An Investigation of Occupational Therapists' and Physical Therapists' Perspectives on the Process of Change That Occurs among Clients during Rehabilitation, Including Their Use of Response Shift and Transformative Learning.

Purpose: A significant change in one's health status creates a process of change that has an impact on one's health-related quality of life. This process has been conceptualized in several theories, including response shift (RS) and transformative learning (TL). The purpose of this study was to investigate occupational therapists' and physical therapists' perspectives on the process of change that occurs in clients during rehabilitation. Method: An interpretive description approach guided this study. Five profession-specific focus groups were conducted. Participants were asked about their ideas, thoughts, and understanding of processes of change. Focus group discussions were recorded and transcribed. Data analysis was carried out using both inductive and deductive methods. Results: Participants were 14 physiotherapists and nine occupational therapists with 5-30 years of experience in rehabilitation settings. Participants recognized personal change in clients and noted that it involves many steps. They tried to facilitate this change by identifying signs of readiness. Without using theory-specific terminology, participants described observing and using concepts of RS and TL. Conclusions: Occupational therapists and physiotherapists play an important role in helping people learn to live with their chronic illnesses and disabilities. Further studies are needed to investigate how therapists can facilitate the process of change, including using RS and TL concepts and how this facilitation could improve clients' health-related quality of life.

Objectif : une modification importante à l'état de santé crée un processus de changement qui influe sur la qualité de vie liée à la santé. Ce processus a été conceptualisé à l'aide de plusieurs théories, y compris le changement de réponse (CR) et l'apprentissage transformationnel (AT). La présente étude vise à explorer le point de vue des ergothérapeutes et des physiothérapeutes à l'égard du processus de changement observé chez les clients pendant la réadaptation. Méthodologie : les chercheurs de la présente étude ont adopté une approche descriptive et interprétative. Ils ont organisé cinq groupes de travail propres aux professions. Ils ont invité les participants à confier leurs idées, leurs réflexions et leur compréhension des processus de changement. Ils ont enregistré et transcrit les discussions des groupes de travail et procédé à l'analyse des données par des méthodes inductives et déductives. Résultats : quatorze physiothérapeutes et neuf ergothérapeutes ayant de cinq à trente ans d'expérience en réadaptation ont participé à l'étude. Ils constataient des changements personnels chez les clients, qui se faisaient en plusieurs étapes. Ils tentaient de les faciliter en repérant les signes de réceptivité. Sans utiliser de terminologie théorique, ils ont décrit avoir observé et utilisé les concepts de RC et d'AT. Conclusions : les ergothérapeutes et les physiothérapeutes jouent un rôle important pour aider les gens à vivre avec leurs maladies et incapacités chroniques. D'autres études s'imposent pour explorer comment les thérapeutes peuvent faciliter un processus de changement, y compris le recours aux concepts de RC et d'AT, et établir en quoi cette facilitation peut améliorer la qualité de vie liée à la santé des clients.

Occupational Performance Coaching for Stroke Survivors: A Pilot Randomized Controlled Trial.

OBJECTIVE: We examined the feasibility of study procedures and explored the potential efficacy of Occupational Performance Coaching for stroke survivors (OPC-Stroke), an intervention designed to improve participation after stroke. METHOD: In this pilot randomized controlled trial, 21 participants were randomized to receive the intervention or usual care. Recruitment, retention, and outcome completion rates were calculated. Direction of change and effect sizes were examined for the outcomes of participation, goal performance and satisfaction, goal self-efficacy, emotional well-being, and cognition. RESULTS: Rates of recruitment (66%) and retention (81%) were satisfactory. Participation scores improved for both groups with different trajectories. Results showed a moderate effect of OPC-Stroke for goal performance (η²partial d = .075) and satisfaction (η²partial d = .078) and a large effect for cognition (η²partial d = .167). Other outcome measures did not change as expected. CONCLUSION: Study procedures were generally feasible. Preliminary findings support testing to examine the efficacy of OPC-Stroke.

Very low neighbourhood income limits participation post stroke: preliminary evidence from a cohort study.

BACKGROUND: Neighbourhood income level is associated with the incidence of stroke and stroke-related mortality. It has also been linked to receipt of appropriate services, post discharge motor recovery and functional status following a stroke. We examined the impact of neighbourhood income on participation among community-dwelling stroke survivors during the two years following the stroke. METHODS: Secondary analysis of data from a prospective cohort study. Participants were 67 individuals who were treated in acute care or rehabilitation following a first ever stroke, and were discharged to the community with FIM™ scores of at least 3 for comprehension, memory and problem solving. On this functional independence measure, these scores indicate that assistance is needed with related tasks up to 50 % of the time. Participation at 6, 9, 12, 18 and 24-months post stroke was measured using the Reintegration to Normal Living Index (RNLI). Income was measured by median neighbourhood annual family income according to postal code. The impact of very low neighbourhood income (median family income $20,000 Cdn or less) on participation at each follow-up period was determined controlling for potential confounders. RESULTS: Six (9.0 %) of the participants lived in very low-income neighbourhoods. These participants had average RNLI scores approximately 25 % lower at each follow-up period. While there was a trend for increasing participation with time among those in higher income neighbourhoods, this was not seen among very low-income neighbourhood participants. Very low me neighbourhood income had an independent effect on participation after controlling for discharge FIM™, 2-min walk test, gender, self-rated health, age, and emotional well-being at all follow-up periods. CONCLUSIONS: Our results indicate that very low neighbourhood income is linked with decreased participation during the first two years following stroke. Our findings indicate the need for further investigation of this relationship, and the importance of close follow-up of stroke survivors living in very low-income contexts.

Health services for linguistic minorities in a bilingual setting: challenges for bilingual professionals.

We explore in this qualitative research the challenges faced by bilingual health and social services professionals in a Canadian bilingual setting, as well as the strategies used to overcome them. Eight focus groups were conducted with a total of 43 bilingual Francophone professionals who offered services in French in 21 health and social service organizations in eastern Ontario, Canada. We highlight linguistic issues affecting a minority Francophone clientele, the shortage of services in French, and organizational issues within these agencies. The solutions that the professionals adopt for better serving the clients and overcoming these challenges focus on adapting services from linguistic angles. In the long term, such an enhanced approach can affect staff well-being. Ensuring access to services for linguistic minority populations and the active offer of same should not rest solely on the shoulders of such professionals, but rather on organizational strategies.

Participation and well-being poststroke: evidence of reciprocal effects.

OBJECTIVE: To explore reciprocal effects between participation and emotional and physical well-being during the first 2 years poststroke. DESIGN: Prospective cohort study. SETTING: Community. PARTICIPANTS: An inception cohort of adults (N=67) who had been discharged from an acute stroke unit or stroke rehabilitation unit after a first stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participation (Reintegration to Normal Living Index), emotional well-being (General Well-being Schedule), and physical well-being (General Self-rating of Health Question) were measured at 6, 9, 12, 18, and 24 months poststroke. Hierarchical linear modeling was used to examine the association between participation and change in well-being, controlling for sex, age, impairment (discharge FIM), and median neighborhood income. RESULTS: Greater engagement in valued activities was significantly associated with subsequent improvement in emotional well-being. The effect of participation on change in physical well-being was marginal. Higher levels of well-being also predicted subsequent increases in participation, with emotional well-being effects moderated by income, and physical well-being effects moderated by level of impairment. CONCLUSIONS: Our results support a 2-pronged approach to addressing well-being poststroke where efforts to improve affect and boost participation are simultaneously applied.

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.

Transformative occupational therapy: We are wired to be transformers.

BACKGROUND: Transformative learning involves critical self-reflection as the motor for transforming values, beliefs, knowledge, and feelings and discovering the new meaning of daily life following a catastrophic injury or illness. Transformation has been conceptualized in various disciplines as a transcendent experience, rebirth process, and meaning-making process and within occupational therapy as a meaning perspective process. PURPOSE: This Muriel Driver lecture explores the concept of transformation and presents the newly developed Meaning Perspectives Transformation model, constructed from research conducted with several different rehabilitation client groups. KEY ISSUES: The model is characterized by three phases: trigger, changing, and outcomes. A client's critical self-reflection acts as a catalyst for moving between the phases and is represented in the model as a moment of readiness for change leading to the development of alternative ways of performing. IMPLICATIONS: The Meaning Perspectives Transformation model provides a tool for being an effective occupational therapist, encouraging therapists to listen closely to their clients to identify their weakening and emerging meaning perspectives and enable their occupational evolution and transformation.

Adaptation following stroke: a personal projects analysis.

OBJECTIVES: Assessment of adaptation following stroke has tended to focus either on acceptance of disability or global indicators of well-being. People with stroke, however, tend to view adaptation in terms of reengagement with personally valued activities. We model the adaptation process by assessing change in importance, control, stress, challenge, pleasure, support and self-identification of personal projects (i.e., one's current activities such as work, leisure, and recreational activities) from prestroke to 24 months poststroke. METHOD: Personal projects, general health, and general well-being were assessed via interviews with a sample of 67 community-residing stroke survivors (39 male; mean age = 64.7 years, SD = 13.2) on five occasions over the first 24 months poststroke. RESULTS: Multilevel (hierarchical) modeling of the longitudinal data indicates that project dimensions of Control, Stress, Challenge, Pleasure, and Support predict well-being in expected ways. Although projects at 6 months poststroke were rated as more important, stressful, challenging, and supported by others and less controllable and pleasurable than prestroke projects, by 12 to 18 months all project ratings had returned to prestroke levels, thereby suggesting successful adaptation. CONCLUSIONS/IMPLICATIONS: Longitudinal analysis of survivors' participation in valued activities poststroke revealed a pattern of adaptation that relates to but goes beyond that suggested by global measures of health, functioning, and well-being. The focus on adaptation of personal projects or valued activities may provide a helpful way of examining and improving well-being poststroke and offer new insights to inform the development of effective interventions for improving well-being following stroke. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

The process of re-engagement in personally valued activities during the two years following stroke.

PURPOSE: Engagement in valued activities is often difficult for people who have experienced stroke. A deeper understanding of the process of re-engagement in personally valued activities would be helpful to those designing interventions to address participation post-stroke. METHOD: Six community-dwelling individuals recovering from a first stroke were interviewed at 6, 9, 12, 18 and 24 months post-stroke. A grounded theory approach was used to construct a substantive theory of re-engagement in valued activities during this period. RESULTS: Two core concepts, social connection and being in charge were identified. Both led to activity engagement and risk taking to test abilities. These led to lowering of current expectations and activity adaptation which supported hope for recovery and further testing. Alternatively, difficulties perceived to be related to ageing led to disengagement. CONCLUSIONS: Rehabilitation practice that addresses and supports autonomy, social connection, risk taking, adaptation and hope among stroke survivors may help individuals regain personally valued activities post-stroke.

Acceptance of chronic neuropathic pain in spinal cord injured persons: a qualitative approach.

Chronic neuropathic pain (CNP) in spinal cord injury (SCI) is a significant problem that has physical, functional, and psychosocial repercussions beyond the consequences of SCI. The notion that acceptance may be a viable alternative to suffering when resolution of pain is unattainable was explored. Studies indicate that acceptance of pain is associated with lower pain intensity, less pain-related anxiety and avoidance, less depression, less physical and psychosocial disability, more daily active time, and improved work status in patients who have other types of chronic pain. This exploratory qualitative study examined acceptance of pain in SCI individuals who have CNP. Grounded theory was used to develop a conceptual framework to describe acceptance in people with CNP and SCI. Data were obtained from in-depth interviews with seven SCI individuals. Six phases were identified, including: "comprehending the perplexity of CNP," "seeking pain resolution," "acknowledging pain permanence," "redefining core values," "learning to live with the pain," and "integrating pain." Two driving forces, "increasing independence" and "evolving pain view," were noted to move the process of acceptance forward. The findings in this study suggest that acceptance of pain appeared to be beneficial in terms of reducing suffering and facilitating a more satisfying and fulfilling life in these SCI individuals. A decreased emphasis on continued searching for a cure for CNP and movement toward a self-management approach was associated with increased pain coping for these SCI individuals. Clinical implications suggest that early intervention to facilitate effective coping and an exploration of the notion of acceptance could be beneficial.

Building on transformative learning and response shift theory to investigate health-related quality of life changes over time in individuals with chronic health conditions and disability.

A major goal of treatment for people living with chronic illness or disability is self-management leading to optimized health-related quality of life. This change process has been described in the adult education literature as transformative learning, while in health-related quality of life research, response shift has emerged as a key concept. Response shift and transformative learning literature were reviewed, and the theoretical frameworks of the 2 concepts were compared and contrasted. Response shift is described as a change in internal standards, values, or definition of a construct (eg, health-related quality of life) over time, commonly seen in individuals with chronic illness. In the context of chronic illness, transformative learning is described as a complex process of personal change including beliefs, feelings, knowledge, and values. Transformative learning is often triggered by the diagnosis of a chronic illness. This results in a critical reflection of taken-for-granted assumptions and leads to new ways of thinking, influencing personal changes in daily living. Comparing the models of response shift and transformative learning in chronic illness, the catalyst in response shift appears comparable with the trigger in transformational learning; mechanisms to process of changing; and perceived quality of life to outcomes. Both transformative learning and response shift have much to offer health care providers in understanding the learning process for the person living with chronic illness or disability to optimize their quality of life. Suggestions for future research in response shift and transformative learning in individuals with chronic health conditions and disability are proposed.

Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.

BACKGROUND AND PURPOSE: The objective of this review was to construct an updated evidence-based clinical practice guideline on the use of physical activity and diet for the management of osteoarthritis (OA) in adults (>18 years of age) who are obese or overweight (body mass index ≥25 kg/m(2)). DATA SOURCES: Articles were extracted from the following databases: MEDLINE, EMBASE (Current Contents), SPORTDiscus, SUM, Scopus, CINAHL, AMED, BIOMED, PubMed, ERIC, the Cochrane Controlled Trials, and PEDro. STUDY SELECTION: The Ottawa Panel and research assistance team strictly applied the inclusion and exclusion criteria from previous Ottawa Panel publications. DATA EXTRACTION: An a priori literature search was conducted for articles related to obesity and OA of the lower extremities that were published from January 1, 1966, to November 30, 2010. Inclusion criteria and the methods to grade the recommendations were created by the Ottawa Panel. RECOMMENDATIONS: were graded based on the strength of evidence (A, B, C, C+, D, D+, or D-) as well as experimental design (I for randomized controlled trials and II for nonrandomized studies). In agreement with previous Ottawa Panel methods, Cochrane Collaboration methods were utilized for statistical analysis. Clinical significance was established by an improvement of ≥15% in the experimental group compared with the control group. There were a total of 79 recommendations from 9 articles. From these recommendations, there were 36 positive recommendations: 21 grade A and 15 grade C+. There were no grade B recommendations, and all recommendations were of clinical benefit. LIMITATIONS: Further research is needed, as more than half of the trials were of low methodological quality. CONCLUSIONS: This review suggests that physical activity and diet programs are beneficial, specifically for pain relief (9 grade A recommendations) and improved functional status (6 grade A and 7 grade C+ recommendations), for adults with OA who are obese or overweight. The Ottawa Panel was able to demonstrate that when comparing physical activity alone, diet alone, physical activity combined with diet, and control groups, the intervention including physical activity and diet produced the most beneficial results.

A model of the process of transformation in primary care for people living with chronic illnesses.

OBJECTIVES: The objective of the research was to construct a conceptual framework that explains the process of personal transformation within a primary care context for people living with chronic illnesses. METHODS: A literature search of articles published from 1990 to 2007 in CINAHL, ERIC, Healthstar, MEDLINE, PsycINFO, dissertation abstracts and SocINFO databases, was conducted to identify qualitative research studies investigating personal change in chronic illness or disability. Five hundred and fifty-six articles were identified; the researchers conducted a metasynthesis of a subgroup of these articles whose focus was on transformation in primary care (n = 5). RESULTS: The metasynthesis project presents a model of the conceptualizations of transformation. Transformation in chronic illness is presented as a process of learning about self and the chronic illness in an iterative and continually changing manner. The primary care context has its greatest influence on critical reflection, which occurs in the first phase (initial response). DISCUSSION: This model illustrates the complex processes that occur for someone living with a chronic illness. Health practitioners who understand why and how people transform in living with chronic illnesses will be able to apply this model in determining people's needs and how to assist people during the transformative process.

Meaning perspective transformation following stroke: the process of change.

PURPOSE: Transformative Learning in an educational theory that posits that individuals learn and grow when their meaning perspectives (frames of reference for interpreting an experience based on knowledge, feelings, values and beliefs) are reformulated following a critical event. This theory has become quite influential in the exploration of adaptation to chronic illness. This study explored whether the change that occurs following stroke follows a process similar to transformative learning. METHOD: Grounded Theory approach was used to explore changes in meaning perspective among 12 people who were members of stroke support organisations, had a stroke at least 1 year prior to the study and described themselves as viewing life positively following stroke. Constant comparison analysis of interviews with these individuals was used to explore their experience following stroke. RESULTS: Meaning perspective transformation occurred with four factors contributing to transformation: triggers, support, knowledge and choices to action. A substantive grounded theory of the process of meaning perspective transformation following stroke is presented, which illustrates the interaction of these contributing factors in initiating and facilitating the transformation process. CONCLUSION: Transformative learning can offer insight into how people who have experienced stroke learn, rebuild competence and re-engage in valued activities.

Ottawa Panel evidence-based clinical practice guidelines for aerobic fitness exercises in the management of fibromyalgia: part 1.

BACKGROUND AND PURPOSE: The objective of this study was to create guidelines for the use of aerobic fitness exercises in the management of adult patients (>18 years of age) with fibromyalgia, as defined by the 1990 American College of Rheumatology criteria. METHODS: Following Cochrane Collaboration methods, the Ottawa Methods Group found and synthesized evidence from comparative controlled trials and formed the Ottawa Panel, with nominated experts from key stakeholder organizations. The Ottawa Panel then developed criteria for grading the recommendations based on experimental design (I for randomized controlled trials, II for nonrandomized studies) and strength of evidence (A, B, C+, C, D+, D, or D-). From the rigorous literature search, 13 randomized control trials and 3 controlled clinical trials were selected. Statistical analysis was based on Cochrane Collaboration methods. Continuous data were calculated with weighted mean differences between the intervention and control groups, and dichotomous data were analyzed with relative risks. Clinical improvement was calculated using absolute benefit and relative difference in change from baseline. Clinical significance was attained when an improvement of 15% relative to a control was found. RESULTS: There were 24 positive recommendations: 10 grade A, 1 grade B, and 13 grade C+. Of these 24 positive recommendations, only 5 were of clinical benefit. DISCUSSION AND CONCLUSION: The Ottawa Panel recommends aerobic fitness exercises for the management of fibromyalgia as a result of the emerging evidence (grades A, B, and C+, although most trials were rated low quality) shown in the literature.

Ottawa Panel evidence-based clinical practice guidelines for strengthening exercises in the management of fibromyalgia: part 2.

BACKGROUND AND PURPOSE: The objective of this study was to create guidelines for the use of strengthening exercises in the management of adult patients (>18 years of age) with fibromyalgia (FM), as defined by the 1990 American College of Rheumatology criteria. METHODS: Following Cochrane Collaboration methods, the Ottawa Methods Group found and synthesized evidence from comparative controlled trials and formed the Ottawa Panel, with nominated experts from key stakeholder organizations. The Ottawa Panel then developed criteria for grading the recommendations based on experimental design (I for randomized controlled trials, II for nonrandomized studies) and strength of evidence (A, B, C+, C, D+, D, or D-). From the rigorous literature search, 5 randomized controlled trials were selected. Statistical analysis was based on Cochrane Collaboration methods. Continuous data were calculated with weighted mean differences between the intervention and control groups, and dichotomous data were analyzed with relative risks. Clinical improvement was calculated using absolute benefit and relative difference in change from baseline. Clinical significance was attained when an improvement of 15% relative to a control was found. RESULTS: There were 5 positive recommendations: 2 grade A and 3 grade C+. All 5 were of clinical benefit. DISCUSSION AND CONCLUSION: The Ottawa Panel recommends strengthening exercises for the management of fibromyalgia as a result of the emerging evidence (grades A, B, and C+, although most trials were rated low quality) shown in the literature.

Occupational performance modification and personal change among clients receiving rehabilitation services for rheumatoid arthritis.

BACKGROUND: A client's personal process of change is recognised as an important element in the rehabilitation process that may affect the acceptance and outcome of recommended occupational therapy self-management interventions. Recent research has examined the transformative process of changing underlying values, beliefs, feelings and knowledge, collectively known as meaning perspectives, in clients receiving rehabilitation for various chronic conditions. AIM/METHODS: This article presents the findings of a Grounded Theory Qualitative retrospective study of 10 adults diagnosed with rheumatoid arthritis receiving occupational therapy to modify their daily living environment and activities to maximise the quality of life and occupational performance. They were interviewed twice in a semidirected manner. RESULTS: Two personal change processes were identified for two different courses of the illness: progressive adaptation during a course of gradual steady development of symptoms without remission, and complex adaptation that led to transformation during a course of acute development of symptoms with periods of remission. CONCLUSION: Implications for more effective and efficient occupational therapy interventions are suggested.

Exploring the impact of a new translation process on the performance of French form writers of the Canadian Certification Exam.

BACKGROUND: In an effort to ensure fairness to French form writers of the Canadian Certification Exam, CAOT instituted a new translation process in 2000. PURPOSE: To determine the impact of this new translation process on the performance of French form writers of the Canadian Certification Exam. METHODS: Average test scores and proportion of unsuccessful candidates were examined between 1986 and 2004 by the language in which the test was administered. FINDINGS: While changes in results for French form writers were observed over the follow-up period, these corresponded to a time before the translation changes were introduced. IMPLICATIONS: The new translation process did not appear to have an impact on the results of French form writers. Further work is recommended to examine and address other potential causes of discrepancies between French and English form writers.

The process of change: listening to transformation in meaning perspectives of adults in arthritis health education groups.

PURPOSE: This study explored client experiences in two different arthritis education groups to develop an understanding of meaningful group experiences in the process of change leading to desired health outcomes. METHOD: A qualitative framework with an inductive, descriptive, phenomenological method guided the study. Ten participants with rheumatoid or inflammatory arthritis were recruited. Individual and focus group interviews provided descriptions of experiences. RESULTS: Arthritis education group experiences led to improved client perceptions of ability to cope with chronic disease through a process of change in feelings, values and beliefs known as meaning perspectives. The change in meaning perspectives occurred through perceptions about disease, self and illness. PRACTICE IMPLICATIONS: This study provides important insights into the client's process of change in meaning perspectives that can lead to health behaviors and desired health outcomes. The study demonstrates the use of the group context as a tool to enable the process of change.