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.

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

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

Exploring the feasibility of videoconference delivery of a self-management program to rural participants with stroke.

Moving On after STroke (MOST(R)) is a multimodal, psycho-educational, and exercise self-management program for people with stroke and their caregivers. The objective of this study was to explore the feasibility of videoconference delivery to rural communities. Seven participants, their caregivers, and two facilitators formed one group, located in an urban center. Five participants and their caregivers from two remote locations were connected by videoconference. Feasibility was assessed by examining recruitment and attendance rates; program adaptations; and participant, facilitator, and staff perceptions. Data sources included logs, surveys, focus groups, and interviews. To examine preliminary outcomes, goal attainment, balance, mood, participation, and walking endurance were measured pre-, post-, and 3 months following intervention. Twelve participants were recruited in 3 weeks. Attendance rates were 89.8% for the local group and 70.4% for the remote group. Program adaptations, facilitation strategies, and involvement of onsite support promoted the success of the videoconference delivery. Participants reported that the program provided people with stroke as well as caregivers with greater awareness of stroke, increased social support, and improved ability to cope. They reported a decrease in loneliness by sharing with others in a similar situation, even if they were in a different community. Pre-post improvements were seen in goal setting, mood, balance, balance confidence, and walking endurance. Videoconferencing is a feasible method for the dissemination of the MOST program to rural areas. This form of delivery is associated with improvements in goal achievement, mood, balance, and endurance, and is well received by all participants.

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

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

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

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

Exploring the feasibility and efficacy of a telehealth stroke self-management programme: a pilot study.

PURPOSE: Moving On after STroke (MOST) is an established self-management programme for persons with stroke and their care partners. Through 18 sessions over 9 weeks, each including discussion and exercise, participants learn about goal-setting, problem-solving, exercise, and community-reintegration skills. This study was undertaken to evaluate the feasibility and efficacy of telehealth delivery of MOST. METHOD: Efficacy was evaluated using an experimental non-randomized trial comparing a telehealth MOST intervention group (T-MOST) (n = 10) with a waiting list control group (WLC) (n = 8). Outcome measures included the Berg Balance Scale (BBS), the Reintegration to Normal Living Index, the Stroke-Adapted Sickness Impact Profile, Goal Attainment Scaling, and the Geriatric Depression Scale. The feasibility evaluation included attendance rates, focus groups, and facilitator logs. In MOST Telehealth, one co-facilitator was local and the other was connected by videoconference. RESULTS: Attendance rates for persons with stroke (83.9%, SD = 2.6) and care partners (76.7%, SD = 2.9) and participant and facilitator experiences indicated feasibility of this mode of programme delivery. There was a significant difference in BBS scores between the T-MOST group and the WLC group (mean difference -4.27, 95%CI: -6.66 to -1.87). Participants reported additional benefits, including increased motivation and awareness of partners' needs. Videoconferencing was reported to decrease their sense of isolation. CONCLUSION: It appears feasible to deliver the MOST programme with two facilitators, one connected by videoconference and one in person. In addition, preliminary evidence suggests that the programme is associated with improved well-being in persons with stroke and their care partners. Practitioners delivering self-management programmes may consider wider dissemination using videoconferencing.

Implementation, process, and preliminary outcome evaluation of two community programs for persons with stroke and their care partners.

PURPOSE: This evaluation compared a new self-management program with land and water exercise (Moving On after STroke or MOST) to a standard education program (Living with Stroke or LWS). PARTICIPANTS: Of 30 persons with stroke (average age 68 and 2 years post stroke), 18 selected MOST and 12 chose LWS. Sixteen care partners participated. METHOD: Assessments at baseline, program completion, and 3-month follow-up included the Reintegration to Normal Living (RNL) Index, Activity-specific Balance Confidence (ABC) scale, exercise participation, and goal attainment (for the MOST group). Program delivery costs were calculated and focus groups conducted to examine participant expectations and experiences. RESULTS: Social support was an important benefit of both programs, but only MOST participants improved significantly on the RNL (p < .05) and ABC (p < .001). Seventy-eight percent of all short-term personal goals in MOST were achieved, and overall goal attainment was above the expected level. At follow-up, a higher percentage of MOST participants were enrolled in exercise programs (p < .05). CONCLUSION: Although self-management programs with exercise are more costly to deliver than standard educational programs, these preliminary results indicate that such programs may be more effective in helping persons with stroke and care partners deal with the challenges of living with stroke.

Theory-based programme development and evaluation in physiotherapy.

PURPOSE: Programme evaluation has been defined as "the systematic process of collecting credible information for timely decision making about a particular program." Where possible, findings are used to develop, revise, and improve programmes. Theory-based programme development and evaluation provides a comprehensive approach to programme evaluation. SUMMARY OF KEY POINTS: In order to obtain meaningful information from evaluation activities, relevant programme components need to be understood. Theory-based programme development and evaluation starts with a comprehensive description of the programme. A useful tool to describe a programme is the Sidani and Braden Model of Program Theory, consisting of six programme components: problem definition, critical inputs, mediating factors, expected outcomes, extraneous factors, and implementation issues. Articulation of these key components may guide physiotherapy programme implementation and delivery and assist in the development of key evaluation questions and methodologies. Using this approach leads to a better understanding of client needs, programme processes, and programme outcomes and can help to identify barriers to and enablers of successful implementation. Two specific examples, representing public and private sectors, will illustrate the application of this approach to clinical practice. CONCLUSIONS: Theory-based programme development helps clinicians, administrators, and researchers develop an understanding of who benefits the most from which types of programmes and facilitates the implementation of processes to improve programmes.