Efficacy of the Rehabilitation Planning Consult for Survivors of Head and Neck Cancer: A Phase 2 Randomized Controlled Trial.

PURPOSE: Survivors of head and neck cancer may have significant lasting impairments and poor access to rehabilitation. To address this, our group developed and evaluated a rehabilitation planning consult (RPC). The RPC is conducted through an initial consultation and a single follow-up session with a rehabilitation professional. During the initial consultation, rehabilitation needs are determined and the survivor sets individualized goals and plans. They then implement their plans independently and are facilitated to evaluate and modify plans as necessary during the follow-up session. METHODS AND MATERIALS: We used a waitlist control design to compare the proportion of participants attaining a minimally importantly different change in quality of life (QOL) on the Short Form 36 Physical Health Summary Score from baseline to 3 months after study enrollment, between patients randomized to receive (n = 77) or wait 14 ± 3 weeks to receive (n = 76) the RPC. Additional outcomes included goal attainment indicators measured using the Brief Rehabilitation Assessment for Survivors of Head and Neck Cancer (BRASH). RESULTS: Of 153 participants recruited, 95 (62%) completed the intervention; 57 were in the immediate (RPC) group and 38 were in the waiting list control (WLC) group. No significant between-group differences were seen in the proportion of patients achieving a minimally important improvement (2.5 units) on the Physical Health Summary Score from baseline to 3 months after recruitment. No between-group differences were seen on any secondary QOL indicators. Among the 67 (RPC n = 42, WLC n = 22) participants who set individualized rehabilitation goals, BRASH scores on goal performance and satisfaction with goal performance were significantly better in the RPC group. CONCLUSIONS: Our results suggest that the RPC may provide benefit in patients' individualized domains of choice among those who set goals, without affecting overall QOL. Future work could refine the subset of patients who benefit and explore the optimal timing and intensity of the intervention.

Evaluation of a pre-professional pathway program: perspectives of former students in the rural pre-medicine program at Selkirk College.

Background: Having a rural background is one of the most predictive factors in eventually having a rural practice, but people from rural areas face several barriers to post-secondary education. Pre-professional rural pathway initiatives are a potential solution. The Rural Pre-Medicine Program (RPM) at Selkirk College, British Columbia was developed to provide students with the credits necessary to apply to medicine and other health professional programs, an introduction to rural healthcare issues, and a unique and comprehensive support program to enable success. Methods: We administered a cross-sectional survey to former students who left the program from its inception in September 2014 to May 2020 to explore the extent to which program aims are being met. Results: The response rate was 49.4% (40/81). Respondents agreed the program increased their skills, their understanding of rural healthcare issues, and enhanced their competitiveness for applying to health professional programs. Most agreed the program increased their future rural work intentions. Respondents suggested that academic programming be more flexible to allow for more varied post-program pathways. Conclusion: This survey provides preliminary evidence the RPM Program is on track to increase the number of people with a rural affinity who prepare to become health professionals.

Contexte: Le fait d'être issu d'un milieu rural est l'un des facteurs les plus prédictifs d'une pratique future dans un tel milieu. Toutefois, les habitants des régions rurales sont confrontés à plusieurs obstacles à l'accès à l'éducation postsecondaire. Les initiatives de parcours pré-professionnels en milieu rural sont une solution potentielle à ce problème. Le programme Rural Pre-Medicine (RPM) du Selkirk College, en Colombie-Britannique, a été conçu pour fournir aux étudiants les crédits nécessaires pour faire une demande d'admission en médecine et dans d'autres programmes de formation professionnelle en santé, une introduction aux enjeux des soins de santé en milieu rural et un programme de soutien unique et complet pour favoriser la réussite. Méthodes: Nous avons mené une enquête transversale auprès d'anciens étudiants ayant quitté le programme entre septembre 2014, année de sa création, et mai 2020 pour déterminer dans quelle mesure les objectifs du programme sont atteints. Résultats: Le taux de réponse a été de 49,4 % (40/81). Les répondants ont reconnu que le programme leur avait permis d'améliorer leurs compétences, de mieux comprendre les enjeux liés aux soins de santé en milieu rural et de rendre plus compétitive leur candidature aux programmes de formation professionnelle en santé. La plupart d'entre eux ont déclaré que le programme les avait confortés dans leur intention de travailler en milieu rural. Ils ont recommandé de rendre le cursus plus souple pour permettre des débouchés plus variés pour les diplômés. Conclusion: Les résultats de cette enquête semblent indiquer que le programme RPM permettrait d'augmenter le nombre de candidats à un métier de la santé attirés par le milieu rural.

Multi-model order spatially constrained ICA reveals highly replicable group differences and consistent predictive results from resting data: A large N fMRI schizophrenia study.

Brain functional networks identified from resting functional magnetic resonance imaging (fMRI) data have the potential to reveal biomarkers for brain disorders, but studies of complex mental illnesses such as schizophrenia (SZ) often yield mixed results across replication studies. This is likely due in part to the complexity of the disorder, the short data acquisition time, and the limited ability of the approaches for brain imaging data mining. Therefore, the use of analytic approaches which can both capture individual variability while offering comparability across analyses is highly preferred. Fully blind data-driven approaches such as independent component analysis (ICA) are hard to compare across studies, and approaches that use fixed atlas-based regions can have limited sensitivity to individual sensitivity. By contrast, spatially constrained ICA (scICA) provides a hybrid, fully automated solution that can incorporate spatial network priors while also adapting to new subjects. However, scICA has thus far only been used with a single spatial scale (ICA dimensionality, i.e., ICA model order). In this work, we present an approach using multi-objective optimization scICA with reference algorithm (MOO-ICAR) to extract subject-specific intrinsic connectivity networks (ICNs) from fMRI data at multiple spatial scales, which also enables us to study interactions across spatial scales. We evaluate this approach using a large N (N > 1,600) study of schizophrenia divided into separate validation and replication sets. A multi-scale ICN template was estimated and labeled, then used as input into scICA which was computed on an individual subject level. We then performed a subsequent analysis of multiscale functional network connectivity (msFNC) to evaluate the patient data, including group differences and classification. Results showed highly consistent group differences in msFNC in regions including cerebellum, thalamus, and motor/auditory networks. Importantly, multiple msFNC pairs linking different spatial scales were implicated. The classification model built on the msFNC features obtained up to 85% F1 score, 83% precision, and 88% recall, indicating the strength of the proposed framework in detecting group differences between schizophrenia and the control group. Finally, we evaluated the relationship of the identified patterns to positive symptoms and found consistent results across datasets. The results verified the robustness of our framework in evaluating brain functional connectivity of schizophrenia at multiple spatial scales, implicated consistent and replicable brain networks, and highlighted a promising approach for leveraging resting fMRI data for brain biomarker development.

Strategy-training post-stroke via tele-rehabilitation: a pilot randomized controlled trial.

PURPOSE: Long-term limitations in social participation are common after stroke. Whether these can be attenuated through a tele-rehabilitation approach is unknown. We were particularly interested in examining transfer of learning effects which could result in broader improvements in social participation. METHODS: We adapted a strategy training rehabilitation approach (tele-CO-OP) for remote delivery. Participants with chronic stroke were randomized to receive the intervention (EXPT) or to a wait list (Control). Feasibility and acceptability were measured via attendance scores, satisfaction with the training and therapist evaluation of engagement with the training. The primary outcome measure was the Canadian Occupational Performance Measure (COPM), a standardized semi-structured interview which elicits difficulties in day-to-day life. RESULTS: Seventeen participants were randomized. Tele-CO-OP was found to be feasible and acceptable: participants reported high satisfaction and engagement, and missed few sessions. Large effect sizes for transfer of learning effects were observed in favor of receiving tele-CO-OP vs being waitlisted. Significant benefits were also conferred to the Control group following receipt of tele-CO-OP. The intervention also appeared to improve mood. CONCLUSIONS: This exploratory study demonstrates the feasibility and acceptability of tele-CO-OP and provides preliminary evidence for transfer of learning effects to untrained everyday social participation activities. Trial registration number: NCT02724813.

Stroke results in long-term limitations in social participation.The Cognitive Orientation to daily Occupational Performance (CO-OP) Approach provides a potential avenue for ameliorating these limitations.This pilot randomized controlled trial demonstrated that it is feasible to deliver tele-CO-OP and that positive benefits may accrue to those receiving the intervention for both trained and untrained activities.Tele-CO-OP is a promising intervention for addressing long-term participation limitations in individuals with chronic stroke.

The impact of an integrated, interprofessional knowledge translation intervention on access to inpatient rehabilitation for persons with cognitive impairment.

INTRODUCTION: Stroke rehabilitation teams' skills and knowledge in treating persons with cognitive impairment (CI) contribute to their reduced access to inpatient rehabilitation. This study examined stroke inpatient rehabilitation referral acceptance rates for persons with CI before and after the implementation of a multi-faceted integrated knowledge translation (KT) intervention aimed at improving clinicians' skills in a cognitive-strategy based approach, Cognitive Orientation to daily Occupational Performance (CO-OP), CO-OP KT. METHODS: CO-OP KT was implemented at five inpatient rehabilitation centres, using an interrupted time series design and data from an electronic referral and database system called E-Stroke. CO-OP KT included a 2-day workshop, 4 months of implementation support, health system support, and a sustainability plan. A mixed effects model was used to model monthly acceptance rates for 12 months prior to the intervention and 6 months post. RESULTS: The dataset was comprised of 2604 pre-intervention referrals and 1354 post. In the mixed effects model, those with CI had a lower pre-intervention acceptance rate than those without. Post-intervention the model showed the acceptance rate for those with CI increased by 8.6% (p = 0.02), whereas those with no CI showed a non-significant increase of less than 1%. CONCLUSIONS: Proportionally more persons with CI gained access to inpatient stroke rehabilitation following an integrated KT intervention.

Impact of COVID-19 on Excessive Alcohol Use in North Carolina.

Excessive alcohol use, already problematic in North Carolina, has increased markedly during COVID-19. Alcohol-related morbidity and mortality have also increased.

Assessment of Walking Speed and Distance Post-Stroke Increases After Providing a Theory-Based Toolkit.

BACKGROUND AND PURPOSE: While underutilized, poststroke administration of the 10-m walk test (10mWT) and 6-minute walk test (6MWT) can improve care and is considered best practice. We aimed to evaluate provision of a toolkit designed to increase use of these tests by physical therapists (PTs). METHODS: In a before-and-after study, 54 PTs and professional leaders in 9 hospitals were provided a toolkit and access to a clinical expert over a 5-month period. The toolkit comprised a guide, smartphone app, and video, and described how to set up walkways, implement learning sessions, administer walk tests, and interpret and apply test results clinically. The proportion of hospital visits for which each walk test score was documented at least once (based on abstracted health records of ambulatory patients) were compared over 8-month periods pre- and post-intervention using generalized mixed models. RESULTS: Data from 347 and 375 pre- and postintervention hospital visits, respectively, were analyzed. Compared with preintervention, the odds of implementing the 10mWT were 12 times greater (odds ratio [OR] = 12.4, 95% confidence interval [CI] 5.8, 26.3), and of implementing the 6MWT were approximately 4 times greater (OR = 3.9, 95% CI 2.3, 6.7), post-intervention, after adjusting for hospital setting, ambulation ability, presence of aphasia and cognitive impairment, and provider-level clustering. Unadjusted change in the percentage of visits for which the 10mWT/6MWT was documented at least once was smallest in acute care settings (2.0/3.8%), and largest in inpatient and outpatient rehabilitation settings (28.0/19.9% and 29.4/23.4%, respectively). DISCUSSION AND CONCLUSIONS: Providing a comprehensive toolkit to hospitals with professional leaders likely contributed to increasing 10mWT and 6MWT administration during inpatient and outpatient stroke rehabilitation.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A390 ).

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.

The cognitive augmented mobility program (CAMP): feasibility and preliminary efficacy.

BACKGROUND: Best evidence suggests incorporating task-specific training, aerobics, and strengthening to improve mobility and gait in persons with stroke (PWS). Related research suggests incorporating cognitive problem-solving strategy training may lead to better skill maintenance and transfer. The present study examined the feasibility and preliminary outcomes of an evidence-based cognitive augmented mobility program (CAMP) for PWS. METHODS: A single-arm pre-post and follow-up design was conducted, in two blocks (NCT03683160). Participants completed an exercise intervention with an integrated cognitive strategy component and had weekly 1:1 sessions with a physiotherapist trained in Cognitive Orientation to daily Occupational Performance (CO-OP), focusing on goal practice and cognitive strategy use. CAMP consisted of a pre-intervention education and goal-setting session and 16 90-minute sessions held in a group format, 2x/wk for 8 weeks. Assessments were conducted 1 week prior to beginning the intervention, 1 week post-intervention, and at a 4-5 week follow-up. RESULTS: CAMP was found to be feasible with 96% session attendance and strong participant satisfaction. Pre to post-CAMP intervention, a large effect was found for endurance (r = 0.53), balance (r = 0.59), mobility (r = 0.63) and goal attainment (r = 0.63) indicators, and large effects were maintained at follow-up for balance, mobility, and goal attainment. A medium effect was found for functional independence (r = 0.38), gait speed (r = 0.39), and balance confidence (r = 0.38). A small effect was found for participation (r = 0.27) and overall stroke recovery (r = 0.25). CONCLUSIONS: Preliminary results suggest CAMP is feasible; there may be a beneficial effect of combining best evidence for mobility and fitness with cognitive strategy training. The positive results for skill maintenance and transfer suggest further investigation is warranted.

Multimodel Order Independent Component Analysis: A Data-Driven Method for Evaluating Brain Functional Network Connectivity Within and Between Multiple Spatial Scales.

Background: While functional connectivity is widely studied, there has been little work studying functional connectivity at different spatial scales. Likewise, the relationship of functional connectivity between spatial scales is unknown. Methods: We proposed an independent component analysis (ICA)-based approach to capture information at multiple-model orders (component numbers), and to evaluate functional network connectivity (FNC) both within and between model orders. We evaluated the approach by studying group differences in the context of a study of resting-state functional magnetic resonance imaging (rsfMRI) data collected from schizophrenia (SZ) individuals and healthy controls (HC). The predictive ability of FNC at multiple spatial scales was assessed using support vector machine-based classification. Results: In addition to consistent predictive patterns at both multiple-model orders and single-model orders, unique predictive information was seen at multiple-model orders and in the interaction between model orders. We observed that the FNC between model orders 25 and 50 maintained the highest predictive information between HC and SZ. Results highlighted the predictive ability of the somatomotor and visual domains both within and between model orders compared with other functional domains. Also, subcortical-somatomotor, temporal-somatomotor, and temporal-subcortical FNCs had relatively high weights in predicting SZ. Conclusions: In sum, multimodel order ICA provides a more comprehensive way to study FNC, produces meaningful and interesting results, which are applicable to future studies. We shared the spatial templates from this work at different model orders to provide a reference for the community, which can be leveraged in regression-based or fully automated (spatially constrained) ICA approaches. Impact statement Multimodel order independent component analysis (ICA) provides a comprehensive way to study brain functional network connectivity within and between multiple spatial scales, highlighting findings that would have been ignored in single-model order analysis. This work expands upon and adds to the relatively new literature on resting functional magnetic resonance imaging-based classification and prediction. Results highlighted the differentiating power of specific intrinsic connectivity networks on classifying brain disorders of schizophrenia patients and healthy participants, at different spatial scales. The spatial templates from this work provide a reference for the community, which can be leveraged in regression-based or fully automated ICA approaches.

Clinician perspectives on implementing a team-based metacognitive strategy training approach to stroke rehabilitation.

INTRODUCTION: The objective of this research study was to explore site and clinician specific experiences, successes and challenges in implementing a complex intervention (cognitive orientation to daily occupational performance approach) to enhance stroke team's ability to address cognitive impairments as part of comprehensive stroke rehabilitation. METHODS: A focus group was held with clinicians from five study sites, all rehabilitation stroke hospitals in a large urban setting, to discuss implementation experiences. Participants were clinicians (site champions) from each of the five participating stroke program study sites and included four occupational therapists, three physiotherapists and one speech-language pathologist. Thematic analysis was used to identify themes that represented clinicians' perspectives. RESULTS: Implementing this complex team-based intervention was influenced by three themes-organizational support, experiential evidence, and clinicians' perspectives. Continued implementation of the intervention following the withdrawal of study support was represented on a continuum that ranged from not using the approach at all to implementing it with all patients. Sites where managers encouraged and supported use of the intervention within teams (organization support), continued to use it after the study support period as did clinicians who were willing to try new interventions (clinicians' perspectives). Development of iterative conclusions through implementation or attempts to implement the intervention had both positive and negative effects on continued implementation (experiential evidence). CONCLUSIONS: Strategies that reinforce development of positive experiential evidence and building organizational support for innovative practice were found to be useful adjuncts in facilitating implementation of complex interprofessional interventions.

Experiences of Physical Therapists and Professional Leaders With Implementing a Toolkit to Advance Walking Assessment Poststroke: A Realist Evaluation.

OBJECTIVE: The iWalk study showed significant increase in use of the 10-Meter Walk Test (10MWT) and 6-Minute Walk Test (6MWT) poststroke following provision of a toolkit. This paper examined the influence of contextual circumstances on use of the toolkit and implementation strategy across acute care and inpatient and outpatient rehabilitation settings. METHODS: A theory-based toolkit and implementation strategy was designed to support guideline recommendations to use standardized tools for evaluation of walking, education, and goal-setting poststroke. The toolkit comprised a mobile app, video, and educational guide outlining instructions for 3 learning sessions. After completing learning sessions, 33 physical therapists and 7 professional leaders participated in focus groups or interviews. As part of a realist evaluation, the study compared and synthesized site-specific context-mechanism-outcome descriptions across sites to refine an initial theory of how the toolkit would influence practice. RESULTS: Analysis revealed 3 context-mechanism-outcomes: (1) No onsite facilitator? No practice change in acute care: Without an onsite facilitator, participants lacked authority to facilitate and coordinate the implementation strategy; (2) Onsite facilitation fostered integration of select practices in acute care: When onsite facilitation occurred in acute care, walk test administration and use of reference values for patient education were adopted variably with high functioning patients; (3) Onsite facilitation fostered integration of most practices in rehabilitation settings: When onsite facilitation occurred, many participants incorporated 1 or both tests to evaluate and monitor walking capacity, and reference values were applied for inpatient and outpatient education and goal setting. Participants preferentially implemented the 10MWT over the 6MWT because set-up and administration were easier and a greater proportion of patients could walk 10 m. CONCLUSION: Findings underscore contextual factors and activities essential to eliciting change in assessment practice in stroke rehabilitation across care settings. IMPACT: This study shows that to foster recommended walking assessment practices, an onsite facilitator should be present to enable learning sessions and toolkit use.

Opioid stewardship training during the transition to residency to prepare medical students to recognize and treat opioid use disorder.

Background: With a drastic shortage of addiction medicine specialists-and an ever-growing number of patients with opioid use disorder (OUD)-there is a dire need for more clinicians to feel confident in prevention and management of OUD and obtain a DEA-X waiver to prescribe medications to treat OUD. Here we determine if it is feasible to certify 4th year medical students with DEA-X waiver training as a component of the PROUD (Prevent and Reduce Opioid Use Disorder) curriculum, and if PROUD enhanced preparedness for medical students to manage OUD as interns. Methods: We implemented a sequential mixed-methods IRB approved study to assess feasibility (completing all required components of DEA-X waiver training) and impact of PROUD (measured by knowledge growth, enhancement for residency, and utilization of training during internship). Students completed 11 hours of required OUD training. Quantitative data included pre-/post- knowledge and curriculum satisfaction assessments as well as long-term impact with follow up survey as interns. Qualitative data was collected by survey and semi-structured focus groups. Results: All 120 graduating medical students completed the required components of the curriculum. Knowledge improved on the Provider Clinical Support Services (12.9-17.3, p < 0.0001) and Brief Opioid Overdose Knowledge assessments (10.15-10.81, p < 0.0001). Course satisfaction was high: 90% recommended online modules; 85% recommended training overall. Six qualitative themes emerged: (1) curriculum content was practical, (2) online modules allowed flexibility, (3) in-person seminars ensured authenticity, (4) timing at the transition to residency was optimal, (5) curriculum enhanced awareness and confidence, and (6) training was applicable to future careers. At 3 months, 60% reported using their training during internship; 64% felt more prepared to treat OUD than peers. Conclusions: PROUD trained 4th year medical students in opioid stewardship. As interns, students felt ready to serve as change agents to prevent, diagnose, and treat OUD.

Supported rural pre-medicine: a descriptive evaluation of a novel undergraduate program's first cohorts.

Selkirk College's Rural Pre-Medicine (RPM) program launched in 2014 as a unique undergraduate initiative designed to increase the number of students who prepare for future careers in rural healthcare and, in the longterm, to play a role in reducing rural health disparities. Preliminary evaluation indicates most students in the program have rural backgrounds and the majority of graduates with follow-up data go on to further health science programming, including medical school. Challenges with retention have been identified. RPM is committed to ongoing program improvement and to providing a model for similar programs in other jurisdictions.

En 2014, le Collège Selkirk a lancé son programme de doctorat de premier cycle en pré-médecine rurale (PMR), une initiative unique visant à attirer davantage d'étudiants vers une carrière dans le domaine de la santé en milieu rural et, à long terme, à réduire les inégalités en matière de santé dans les zones rurales. L'évaluation préliminaire indique que la plupart des étudiants inscrits dans ce programme sont issus du milieu rural et que la majorité des diplômés pour lesquels des données étaient disponibles poursuivent leurs études en sciences de la santé, y compris en médecine. Des problèmes de rétention ont été mis en évidence. Le PMR s'inscrit dans une démarche d'amélioration continue et désire faire du programme un modèle à suivre ailleurs au Canada.

Cognitive oriented strategy training augmented rehabilitation (COSTAR) for ischemic stroke: a pilot exploratory randomized controlled study.

Purpose: To investigate the effect of adding cognitive strategy training to task-specific training (TST), called Cognitive Oriented Strategy Training Augmented Rehabilitation (COSTAR), compared with TST on activity and participation for chronic stroke survivors in an outpatient occupational therapy settingMaterials and methods: We conducted an exploratory, single-blind, randomized controlled trial. Participants were randomized to TST or COSTAR protocol. Our primary outcomes measured activity and participation after stroke: the Stroke Impact Scale (SIS), Canadian Occupational Performance Measure (COPM), and Performance Quality Rating Scale (PQRS).Results: Forty-four participants were randomized. The COSTAR group had an attrition rate of 50% and an average of 9.8 of 12 sessions were completed; the TST group had an attrition rate of 25% and an average of 10.7 sessions were completed. Generally both groups improved on the majority of primary and secondary outcomes. There is little evidence to support a beneficial effect of COSTAR over TST for improvement of primary measures of activity performance or secondary measures.Conclusion: Negligible findings may be attributed to an inadvertent treatment group equivalency. Further, the research design did not allow for adequate measurement of the effect of each intervention on participants' ability to generalize learned skills.Implications for rehabilitationStroke rehabilitation is largely based upon the principles of task-specific training, which is associated with improvements in upper extremity motor performance; however, TST requires a heavy dosage and lacks generalization to untrained activities.Cognitive strategy use has been associated with improved generalization of treatment to untrained activities and novel contexts however, it is often not used in TST protocols.The results of this preliminary study found no clear advantage between task-specific training and strategy-adapted task-specific training on trained and untrained activities when both interventions targeted activity performance.Task-specific training, if focused at the activity performance level rather than the impairment reduction level, may have a stronger effect on improving in individual's ability to participate in everyday life activities even without the use of cognitive-strategies.Incorporating cognitive strategy-use into TST would likely produce the greatest effect on generalization and transfer of the treatment effects to other activities and contexts rather than solely on activity performance of trained activities.

A Proof-of-Concept Investigation of an Energy Management Education Program to Improve Fatigue and Life Participation in Adults on Chronic Dialysis.

BACKGROUND: Fatigue and its negative impact on life participation are top research priorities of people on chronic dialysis therapy. Energy management education (EME) is a fatigue management approach that teaches people to use practical strategies (eg, prioritizing, using efficient body postures, organizing home environments) to manage their energy expenditure during everyday life. OBJECTIVE: The aim of this study is to explore whether EME is associated with improvements in fatigue and life participation in adults on chronic dialysis. DESIGN: Five single-case interrupted time-series AB studies, and follow-up qualitative interviews. SETTING: The hemodialysis and peritoneal dialysis units at an academic hospital in Toronto, Canada. PATIENTS: In total, 5 patients on chronic dialysis therapy were purposively selected to represent diversity in age, gender, and modality. MEASUREMENTS: Brief questionnaires assessing fatigue and life participation were administered weekly during the baseline and intervention periods. Additional validated questionnaires (the Fatigue Impact Scale, 36-Item Short-Form Health Survey [SF-36] Vitality Scale, and Canadian Occupational Performance Measure) were also administered at baseline and post-intervention. METHODS: All participants underwent "The PEP Program," a personalized, web-supported EME program designed to meet the needs of people on dialysis. During the program, participants complete 2 brief web modules about energy management, and then use energy management principles and a problem-solving framework to work on 3 life participation goals during sessions with a trained program administrator. Data were analyzed using visual analysis and the Tau-U statistic for the weekly time-series data, and thematic analysis for the qualitative interviews. RESULTS: Three of 5 participants displayed a consistently positive response to the Personal Energy Planning (PEP) program across multiple measures of fatigue and life participation. Tau-U effect size estimates ranged from small to moderate, according to the time-series data. All 5 participants expressed that the program had benefited them in qualitative follow-up interviews, with the most common reported benefit being that the program made day-to-day activities easier. The format of the program was also said to be feasible and convenient. LIMITATIONS: An exploratory, proof-of-concept study that used a small set of participants and lacked an active control comparison. CONCLUSIONS: The PEP program might have potential for improving fatigue-related outcomes in people on chronic dialysis. Larger, controlled studies of the program are warranted.

CONTEXTE: La fatigue et les effets négatifs qu'elle entraîne sur la participation à la vie constituent les principales priorités de recherche des personnes suivant un traitement de dialyse chronique. L'éducation à l'économie d'énergie, qui sensibilise les patients à des stratégies concrètes (priorisation, adoption de postures plus ergonomiques, organisation de l'environnement de vie) pour réduire leurs dépenses énergétiques au quotidien, est l'approche préconisée pour gérer la fatigue. OBJECTIF: Examiner l'association entre la sensibilisation à une bonne gestion de l'énergie et une amélioration de la fatigue et de la participation à la vie chez des adultes suivant des traitements de dialyse chronique. TYPE D'ÉTUDE: Cinq études chronologiques interrompues de type AB à cas unique, et entretiens de suivi qualitatif. CADRE: Les unités d'hémodialyse et de dialyse péritonéale d'un hôpital universitaire de Toronto (Canada). SUJETS: Des patients (n = 5) suivant des traitements de dialyse chronique sélectionnés à dessein pour être représentatifs de la diversité d'âges, de genres et de modalités. MESURES: Pendant la phase initiale et la période d'intervention, de courts questionnaires évaluant la fatigue et la participation à la vie, de même que des questionnaires validés supplémentaires (Fatigue Impact Scale, SF-36 Vitality Scale et Mesure canadienne du rendement occupationnel), ont été soumis chaque semaine aux patients. MÉTHODOLOGIE: Tous les participants ont suivi le « Programme d'éducation prédialyse ¼ (PEP), un programme en ligne d'éducation à la bonne gestion de l'énergie, adapté aux besoins des patients dialysés. Au cours du programme, les participants devaient compléter deux courts modules, puis intégrer les principes de gestion de l'énergie et un cadre de résolution de problèmes afin de travailler sur trois objectifs de participation à la vie au cours de séances avec un administrateur de programme formé. Les données ont été traitées avec l'analyse visuelle. La statistique Tau-U a été employée pour les séries hebdomadaires de données chronologiques et une analyse thématique pour les entretiens qualitatifs. RÉSULTATS: Trois des cinq participants ont réagi de façon positive et constante au PEP pour différentes mesures de fatigue et de participation à la vie. Selon les données des séries chronologiques, les estimations de la taille de l'effet Tau-U variaient de faible à modérée. Lors des entretiens de suivi qualificatif, tous les participants ont mentionné que le programme leur avait été bénéfique; le bienfait le plus souvent cité étant que celui-ci avait facilité leurs activités quotidiennes. Les participants ont également jugé le format du programme pratique et réalisable. LIMITES: Il s'agit d'une étude exploratoire visant une preuve de concept dont l'échantillon est faible et n'a pas fait l'objet d'une comparaison avec un contrôle actif. CONCLUSION: Le programme d'éducation prédialyse a le potentiel d'améliorer la qualité de vie des personnes sous dialyse chronique en les aidant à mieux gérer la fatigue. L'évaluation du programme requiert des études contrôlées de plus grande envergure.

Does training in a top-down approach influence recorded goals and treatment plans?

BACKGROUND.: Five stroke rehabilitation teams were supported in the implementation of Cognitive Orientation to daily Occupational Performance (CO-OP) as part of a knowledge translation (KT) project called CO-OP KT. Medical record auditors noted there was occasionally a disconnect between client goals and treatment plans, revealing a need to better understand the characteristics of each and their relationship to each other. PURPOSE.: This study aimed to examine the characteristics of goals and treatment plans in occupational therapy before and after CO-OP KT. METHOD.: A descriptive secondary analysis of medical record data was employed. FINDINGS.: Post intervention, there was a change in goal specificity (p = .04) and therapist-client goal alignment (p = .05). Occupation-based goals were often paired with a bottom-up, impairment-based treatment. Top-down treatments, when present, lacked the same detail given to bottom-up plans. IMPLICATIONS.: CO-OP KT seemed to lead to more specific goals, but matching top-down treatment plans were not found.

The implications of the Canadian Stroke Best Practice Recommendations for design and allocation of rehabilitation after hospital discharge: a problematization.

Introduction: Implementation of the Canadian Stroke Best Practice Recommendations has improved inpatient rehabilitation. As attention is turned to the design and allocation of rehabilitation after hospitalization, examination of their implications for post-discharge rehabilitation could help optimize service planningMethods: Critical discourse analysis modeled on Alvesson and Sandberg's method of problematization was conducted to determine how the Canadian Stroke Best Practice Recommendations envision and shape post-discharge rehabilitation, and identify any tensions and potential ways to resolve them.Results: Within the Canadian Stroke Best Practice Recommendations post-discharge rehabilitation is implicitly viewed as a continuation of inpatient rehabilitation. Rehabilitation is largely envisioned as a set of biomedical procedures aimed at normalization through correction of impairment. There is potential tension between this implicit goal and the explicit goal of providing patient and family-centered care and promoting reengagement in valued activities and roles.Conclusion: An alternate vision of post-discharge rehabilitation could help resolve this tension. Post-discharge rehabilitation could be envisioned as a self-management intervention. Rather than primarily an expert-driven process of measuring impairment and applying procedures aimed at normalization, rehabilitation would be considered facilitation of self-management with the goal of reengaging in forms of participation that comprise a satisfying life.Implications for RehabilitationImplicit assumptions within best practice guidelines powerfully influence recommendations. These ideas are difficult to examine because they seem self-evident.Implicit assumptions in the Canadian Stroke Best Practice Guidelines envision post-discharge stroke rehabilitation as an expert-driven, impairment-focused biomedical procedure.This biomedical image makes it difficult to provide care that meets the guideline's explicit goals of client- and family-centeredness.Reimagining post-discharge stroke rehabilitation as a chronic self-care management intervention aimed at developing a satisfying life after stroke could improve patient care.

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.