with the chronic effects of stroke. CONCLUSION: This foundational evidence supports the further development of novel cognitive strategy-based interventions with the intention of improving long-term stroke outcomes.