Utility of the Canadian Occupational Performance Measure in community-based brain injury rehabilitation

Completing an interdisciplinary outpatient intervention improves patient rehabilitation goals following a mild traumatic brain injury

BACKGROUND

Individualized and interdisciplinary rehabilitation programs are recommended following a mild traumatic brain injury (mTBI), but often have long waitlists. Accordingly, innovative evidence-based programs are needed.

OBJECTIVES

The first objective of this study was to determine the number and types of rehabilitation goals chosen by individuals completing an interdisciplinary outpatient rehabilitation intervention (BrainEx90) for persisting symptoms following an mTBI. The second objective was to investigate whether completing BrainEx90 or choosing specific types of goals influenced performance and satisfaction ratings of these goals.

METHODS

217 individuals (44.4 ± 13.5 years old) with persisting symptoms following an mTBI completed BrainEx90, a 16-session interdisciplinary group outpatient rehabilitation intervention at Parkwood Institute between November 2013 and September 2019. Performance and satisfaction ratings of self-identified goals before and after BrainEx90 were assessed using the Canadian Occupational Performance Measure, and changes in ratings were analyzed using a linear mixed effects model.

RESULTS

1008 goals were identified and categorized as: productivity (45%); leisure (37%); and self-care (18%). Satisfaction ratings were significantly higher for all goal types following BrainEx90. Satisfaction with self-care goals improved significantly more than leisure [t(151) = 3.24, p < .01] and productivity [t(144) = 2.97, p < .01] goals. Performance ratings were also significantly greater following BrainEx90 [2.4, 95% CI [2.27, 2.53], p < .01)].

CONCLUSION

Performance and satisfaction of self-identified rehabilitation goals significantly improved following BrainEx90. Satisfaction with self-care goals demonstrated the greatest improvements, yet the most identified goal type was productivity.

Occupational performance coaching for stroke survivors delivered via telerehabilitation using a single-case experimental design

INTRODUCTION

Sustaining a stroke has a devastating, long-term impact on participation in everyday life. Despite the recognition of participation as a key outcome of stroke rehabilitation, there are few effective interventions that address participation. Occupational performance coaching is a promising intervention designed to improve participation among stroke survivors. Delivery of occupational performance coaching using telerehabilitation could improve access. This study examined the feasibility, acceptability and potential efficacy of telerehabilitation occupational performance coaching.

METHOD

A single-case experimental design was used. Six community-dwelling stroke survivors received 10 sessions of telerehabilitation occupational performance coaching over 16 weeks. We examined the feasibility and acceptability of telerehabilitation occupational performance coaching, improvement in performance and satisfaction with identified goals.

RESULTS

Telerehabilitation occupational performance coaching was feasible and acceptable to deliver; participants who started the intervention completed it and reported high satisfaction and a strong therapeutic relationship. All participants experienced technological issues that required resolution. Goal-performance and/or satisfaction improved for five of six participants. Sixty-four percent of goals showed trends for improvement and 43% showed significant improvements.

CONCLUSIONS

Findings support the feasibility and acceptability of telerehabilitation occupational performance coaching, along with its efficacy for improving performance and satisfaction with performance of goals. Further research is needed to prove the effectiveness of telerehabilitation occupational performance coaching and to determine who may benefit most.

Using a wearable camera to support everyday memory following brain injury: a single-case study

Background:

Wearable cameras have been shown to improve memory in people with hippocampal amnesia and Alzheimer's disease. It is not known whether this benefit extends to people with amnesia of complex or uncertain origin.

Method:

This case study examined the effect of wearable camera use on memory and occupational performance in a patient with memory loss and complex mental health problems following a severe neurological incident. With the help of his occupational therapist (OT), Mr A used a wearable camera to record a series of eight personally significant events over a 6-week period. During visits from his OT, Mr A was asked to report what he could remember about the events, both before (baseline) and during the review of time-lapsed photographs captured automatically by the camera.

Results:

The results showed striking improvements in recall while reviewing the photographs, relative to baseline recall, but the additional details recalled during review did not appear to be maintained at later tests, after several days. Across the study period, there were moderate increases in occupational performance, measured using the Canadian Occupational Performance Measure. However, after the study period ended, Mr A ceased to use the wearable camera due to technological difficulty.

Conclusion:

There was a clear benefit of wearable camera use, but the real-world impact of the technology was limited by the complexity of the system. The results of the study are discussed alongside novel clinical insights and suggestions for developing wearable camera support systems that can be used independently by people with memory problems.

Goal-oriented cognitive rehabilitation for early-stage Alzheimer's and related dementias: the GREAT RCT

BACKGROUND

Cognitive rehabilitation (CR) is an individualised, person-centred intervention for people with mild to moderate dementia that addresses the impact of cognitive impairment on everyday functioning.

OBJECTIVES

To determine whether or not CR is a clinically effective and cost-effective intervention for people with mild to moderate Alzheimer's disease or vascular or mixed dementia, and their carers.

DESIGN

This multicentre randomised controlled trial compared CR with treatment as usual (TAU). Following a baseline assessment and goal-setting to identify areas of everyday functioning that could be improved or better managed, participants were randomised (1 : 1) via secure web access to an independent randomisation centre to receive either TAU or CR and followed up at 3 and 9 months post randomisation.

SETTING

Community.

PARTICIPANTS

Participants had an International Classification of Diseases, Tenth Edition, diagnosis of Alzheimer's disease or vascular or mixed dementia, had mild to moderate cognitive impairment (Mini Mental State Examination score of ≥ 18 points), were stable on medication if prescribed, and had a family carer who was willing to contribute. The exclusion criteria were people with a history of brain injury or other neurological disorder and an inability to speak English. To achieve adequate power, we needed 350 people to complete the trial, with 175 people in each trial arm.

INTERVENTION

Cognitive rehabilitation consisted of 10 therapy sessions over 3 months, followed by four maintenance sessions over 6 months, delivered in participants' homes. The therapists were nine occupational therapists and one nurse.

OUTCOME MEASURES

The primary outcome was self-reported goal attainment at 3 months. Goal attainment was also assessed at 9 months. Carers provided independent ratings of goal attainment at both time points. The secondary outcomes were participant quality of life, mood, self-efficacy and cognition, and carer stress, health status and quality of life. The assessments at 3 and 9 months were conducted by researchers who were blind to the participants' group allocation.

RESULTS

A total of 475 participants were randomised (CR arm, n = 239; TAU arm, n = 236), 427 participants (90%) completed the trial and 426 participants were analysed (CR arm, n = 208, TAU arm, n = 218). At 3 months, there were statistically significant large positive effects for participant-rated goal attainment [mean change in the CR arm: 2.57; mean change in the TAU arm: 0.86; Cohen'sd = 0.97, 95% confidence interval (CI) 0.75 to 1.19], corroborated by carer ratings (Cohen'sd = 1.11, 95% CI 0.89 to 1.34). These effects were maintained at 9 months for both the participant ratings (Cohen's d = 0.94, 95% CI 0.71 to 1.17) and the carer ratings (Cohen's d = 0.96, 95% CI 0.73 to 1.20). There were no significant differences in the secondary outcomes. In the cost-utility analyses, there was no evidence of cost-effectiveness in terms of gains in the quality-adjusted life-years (QALYs) of the person with dementia (measured using the DEMentia Quality Of Life questionnaire utility score) or the QALYs of the carer (measured using the EuroQol-5 Dimensions, three-level version) from either cost perspective. In the cost-effectiveness analyses, by reference to the primary outcome of participant-rated goal attainment, CR was cost-effective from both the health and social care perspective and the societal perspective at willingness-to-pay values of £2500 and above for improvement in the goal attainment measure. There was no evidence on the cost-effectiveness of the self-efficacy measure (the Generalized Self-Efficacy Scale) from either cost perspective.

LIMITATIONS

Possible limitations arose from the non-feasibility of using observational outcome measures, the lack of a general measure of functional ability and the exclusion of people without a carer or with rarer forms of dementia.

CONCLUSIONS

Cognitive rehabilitation is clinically effective in enabling people with early-stage dementia to improve their everyday functioning in relation to individual goals targeted in the therapy sessions.

FUTURE WORK

Next steps will focus on the implementation of CR into NHS and social care services and on extending the approach to people with rarer forms of dementia.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN21027481.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 10. See the NIHR Journals Library website for further project information.

Yoga improves balance, mobility, and perceived occupational performance in adults with chronic brain injury: A preliminary investigation

BACKGROUND AND PURPOSE

This was a preliminary investigation to investigate potential benefits of group yoga, as past work has indicated that one-on-one yoga can improve functional deficits in adults with brain injury.

MATERIALS AND METHODS

Participants served as their own controls. Nine participants with chronic brain injury were recruited, and seven (four female) completed the study. Performance measures of balance and mobility and self-reported measures of balance confidence, pain, and occupational performance and satisfaction were used. Data were collected 3 times: baseline (study onset), pre-yoga (after an 8-week no-contact period), and post-yoga (after 8 weeks of yoga). Group yoga was led by a yoga instructor/occupational therapist, and sessions lasted 1 h and occurred twice a week.

RESULTS

No participants withdrew due to adverse effects from yoga. There were no significant changes between baseline and pre-yoga. Significant improvement was observed post-yoga in balance (p = 0.05), mobility (p = 0.03), and self-reported occupational performance (p = 0.04).

CONCLUSION

We observed significant improvements in balance, mobility, and self-reported occupational performance in adults with chronic brain injury.

Goal statements in brain injury rehabilitation: A cohort study of client-centredness and relationship with goal outcome

Background:

Currently, there is increasing recognition of the need to use a client-centred approach to goal setting in rehabilitation. However, there is limited research to guide practice with community-dwelling clients with acquired brain injury. An understanding of the characteristics of client-centred goals and the extent to which client-centeredness influences goal outcomes is required.

Objective:

To examine the relationships between the client-centredness of goals and their characteristics, content, recall and outcomes of client-centred goals in brain injury rehabilitation.

Methods:

A prospective cohort design study was employed. Participants were 45 clients with brain injury receiving outpatient rehabilitation, who completed measures of client-centredness after goal setting. Each goal was classified according to whether it was specific, measurable, non-jargonistic, and participation-focussed, included a timeframe and was recalled by participants.

Results:

Participants set 223 goals with 20 clinicians from multiple disciplines. Levels of client-centredness did not differ according to the characteristics, content and recall of goals, with the exception of goal specificity (p< 0.01). Client-centredness was significantly and positively correlated with goal outcomes (p< 0.05).

Conclusions:

The use of client-centred goals is recommended for improved rehabilitation outcomes. Applying goal documentation criteria does not necessarily mean that goals will be client-centred, and highly specific goal statements may not reflect what is important and meaningful to clients.

Individual goal-oriented cognitive rehabilitation to improve everyday functioning for people with early-stage dementia: A multicentre randomised controlled trial (the GREAT trial)

OBJECTIVES

To determine whether individual goal-oriented cognitive rehabilitation (CR) improves everyday functioning for people with mild-to-moderate dementia.

DESIGN AND METHODS

Parallel group multicentre single-blind randomised controlled trial (RCT) comparing CR added to usual treatment (CR) with usual treatment alone (TAU) for people with an ICD-10 diagnosis of Alzheimer, vascular or mixed dementia, and mild-to-moderate cognitive impairment (Mini-Mental State Examination [MMSE] score ≥ 18), and with a family member willing to contribute. Participants allocated to CR received 10 weekly sessions over 3 months and four maintenance sessions over 6 months. Participants were followed up 3 and 9 months post randomisation by blinded researchers. The primary outcome was self-reported goal attainment at 3 months. Secondary outcomes at 3 and 9 months included informant-reported goal attainment, quality of life, mood, self-efficacy, and cognition and study partner stress and quality of life.

RESULTS

We randomised (1:1) 475 people with dementia; 445 (CR = 281) were included in the intention to treat analysis at 3 months and 426 (CR = 208) at 9 months. At 3 months, there were statistically significant large positive effects for participant-rated goal attainment (d = 0.97; 95% CI, 0.75-1.19), corroborated by informant ratings (d = 1.11; 95% CI, 0.89-1.34). These effects were maintained at 9 months for both participant (d = 0.94; 95% CI, 0.71-1.17) and informant (d = 0.96; 95% CI, 0.73-1.2) ratings. The observed gains related to goals directly targeted in the therapy. There were no significant differences in secondary outcomes.

CONCLUSIONS

CR enables people with early-stage dementia to improve their everyday functioning in relation to individual goals targeted in the therapy.

Canadian Occupational Performance Measure Supported by Talking Mats: An Evaluation of the Clinical Utility

BACKGROUND

Some clients with cognitive and communicative impairments after a brain injury are unable to participate in the Canadian Occupational Performance Measure (COPM) without support. The study originates from an assumption that some of these clients are able to participate independently in the COPM interview by using a visual material.

AIM

The aim was to investigate the clinical utility of COPM supported by Talking Mats (TM) for community-based clients with cognitive and communicative impairments.

METHODS

Six clients (51-60 years) were included. After matching the visual material of TM to COPM, the COPM interview was administered twice with an interval of 10 days, once using TM and once without. Interviews were videotaped and studied by six evaluators.

RESULTS

The most obvious benefits of using TM as a supportive tool in the COPM interview were related to the first two steps of the COPM interview.

CONCLUSION

Using TM in the COPM interview with clients with cognitive and communicative impairments after a brain injury is recommended as the basis for goal setting. The present study demonstrates a possibility to include a COPM interview to clients who had not been able to complete a COPM interview and thus start a rehabilitation process in a client-centered manner.

Effects of An Occupational Therapy Memory Strategy Education Group Intervention on Irish Older Adults' Self-Management of Everyday Memory Difficulties

An occupational therapy memory strategy education group (MSEG) was developed to assist clients with varying levels of memory impairment to adopt strategies to manage memory impairment in their daily lives. Participants were healthy older adults presenting with subjective memory complaints (SMC, n = 14), mild cognitive impairment (MCI, n = 33), or early stages of dementia (n = 13). Clients and their caregivers attended a one-hour session each week for six weeks. Outcome measures were taken at baseline, two weeks post completion of the group, and at a 3-month follow-up for 47 participants. Statistically significant improvements post-program were scored on the Rivermead Behavioural Memory Test (p = 0.001) and a dementia quality of life measure (p = 0.02), with increased use of external memory aids (p < 0.001) and significant improvements in participants' self-ratings of performance (p < 0.001) and satisfaction with their performance (p < 0.001) using the Canadian Occupational Performance Measure. Findings suggest positive outcomes that were maintained at 3-month follow-up and thus, support the role of occupational therapy in delivering occupation-focused memory strategy programs.

Survey of cognitive rehabilitation practices in the state of Kuwait

Background Rehabilitation professionals must be astute at recognizing, assessing, and treating individuals with cognitive deficits. No research is available to examine cognitive rehabilitation practices applied to individuals with neurological conditions in Kuwait.

OBJECTIVES

To identify the use of cognitive assessments, the availability of resources, and the barriers to cognitive rehabilitation practices in Kuwait. Methods Face-to-face interviews were conducted with health care professionals working with adult individuals with neurological conditions. These professionals included occupational therapists, speech-language pathologists, psychiatrists, and neurologists. Results The most commonly used cognitive based assessments are MMSE (41%), and MoCA and LOTCA (15.2%). The only clinical assessment used is the Line-Bisection Test (2.2%). The most used occupation-based assessments are FIM (6.5%), COPM (4.3%), the Interest Checklist (2.2%), and the Barthel Index (2.2%). Resources related to cognitive rehabilitation in Kuwait that are unavailable to practitioners include journal clubs (91%), special interest groups (89%), and continuing education programmes (82.6%). Barriers to cognitive rehabilitation practice included lack of sufficient funds for continuing education, lack of time, lack of standardized assessments, and lack of inter-professional teamwork. Conclusion Many adults in Kuwait live with cognitive impairment. There is a need to develop appropriate evidence-based cognitive rehabilitation clinical guidelines in Kuwait.

Development of Self-Awareness After Severe Traumatic Brain Injury Through Participation in Occupation-Based Rehabilitation: Mixed-Methods Analysis of a Case Series

OBJECTIVE. We examined participation in goal planning and development of self-awareness for people with impaired self-awareness after traumatic brain injury.

METHOD. We performed a mixed-methods study of 8 participants recently discharged from inpatient rehabilitation. Self-awareness was measured using discrepancy between self and significant other ratings on the Mayo–Portland Adaptability Index (MPAI–4) at four time points. We calculated effect size to evaluate the change in MPAI–4 discrepancy over time.

RESULTS. Seven participants identified their own goals. We found a large reduction in mean MPAI–4 discrepancy (M = 8.57, SD = 6.59, N = 7, d = 1.08) in the first 6 wk and a further small reduction (M = 5.33, SD = 9.09, N = 6, d = 0.45) in the second 6 wk of intervention. Case data indicated that 7 participants demonstrated some growth in self-awareness.

CONCLUSION. Engagement in occupation-based, goal-directed rehabilitation appeared to foster awareness of injury-related changes to varying extents.

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.

Proving the Effectiveness of Community Occupational Therapy in the Equipment and Adaptation Setting Using the Canadian Occupational Performance Measure

The Community Occupational Therapy Service (Equipment and Adaptations) at Worcestershire Health and Care National Health Service Trust, Redditch and Bromsgrove Locality identified the need to find an outcome measure that would determine its effectiveness. The Canadian Occupational Performance Measure was chosen as a client-centred, reliable, and validated outcome measure that was integrated within existing paperwork. The process followed is outlined in this practice analysis.

The service completed 1,869 Canadian Occupational Performance Measure scores, which showed a statistically significant increase in client ratings of performance and satisfaction in 90% of clients, illustrating the effectiveness of the service. The aim of this practice analysis is to explain the process that this service followed to integrate the Canadian Occupational Performance Measure into practice and, thus, share the benefit of using it as an outcome measure with colleagues who work in a similar setting. The authors highlight the importance of continuing with the Canadian Occupational Performance Measure and look to develop its use further.

The validity of occupational performance assessments: a validity generalization meta-analysis

The purpose of this meta-analysis was to determine sample weighted mean validity effect sizes for occupational performance assessments, and their generalizability from research to clinical settings. The bare-bones Validity Generalization (VG) guidelines developed by Hunter and Schmidt ( 2004 ) augmented by Maximum Likelihood (ML) procedures were used to complete the meta-analysis. The sample consisted of 27 studies in which convergent, divergent, and predictive validity estimates of occupational performance assessments were investigated. The mean coefficients of assessments validated in the studies constituting the sample for this meta-analysis ranged from medium to large. Further meta-analysis with complete dis-attenuation of observed mean validity coefficients is indicated.

Goal-oriented cognitive rehabilitation in early-stage dementia: study protocol for a multi-centre single-blind randomised controlled trial (GREAT)

Background

Preliminary evidence suggests that goal-oriented cognitive rehabilitation (CR) may be a clinically effective intervention for people with early-stage Alzheimer’s disease, vascular or mixed dementia and their carers. This study aims to establish whether CR is a clinically effective and cost-effective intervention for people with early-stage dementia and their carers.

Methods/design

In this multi-centre, single-blind randomised controlled trial, 480 people with early-stage dementia, each with a carer, will be randomised to receive either treatment as usual or cognitive rehabilitation (10 therapy sessions over 3 months, followed by 4 maintenance sessions over 6 months). We will compare the effectiveness of cognitive rehabilitation with that of treatment as usual with regard to improving self-reported and carer-rated goal performance in areas identified as causing concern by people with early-stage dementia; improving quality of life, self-efficacy, mood and cognition of people with early-stage dementia; and reducing stress levels and ameliorating quality of life for carers of participants with early-stage dementia. The incremental cost-effectiveness of goal-oriented cognitive rehabilitation compared to treatment as usual will also be examined.

Discussion

If the study confirms the benefits and cost-effectiveness of cognitive rehabilitation, it will be important to examine how the goal-oriented cognitive rehabilitation approach can most effectively be integrated into routine health-care provision. Our aim is to provide training and develop materials to support the implementation of this approach following trial completion.

Trial registration

Current Controlled Trials ISRCTN21027481

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.

Clinical Utility of the Canadian Occupational Performance Measure in Spinal Cord Injury Rehabilitation

Introduction:

Collaborative goal setting is an important part of the occupational therapy process in spinal cord injury rehabilitation. Little is known about the clinical utility of the Canadian Occupational Performance Measure (COPM) with this population, although it has potential advantages over informal methods of goal setting commonly used in a spinal injury unit (SIU). The aim of this study was to investigate the goal setting process and clinical utility of the COPM from the perspective of occupational therapists within a SIU.

Method:

A focus group was conducted with six occupational therapists working in a SIU to explore their experiences and use of goal setting and the COPM. Inductive thematic analysis identified key themes from their comments.

Findings:

Focus group themes were the impact of client adjustment and other factors, organisational and administrative factors, therapist skill level and experience requirements, benefits of the COPM and incorporating the COPM into practice.

Conclusion:

Formal goal setting was a concept that was identified as a priority by the participants; however, there were organisational, client and therapist related factors that were considered as both barriers and facilitators to formal goal setting and the use of the COPM in this setting.

Goal-oriented cognitive rehabilitation for an individual with Mild Cognitive Impairment: behavioural and neuroimaging outcomes

An individual, goal-oriented cognitive rehabilitation intervention was conducted with AB, a 77-year-old woman with MCI. Outcomes were evaluated using a client-centred measure of goal achievement and an experimental associative learning task testing a skill practised in the intervention. Pre- and post-intervention fMRI scans were compared to examine changes in brain activation. Following intervention, AB showed improved performance on rehabilitation goals and on the associative learning task. There were significant decreases in brain activation in sensory areas and significant increases in memory-related areas. Both client-centred measures and fMRI may assist in detecting clinically-meaningful changes resulting from cognitive rehabilitation interventions.