The Aftermath and the Aftermyth: Learning From Memoirists Who Experienced Sexual Assault While at University.

There is an abundance of research on the health consequences of sexual assault during university, but less attention has been paid to how sexual assault also shapes women's everyday lives. To develop an understanding of the everyday aftermath of sexual assault, we used narrative inquiry to analyze how women textually represent everyday living after sexual assault during university within four memoirs. Memoirists discussed their lives as significantly changed and worked to repair their lives after sexual assault by engaging in a range of everyday activities. Although no single behavioral response was described, some memoirists were perceived as deviant if they engaged in behaviors that contradicted prevailing cultural myths and expectations about how one should behave after sexual assault. We need to create room for women to engage in personal, idiosyncratic responses if we are to challenge restrictive standards for doing in the aftermath of sexual assault during university.

Cognitive Orientation to daily Occupational Performance (CO-OP): A New Approach for Children with Cerebral Palsy.

AIMS: The results of a small single-case study series suggested that Cognitive Orientation to daily Occupational Performance (CO-OP) may be a successful approach for children with cerebral palsy (CP). Therefore a pilot randomized controlled trial was conducted with the following research questions-is CO-OP a feasible approach to use with children with CP, what are the effects of CO-OP when compared to usual practice, and is a larger study warranted? METHODS: 18 children between age 7 and 12 (nine in CO-OP group and nine in Current Usual Practice Approach (CUPA) group) received ten 1-hour sessions of intervention on average once per week at home. Primary outcome measures were the Canadian Occupational Performance Measure and the Performance Quality Rating Scale (PQRS). PQRS assessors were blind to group allocation and timing of assessment. RESULTS: All children in the CO-OP group were able to learn the strategies and achieve their chosen goals, thus demonstrating the feasibility of the approach. Both approaches equally promoted skill acquisition and skill maintenance at follow-up. Effect sizes suggest that CO-OP may show some advantage for transfer and maintenance. CONCLUSION: Based on these initial findings, further research is warranted.

Elucidating a Goal-Setting Continuum in Brain Injury Rehabilitation.

For individuals with brain injury, active participation in goal setting is associated with better rehabilitation outcomes. However, clinicians report difficulty engaging these clients in goal setting due to perceived or real deficits (e.g., lack of awareness). We conducted a study using grounded theory methods to understand how clinicians from occupational therapy facilitate client engagement and manage challenges inherent in goal setting with this population. Through constant comparative analysis, a goal-setting continuum emerged. At one end of the continuum, therapists embrace client-determined goals and enable clients to decide their own goals. At the other, therapists accept preset organization-determined goals (e.g., "the goal is discharge") and pay little attention to client input. Although all participants aspired to embrace client-determined goal setting, most felt powerless to do so within perceived organizational constraints. Views of advocacy and empowerment help to explain our findings and inform more inclusive practice.

Efficacy of interventions to improve motor performance in children with developmental coordination disorder: a combined systematic review and meta-analysis.

AIM: The aim of this study was to review systematically evidence about the efficacy of motor interventions for children with developmental coordination disorder (DCD), and to quantify treatment effects using meta-analysis. METHOD: Included were all studies published between 1995 and 2011 that described a systematic review, (randomized) clinical trial, or crossover design about the effect of motor intervention in children with DCD. Studies were compared on four components: design, methodological quality, intervention components, and efficacy. Twenty-six studies met the inclusion criteria for the review. Interventions were coded under four types: (1) task-oriented intervention, (2) traditional physical therapy and occupational therapy, (3) process-oriented therapies, and (4) chemical supplements. For the meta-analysis, effect sizes were available for 20 studies and their magnitude (weighted Cohen's d [d(w) ]) was compared across training types. RESULTS: The overall effect size across all intervention studies was d(w) =0.56. A comparison between classes of intervention showed strong effects for task-oriented intervention (d(w) =0.89) and physical and occupational therapies (d(w) =0.83), whereas that for process-oriented intervention was weak (d(w) =0.12). Of the chemical supplements, treatment with methylphenidate was researched in three studies (d(w) =0.79) and supplementation of fatty acids plus vitamin E in one study (no effect). The post hoc comparison between treatment types showed that the effect size of the task-oriented approach was significantly higher than the process-oriented intervention (p=0.01) and comparison (p=0.006). No significant difference in the magnitude of effect size between traditional physical and occupational therapy approaches and any of the other interventions emerged. INTERPRETATION: In general, intervention is shown to produce benefit for the motor performance of children with DCD, over and above no intervention. However, approaches from a task-oriented perspective yield stronger effects. Process-oriented approaches are not recommended for improving motor performance in DCD, whereas the evidence for chemical supplements for children with DCD is currently insufficient for a recommendation.

Occupation-based strategy training for adults with traumatic brain injury: a pilot study.

OBJECTIVE: To evaluate, before undertaking a larger trial, feasibility of the study processes to determine the effectiveness of occupation-based strategy training for producing changes on trained real-world behaviors, and to determine whether far transfer of training effects to measures of real-world impact, including participation in everyday life, could be achieved. DESIGN: Partially randomized controlled trial with pre- and postintervention assessments done by assessors masked to the treatment arm. SETTING: Testing occurred at a research institute, interventions at participants' homes. PARTICIPANTS: People (N=13) with chronic traumatic brain injury (TBI), 7 in the experimental group (mean age, 42.6y; mean time post-TBI, 9.8y; 4 men) and 6 in the control arm (mean age, 40.5y; mean time post-TBI, 10.8y; 3 men), were assessed immediately before and after the intervention phase. INTERVENTION: Occupation-based strategy training, an adapted version of the Cognitive Orientation to daily Occupational Performance (CO-OP), was provided in two 1-hour sessions per week for 10 weeks. MAIN OUTCOME MEASURES: Canadian Occupational Performance Measure, Dysexecutive Questionnaire, Mayo-Portland Adaptability Inventory-4 Participation Index, and Assessment of Motor and Process Skills. RESULTS: The study processes (testing and intervention) were acceptable to all participants. Evidence of far transfer was found as the experimental group improved significantly more than the control group on performance and satisfaction with performance ratings on untrained goals (P<.05), and reported increased levels of participation (P<.01). CONCLUSIONS: Findings must be interpreted with caution since the sample is small and comparisons are made with a no-treatment control. Nevertheless, they suggest that the training is feasible and a larger trial warranted.

Telerehabilitation for addressing executive dysfunction after traumatic brain injury.

PRIMARY OBJECTIVE: To investigate the feasibility of implementing the Cognitive Orientation to daily Occupational Performance approach (CO-OP) in a telerehabilitation format and to examine its impact on community integration and executive dysfunction for adults with traumatic brain injury (TBI). RESEARCH DESIGN: A pilot series of three case studies with 3-month follow-up was conducted. METHODS AND PROCEDURES: Three adults (all males, >10 years post-TBI) and their significant others were recruited. The CO-OP intervention, a meta-cognitive approach, was delivered through videoconferencing via Internet to train three of five participant-identified goals. Two goals were not trained to allow examination of transfer. Outcome measures included the Canadian Occupational Performance Measure, the Mayo-Portland Adaptability Inventory-4 Participation Index, and the Dysexecutive Questionnaire. Descriptive statistical analysis was used. MAIN OUTCOMES AND RESULTS: The CO-OP approach administered in a telerehabilitation format was found to be feasible. All participants indicated self-reported improvement in both trained and untrained goals. Trends toward fewer symptoms of executive dysfunction and greater community integration were demonstrated. All participants expressed satisfaction with the Internet delivery method. CONCLUSIONS: Telerehabilitation shows promise as a way to deliver the CO-OP approach and may help promote community integration of individuals living with TBI. Further study is warranted.

Exploring if and how evidence-based practice of occupational and physical therapists evolves over time: A longitudinal mixed methods national study.

BACKGROUND: Occupational therapists (OTs) and physiotherapists (PTs) are expected to provide evidence-based services to individuals living with disabilities. Despite the emphasis on evidence-based practice (EBP) by professional entry-level programs and professional bodies, little is known about their EBP competencies upon entry to practice and over time or what factors impact EBP use. The aim of the study was to measure and understand how EBP evolves over the first three years after graduation among Canadian OTs and PTs, and how individual and organizational factors impact the continuous use of EBP. METHODS: A longitudinal, mixed methods sequential explanatory study. We administered a survey questionnaire measuring six EBP constructs (knowledge, attitudes, confidence, resources, use of EBP and evidence-based activities) annually, followed by focus group discussions with a subset of survey participants. We performed group-based trajectory modeling to identify trajectories of EBP over time, and a content analysis of qualitative data guided by the Theoretical Domains Framework. RESULTS: Of 1700 graduates in 2016-2017, 257 (response rate = 15%) responded at baseline (T0) (i.e., at graduation), and 83 (retention rate = 32%), 75 (retention rate = 29%), and 74 (retention rate = 29%) participated at time point 1 (T1: one year into practice), time point 2 (T2: two years into practice, and time point 3 (T3: three years into practice) respectively. Group-based trajectory modeling showed four unique group trajectories for the use of EBP. Over 64% of participants (two trajectories) showed a decline in the use of EBP over time. Fifteen practitioners (7 OTs and 8 PTs) participated in the focus group discussions. Personal and peer experiences, client needs and expectations, and availability of resources were perceived to influence EBP the most. CONCLUSIONS: Though a decline in EBP may be concerning, it is unclear if this decline is clinically meaningful and whether professional expertise can offset such declines. Stakeholder-concerted efforts towards the common goal of promoting EBP in education, practice and policy are needed.

Developing multisectoral strategies to promote evidence-based practice in rehabilitation: findings from an end-of-grant knowledge translation symposium.

PURPOSE: Following a longitudinal study to understand how evidence-based practice evolves during the initial years of occupational therapy (OT) and physiotherapy (PT) practice, we held an end-of-grant symposium with representatives from education, practice, research, and policy. The objectives were to: (1) elicit feedback on the implications of the study results; and (2) co-develop a list of actionable recommendations for each sector. METHODS: Qualitative participatory approach. The symposium was held over two half days and consisted of a presentation of study findings, a discussion on the implications of the research for each sector and future recommendations. Discussions were audio recorded, transcribed verbatim and analyzed using qualitative thematic analysis. RESULTS: The themes related to implications of the longitudinal study included: (1) A need to rethink what evidence-based practice (EBP) really is; (2) How to practice EBP; and (3) The continuing challenge of measuring EBP. The co-development of actionable recommendations resulted in nine strategies. CONCLUSIONS: This study highlighted how we may collectively promote EBP competencies in future OTs and PTs. We generated sector-specific avenues that may be pursued to promote EBP and argued for the importance of pooling efforts from the four sectors so that we may achieve the intended ethos of EBP.IMPLICATIONS FOR REHABILITATIONThere is a need to revisit the definition of evidence-based practice (EBP) and the traditional 3-circle model in rehabilitation to include a broader conceptualization of what constitutes evidence.We recommend using EBP measures as tools for self-reflection and professional development that can support practitioners to be reflective and accountable evidence-based practitioners.Optimal promotion of EBP competencies in occupational therapists and physiotherapists should rest upon collaborative efforts from the education, practice, research, and policy sectors.

Anatomy of cognitive strategies: a therapist's primer for enabling occupational performance.

BACKGROUND: Promoting effective strategy use is an integral part of enabling occupational performance; however, there are variations in how strategies are defined, discussed, used, and applied in occupational therapy practice. PURPOSE: Focusing on cognitive strategies, in this paper, we define and describe strategies and their types and divide the concept of strategies into two dimensions: strategy attributes and strategy use. A comprehensive framework for each dimension (attribute and use) is proposed as a clinical reasoning guide as well as a foundation for future research. The frameworks are designed to reduce ambiguity, deepen understanding, and serve as clinical reasoning guides assisting therapists in specifying, describing, and observing cognitive strategies during occupational performance. KEY ISSUES: We argue that there is a need for therapists to use consistent terminology and to be able to systematically select cognitive strategies and evaluate their use. IMPLICATIONS: The proposed strategy frameworks provide clinical guides for systematic analysis and selection of cognitive strategies as well as for observing components of strategy use during clients' occupational performance. We suggest the need for greater specification and description of strategies during intervention and highlight directions for future research.

Harnessing cognitive strategy use for functional problems and proposed underlying mechanisms in childhood-onset dystonia.

BACKGROUND: There is a significant gap in knowledge about rehabilitation techniques and strategies that can help children and young people with hyperkinetic movement disorders (HMD) including dystonia to successfully perform daily activities and improve overall participation. A promising approach to support skill acquisition is the Cognitive Orientation to daily Occupational Performance (CO-OP) intervention. CO-OP uses cognitive strategies to help patients generate their own solutions to overcome self-identified problems encountered in everyday living. PURPOSE: 1. To identify and categorize strategies used by children with HMD to support skill acquisition during CO-OP; 2. To review the possible underlying mechanisms that might contribute to the cognitive strategies, in order to facilitate further studies for developing focused rehabilitation approaches. METHODS: A secondary analysis was performed on video-recorded data from a previous study exploring the efficacy of CO-OP for childhood onset HMD, in which CO-OP therapy sessions were delivered by a single occupational therapist. For the purpose of this study, we reviewed a total of 40 randomly selected hours of video footage of CO-OP sessions delivered to six participants (age 6-19 years) over ten intervention sessions. An observational recording sheet was applied to identify systematically the participants' or therapist's verbalizations of cognitive strategies during the therapy. The strategies were classified into six categories in line with published literature. RESULTS: Strategies used by HMD participants included distraction, externally focussed attention, internally focussed attention, emotion self-regulation, motor imagery and mental self-guidance. We postulate different underlying working mechanisms for these strategies, which have implications for the therapeutic management of children and young people with HMD including dystonia. CONCLUSIONS: Cognitive strategy training can fundamentally change and improve motor performance. On-going work will address both the underlying neural mechanisms of therapeutic change and the mediators and moderators that influence how change unfolds.

Training clinicians in a problem-solving fatigue programme for patients receiving maintenance haemodialysis.

BACKGROUND: Personal Energy Planning is a problem-solving based programme that guides people receiving maintenance haemodialysis treatment to use energy management strategies to address life participation challenges. The feasibility of training dialysis clinicians to become Personal Energy Planning coaches (i.e., programme administrators) is currently unknown. OBJECTIVES: To explore the feasibility of training dialysis clinicians to administer the Personal Energy Planning programme. DESIGN: Feasibility study involving an adherence evaluation of two trained dialysis clinician coaches' problem-solving facilitation skills, and one qualitative interview with each coach. PARTICIPANTS: Two Personal Energy Planning coaches with nursing backgrounds who administered the programme to 10 patients receiving maintenance haemodialysis treatment over a total of 34 sessions. APPROACH: Audio recordings of one session per treatment recipient (n = 10) were evaluated using an established treatment adherence checklist. The proportion of treatment sessions where the item was observed by two adherence raters was calculated. In addition, coaches were interviewed about their experiences learning and administering the programme; interviews were analysed using inductive thematic analysis. FINDINGS: Some core facilitation skills (e.g., patient-centred goal setting and analysis of performance breakdowns) were consistently used; however, other facilitation skills (e.g., guided discovery and global problem-solving strategy) were not regularly implemented. The coaches discussed challenges (e.g., supporting patient problem-solving and fluctuating patient health) with administering the intervention. Certain training resources (e.g., coaching handbook and expert consultation) were identified as valuable to their learning. CONCLUSIONS: With modifications to training materials, it might be feasible to train dialysis clinicians to administer Personal Energy Planning with people receiving maintenance haemodialysis treatment.

Analysis of Cognitive Environmental Support (ACES): preliminary testing.

Although the environment can impact, or otherwise support, cognition, no measure currently exists to help the clinician identify items within the environment that may support cognition. To address this gap in the literature, the Analysis of Cognitive Environmental Support (ACES) was developed. Here, content validity, concurrent validity and inter-rater reliability were assessed, in parallel, for the ACES. Based on the findings, modifications were made to the tool, which is included in an effort to initiate further research regarding its clinical utility.

Introducing the Leadership in Enabling Occupation (LEO) model.

BACKGROUND: Occupational therapy is a broad profession yet access to services remains restricted and uneven across Canada. Access to the potential breadth of occupational therapy is severely restrained by complex supply, retention, and funding challenges. To improve access to occupational therapy, widespread leadership is needed by all practitioners. PURPOSE: This brief report introduces the Leadership in Enabling Occupation (LEO) Model, which displays the inter-relationship of four elements of everyday leadership as described in "Positioning Occupational Therapy for Leadership," Section IV, of Enabling Occupation II: Advancing a Vision of Health, Well-being and Justice through Occupation (Townsend & Polatajko, 2007). KEY ISSUES: All occupational therapists have the power to develop leadership capacity within and beyond designated leadership positions. IMPLICATIONS: LEO is a leadership tool to extend all occupational therapists' strategic use of scholarship, new accountability approaches, existing and new funding, and workforce planning to improve access to occupational therapy.

The meaning gap in occupational therapy: finding meaning in our own occupation.

BACKGROUND: Occupation is a core concept of our profession, yet little is understood about how therapists use occupation in clinical practice. PURPOSE: This study explores frontline clinicians' experience with occupation-based practice in a large academic health sciences centre. METHODS: A qualitative constructivist study was conducted using thematic analysis, following in-depth interviews with 12 occupational therapists. FINDINGS: Participants described the existence of two realities: Occupational therapy as they felt it should be practiced and as it actually is practiced. When the two were incongruent, participants experienced a meaning gap, which was expressed through four themes to reveal that a personal sense of occupation guides practice and transforms the meaning of the job. IMPLICATIONS: The exploration of personal occupational meaning through conscious self-reflection and co-creation of meaning with clients and their health care teams may serve to bridge the meaning gap.

Efficacy of the Cognitive Orientation to daily Occupational Performance (CO-OP) approach with and without parental coaching on activity and participation for children with developmental coordination disorder: A randomized clinical trial.

BACKGROUND: Cognitive Orientation to daily Occupational Performance (CO-OP) is recommended for its effectiveness in improving activity performance in children with Developmental Coordination Disorder (DCD). Since parental support is a key element in CO-OP, parental coaching seems relevant to be investigated. AIMS: Compare the efficacy of the CO-OP Approach with and without additional parental coaching to improve activity and participation in children with DCD. METHODS AND PROCEDURES: Randomized clinical trial with 7-12-years-old children with DCD, randomly assigned to experimental (E-group) or active control (AC-group) groups, with 11 children each. Both groups received traditional CO-OP, E-group received four additional parental group-coaching sessions. Occupational performance and satisfaction on intervention goals were measured at baseline, post-intervention, and follow-up. Participation, motor performance and executive function were assessed at baseline and post-intervention. OUTCOMES AND RESULTS: CO-OP with and without additional parental coaching resulted in improved occupational performance according to children, parents, and external evaluators. Children showed statistically significant gains in motor performance and cognitive flexibility. Participation measures did not change. CONCLUSIONS AND IMPLICATIONS: As coaching did not add additional gains, parent's required participation in CO-OP might be enough to support children's occupational performance.

Rehabilitation in childhood-onset hyperkinetic movement disorders including dystonia: Treatment change in outcomes across the ICF and feasibility of outcomes for full trial evaluation.

BACKGROUND: Childhood-onset hyperkinetic movement disorders (HMD), including dystonia are notoriously difficult to treat and there are limited studies showing successful medical, surgical or non-pharmacological interventions. METHODS: This prospective study used grouped data (n = 22) from two studies of the Cognitive Orientation to daily Occupational Performance (CO-OP) Approach for patient-selected goals. Eligibility included aged 6-21 years, deep brain stimulation in place, with manual ability classification system level I-IV. Outcome was assessed on a range of patient-reported and clinician-rated measures across the International Classification of Function at end-treatment (10 weekly sessions) (series 1 and 2) and 3-month follow-up (series 1). Feasibility of outcomes to be used in a full trial were explored. FINDINGS: Nineteen participants completed the intervention and were included in the analysis. Of the primary outcome measures, the self-reported Canadian Occupational Performance Measure showed improvement in goal performance (mean change 4.08, 95% CI [3.37,4.79] post-; 4.18 [5.10,5.26] follow-up), and satisfaction (4.03 [3.04,5.03) post-; 4.44 [3.07,5.82] follow-up]. The Assessment of Motor and Process Skills showed improved motor score (0.52 [0.01,1.03] at follow-up only, while the process score did not change. Objective blind-rated pooled data using the Performance Quality Rating Scale-individualized indicated significant change for trained goals (3.79 [3.37,4.21] post-; (4.01,5.10) follow-up] and untrained goals (1.90 [1.24,2.55] post 1.91 [0.23,3.60] follow-up]. Motor impairment assessed by the Burke-Fahn Motor Disability Rating Scale was unchanged (-3.26 [-6.62,0.09] post-; -1.11 [-8.05,5.82] follow-up). Improvement was also observed in self-efficacy (0.97 [0.47,1.47] post-; 1.37 [1.91-0.83] follow-up) and Quality of Life (0.12 [0.03-0.22] follow-up). Goal improvement; self-efficacy and quality of life captured significant change post-intervention. This improvement was shown despite no change on impairment-related measures and were shown to be feasible measures to use in a larger study of CO-OP for this population.

Individual and organizational factors associated with evidence-based practice among physical and occupational therapy recent graduates: A cross-sectional national study.

BACKGROUND: Occupational therapy (OT) and physical therapy (PT) programs in Canada have moved to graduate-level entry education to address graduates' readiness for evidence-based practice (EBP). Whether rehabilitation professionals with advanced training in EBP are meeting their responsibilities as evidence-based professionals upon entry into practice and the factors that influence the use of evidence is unclear. The aim of this study was to examine the individual and organizational factors associated with the use of EBP and supporting evidence-based activities among graduates of professional OT and PT master's programs. METHODS: A cross-sectional design using a survey of recent graduates of the 29 OT and PT programs in Canada. The survey measured six constructs supportive of EBP (ie, knowledge, attitudes, confidence, organizational resources, actual use of EBP, and evidence-based activities). Analyses consisted of descriptive statistics to characterize the sample and the different variables and ordinal multivariate regression analysis. RESULTS: 257 graduates (15%) completed the survey. Attitudes towards EBP was positively associated both with evidence-based activities (odds ratio = 1.36 with a 95% CI: 1.22 to 1.52) and use of EBP (odds ratio = 1.23 with a 95% CI: 1.12 to 1.36); greater confidence was related to greater use of EBP (OR = 1.12, 95% CI: 1.01 to 1.24); and working in a private practice setting was found to be related to performing more evidence-based activities (odds ratio = 3.15, 95% CI: 1.40 to 7.12). CONCLUSIONS: Despite a greater focus on EBP knowledge in these curricula across Canada, knowledge was not related to EBP use nor evidence-based activities upon entry into practice. On the other hand, attitudes, confidence and working in private practice were. University programs should consider curricular strategies that increase the use of EBP, provide opportunities to engage in evidence-based activities with an emphasis on promoting the development of positive attitudes towards EBP and increasing learners' confidence in their ability to be evidence-based professionals.

'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.

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.