Developing complex interventions: lessons learned from a pilot study examining strategy training in acute stroke rehabilitation

Validity of the Chinese version of the weekly calendar planning activity (WCPA) on assessing executive function in adults with stroke

The weekly calendar planning activity (WCPA) is a performance-based assessment of executive function (EF) via a cognitively-based instrumental activity of daily life (C-IADL). This study aimed to examine the validity of the Chinese version of the WCPA in adults with stroke and to explore the characteristics of cognitive strategy use among the population. Fifty-eight hospitalized patients with stroke aged 26-82 years and 53 controls completed the WCPA, two neuropsychological tests and instrumental activity of daily life (IADL) scale. Participants with stroke were subdivided into a stroke cognitive impaired group (Stroke-CI) and a general stroke group (Stroke-NCI) based on the Montreal Cognitive Assessment. Results showed that the WCPA was able to discriminate between Stroke-CI with controls and the Stroke-NCI group with controls. We found significant limitations in stroke patients' ability to use strategies. Concurrent and ecological validities were demonstrated through correlations between the neuropsychological test scores, IADL and the WCPA performance. This study provides initial evidence for the validity of the Chinese version of the WCPA-10 for adults with stroke and suggests the need to use performance-based tests even in patients with normal cognitive screening test results. The WCPA could provide useful information for strategy-based interventions for adults with stroke.

Effects of the CO-OP Approach in Addressing the Occupational Performance of Adults With Stroke: A Systematic Review

BACKGROUND

Stroke is the third leading cause of permanent disability worldwide. It is associated with difficulties in occupational performance, an area targeted by the Cognitive Orientation to daily Occupational Performance (CO-OP).

OBJECTIVE

To investigate the evidence available for the effectiveness of the CO-OP in addressing adults' performance of activities of daily living.

DATA SOURCES

Randomized controlled trials (RCTs) or pilot RCTs of the CO-OP written in English and published through December 2021 were retrieved from PubMed, SCOPUS, ScienceDirect, OTseeker, and EBSCO.

STUDY SELECTION AND DATA COLLECTION

The studies' participants were adults with stroke, evaluated on occupational performance before and after CO-OP administration. The American Occupational Therapy Association Evidence-Based Practice Project methodology was followed. Quality appraisal was conducted using the Cochrane Collaboration's Risk of Bias 2 tool.

RESULTS

Four RCTs and 3 pilot RCTs met the inclusion criteria. Inconsistent results are presented for trained and untrained goals, with the last ones being scarcely investigated.

LIMITATIONS

The limited number of studies, combined with the methodological limitations observed, did not allow for definite conclusions to be reached.

CONCLUSIONS AND RELEVANCE

The CO-OP is a promising client-centered, occupation-based approach, but future adequately powered studies addressing the potential for generalization are needed. Plain-Language Summary: The Cognitive Orientation to daily Occupational Performance is a relatively new treatment method that uses cognitive techniques to guide patients into discovering ways to perform activities of daily living independently. This systematic review presents the available evidence regarding CO-OP's effectiveness when used with adults after stroke. The findings showed that CO-OP has a positive impact in this population, but further research is needed to reach more concrete conclusions. Stroke patients may benefit from CO-OP because it can be a cost-effective, short-duration, task-oriented treatment.

Pre-Implementation Analysis of the Usability and Acceptability of a Poststroke Complex Telehealth Biofeedback Intervention

IMPORTANCE

Complex telehealth interventions can facilitate remote occupational therapy services and improve access for people living with chronic neurological conditions. Understanding the factors that influence the uptake of these technologies is important.

OBJECTIVE

To explore the fit between electromyography (EMG) biofeedback and telerehabilitation for stroke survivors, optimize EMG biofeedback interventions, and, more broadly, support other efforts to develop complex telerehabilitation interventions.

DESIGN

Pre-implementation mixed-methods analysis of usability and acceptability data collected during a pilot and feasibility study.

SETTING

Community.

PARTICIPANTS

Adult stroke survivors with hemiparesis (N = 11; M age = 54 yr).

INTERVENTION

Game-based EMG biofeedback system for arm sensorimotor rehabilitation, delivered via telehealth.

OUTCOMES AND MEASURES

Post-Study System Usability Questionnaire, an extended Unified Theory of Acceptance and Use of Technology model questionnaire, and semistructured interview. We coded the interview data using questionnaire constructs.

RESULTS

Participants used an EMG biofeedback intervention at home. Quantitative measures show high levels of perceived usability and acceptability, supported by qualitative findings describing specific facilitators and barriers.

CONCLUSIONS AND RELEVANCE

Pre-implementation studies can improve the design and relevance of complex telehealth interventions. One major conclusion from this study is the influence of therapy providers on acceptability and usability of complex telehealth interventions. Plain-Language Summary: This study contributes to an emerging body of literature that examines the use of complex telehealth interventions with survivors of neurological injury. The findings highlight the value and support the development and use of complex telehealth interventions, which have the potential to improve remote access to occupational therapy for clients living with chronic neurological conditions. Complex telehealth interventions can open doors for survivors of neurological injury who face barriers to accessing occupational therapy and would benefit from technology-enabled therapy at home.

Implementing strategy training in Taiwan: perspectives of individuals with Acquired brain injury

PURPOSE

Strategy training is a rehabilitation intervention that aims to enhance problem-solving skills with respect to daily activity-related challenges and has achieved favorable results in Western countries. This study explored the perspectives of individuals with acquired brain injury (ABI) in Taiwan who received strategy training.

MATERIALS AND METHODS

Semi-structured interviews with community-dwelling adults with ABI were conducted, and reflective memos made by research team members were recorded. Interviews and memos were analyzed through thematic analysis.

RESULTS

This study included 55 participants. The analysis of the participants' interview responses and memos yielded nine themes under three categories: 1) expectations regarding strategy training, 2) perceived benefits of strategy training, and 3) barriers affecting the process and outcomes of strategy training.

CONCLUSIONS

All the participants endorsed strategy training through different gains. Most participants' expectations before the intervention were uncertain. Including family members into the strategy training is of key importance for a successfulness of their goals. The participants' experiences about strategy training were affected by various barriers (i.e., health and medical problems, the physical environment, and natural events). Clinicians and researchers should consider these expectations, benefits, and barriers when studying and implementing strategy training in non-Western contexts.IMPLICATIONS FOR REHABILITATIONStrategy training provides clients the opportunity to actively engage in their own goal setting and decision making.Strategy training increases the client's confidence in their ability to participate in the community, communicate, and perform daily living and physical activities.Therapists should consider the health conditions and physical environment of clients when helping them set goals and before facilitating their engagement in the community.Taiwanese family members play a crucial role in supporting acquired brain injury survivors in strategy training.

Development of a Dyad-Focused Intervention for Stroke Survivors and Their Family Caregivers: A Feasibility Study

IMPORTANCE

Transitioning from the hospital to the community poses significant challenges for stroke survivors and their caregivers.

OBJECTIVE

To examine the feasibility and preliminary effects of a dyad-focused strategy training intervention.

DESIGN

Single-arm trial with data collection at baseline, postintervention, and 3-mo follow-up.

SETTING

Rehabilitation settings in Taiwan.

PARTICIPANTS

Sixteen stroke survivor-caregiver dyads.

INTERVENTIONS

Dyad-focused strategy training was provided to stroke survivor-caregiver dyads twice a week over 6 wk. The training included shared decision-making, goal setting, performance evaluation, strategy development and implementation, and therapeutic guided discovery.

OUTCOMES AND MEASURES

Feasibility indicators were Goal Attainment Scaling, Dyadic Relationship Scale, Participation Measure-3 Domains, 4 Dimensions, Activity Measure for Post-Acute Care, Montreal Cognitive Assessment, Trail Making Test, Stroop Color and Word Test, Preparedness for Caregiving Scale, and Zarit Burden Interview.

RESULTS

In total, 15 dyads completed all intervention sessions with full attendance. Both stroke survivors and their caregivers demonstrated high engagement and comprehension and reported moderate to high satisfaction with the intervention. From baseline to postintervention, the effects on goal attainment, frequency and perceived difficulty of community participation, executive function, mobility function, and caregiver preparedness were significant and positive.

CONCLUSIONS AND RELEVANCE

Our study supports the feasibility and preliminary efficacy of dyad-focused strategy training for stroke survivor-caregiver dyads transitioning from the hospital to the community in Taiwan. Our preliminary evidence indicates that dyads who receive strategy training exhibit advancement toward their goals and experience considerable enhancements in their individual outcomes. Plain-Language Summary: This study addresses the scarcity of interventions catering to both stroke survivors and their caregivers. By demonstrating the feasibility of our dyad-focused intervention, the research offers preliminary evidence that supports the potential advantages of involving both stroke survivors and their caregivers in the intervention process.

Feasibility of using the Cognitive Orientation to daily Occupational Performance in a population of Danish stroke survivors: Adaptation and study protocol

BACKGROUND

A need was identified for an occupational therapy intervention for stroke survivors in a Danish municipal healthcare setting with emphasis on its ability to transfer and generalise what is learned in occupational therapy to everyday life post therapy. Being a possible candidate, the Cognitive Orientation to daily Occupational Performance (CO-OP) approach needed to be adapted to the target group and context, and its feasibility needed examination regarding reach, dose, intervention components, fidelity, perceived value, benefits, harms, and potential outcomes.

AIM

To adapt the CO-OP to a Danish healthcare setting and present a protocol for examining its feasibility.

MATERIAL AND METHODS

The Adapting interventions to new contexts (ADAPT) guidance was followed to (1) Assess the rationale for intervention and consider intervention-context fit, (2) Plan and undertake adaptations, and (3) Plan a feasibility study.

RESULTS

Intervention materials and procedures were translated and adapted for home-based occupational therapy with people in the subacute phase of stroke. A protocol was developed to examine feasibility aspects. Quantitative and qualitative evaluations were planned and measurements chosen.

CONCLUSIONS AND SIGNIFICANCE

The planned feasibility study will contribute to further developing and refining the intervention before performing a possible large-scale effectiveness study.

Pilot RCT examining feasibility and disability outcomes of a mobile health platform for strategy training in inpatient stroke rehabilitation (iADAPT)

BACKGROUND

Strategy training is an intervention that may reduce disability when delivered in inpatient rehabilitation following stroke. However, shorter lengths of stay and challenges with continuity of care following discharge results in difficulties in achieving adequate intervention dosage and carryover of training.

OBJECTIVE

We examined whether strategy training using a mobile health platform (iADAPT) is feasible during inpatient stroke rehabilitation and following discharge.

METHODS

In this RCT, participants were randomized to receive strategy training using either the iADAPT application (n = 16) or a workbook (n = 15). Participants in both groups received 7 in-person sessions during inpatient rehabilitation and 3 remote sessions following discharge. We calculated descriptive statistics to examine acceptance, attendance, and adherence, and within-group effect sizes on satisfaction and disability.

RESULTS

Participants in the iADAPT group attended fewer total intervention sessions (n = 5.5, workbook n = 9.0) but attempted a similar number of goals (n = 7.6, workbook n = 8.2). Both groups reported similar satisfaction with in-person intervention (Treatment Expectancy: iADAPT d = 0.60, workbook d = 0.47; Patient Provider Connection: iADAPT d = 0.18, workbook d = 0.31), but the mobile health group reported greater satisfaction with remote intervention (Treatment Expectancy: iADAPT d = -0.91, workbook d = -0.97; Patient Provider Connection: iADAPT d = 0.85, workbook d = -1.80). .

CONCLUSIONS

Considering these promising feasibility metrics and the benefits of mobile health, it is worth continuing to explore the efficacy of strategy training using a mobile health platform.

Occupational therapy for cognitive impairment in stroke patients

BACKGROUND

Cognitive impairment is a frequent consequence of stroke and can impact on a person's ability to perform everyday activities. Occupational therapists use a range of interventions when working with people who have cognitive impairment poststroke. This is an update of a Cochrane Review published in 2010.

OBJECTIVES

To assess the impact of occupational therapy on activities of daily living (ADL), both basic and instrumental, global cognitive function, and specific cognitive abilities in people who have cognitive impairment following a stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, four other databases (all last searched September 2020), trial registries, and reference lists.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that evaluated an intervention for adults with clinically defined stroke and confirmed cognitive impairment. The intervention needed either to be provided by an occupational therapist or considered within the scope of occupational therapy practice as defined in the review. We excluded studies focusing on apraxia or perceptual impairments or virtual reality interventions as these are covered by other Cochrane Reviews. The primary outcome was basic activities of daily living (BADL) such as dressing, feeding, and bathing. Secondary outcomes were instrumental ADL (IADL) (e.g. shopping and meal preparation), community integration and participation, global cognitive function and specific cognitive abilities (including attention, memory, executive function, or a combination of these), and subdomains of these abilities. We included both observed and self-reported outcome measures.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies that met the inclusion criteria, extracted data, and assessed the certainty of the evidence. A third review author moderated disagreements if consensus was not reached. We contacted trial authors for additional information and data, where available. We assessed the certainty of key outcomes using GRADE.  MAIN RESULTS: We included 24 trials from 11 countries involving 1142 (analysed) participants (two weeks to eight years since stroke onset). This update includes 23 new trials in addition to the one study included in the previous version. Most were parallel randomised controlled trials except for one cross-over trial and one with a two-by-two factorial design. Most studies had sample sizes under 50 participants. Twenty studies involved a remediation approach to cognitive rehabilitation, particularly using computer-based interventions. The other four involved a compensatory and adaptive approach. The length of interventions ranged from 10 days to 18 weeks, with a mean total length of 19 hours. Control groups mostly received usual rehabilitation or occupational therapy care, with a few receiving an attention control that was comparable to usual care; two had no intervention (i.e. a waiting list). Apart from high risk of performance bias for all but one of the studies, the risk of bias for other aspects was mostly low or unclear.  For the primary outcome of BADL, meta-analysis found a small effect on completion of the intervention with a mean difference (MD) of 2.26 on the Functional Independence Measure (FIM) (95% confidence interval (CI) 0.17 to 4.22; P = 0.03, I2 = 0%; 6 studies, 336 participants; low-certainty evidence). Therefore, on average, BADL improved by 2.26 points on the FIM that ranges from 18 (total assist) to 126 (complete independence). On follow-up, there was insufficient evidence of an effect at three months (MD 10.00, 95% CI -0.54 to 20.55; P = 0.06, I2 = 53%; 2 studies, 73 participants; low-certainty evidence), but evidence of an effect at six months (MD 11.38, 95% CI 1.62 to 21.14, I2 = 12%; 2 studies, 73 participants; low-certainty evidence). These differences are below 22 points which is the established minimal clinically important difference (MCID) for the FIM for people with stroke. For IADL, the evidence is very uncertain about an effect (standardised mean difference (SMD) 0.94, 95% CI 0.41 to 1.47; P = 0.0005, I2 = 98%; 2 studies, 88 participants). For community integration, we found insufficient evidence of an effect (SMD 0.09, 95% CI -0.35 to 0.54; P = 0.68, I2 = 0%; 2 studies, 78 participants). There was an improvement of clinical importance in global cognitive functional performance after the intervention (SMD 0.35, 95% CI 0.16 to 0.54; P = 0.0004, I2 = 0%; 9 studies, 432 participants; low-certainty evidence), equating to 1.63 points on the Montreal Cognitive Assessment (MoCA) (95% CI 0.75 to 2.52), which exceeds the anchor-based MCID of the MoCA for stroke rehabilitation patients of 1.22. We found some effect for attention overall (SMD -0.31, 95% CI -0.47 to -0.15; P = 0.0002, I2 = 20%; 13 studies, 620 participants; low-certainty evidence), equating to a difference of 17.31 seconds (95% CI 8.38 to 26.24), and for executive functional performance overall (SMD 0.49, 95% CI 0.31 to 0.66; P < 0.00001, I2 = 74%; 11 studies, 550 participants; very low-certainty evidence), equating to 1.41 points on the Frontal Assessment Battery (range: 0-18). Of the cognitive subdomains, we found evidence of effect of possible clinical importance, immediately after intervention, for sustained visual attention (moderate certainty) equating to 15.63 seconds, for working memory (low certainty) equating to 59.9 seconds, and thinking flexibly (low certainty), compared to control.

AUTHORS' CONCLUSIONS

The effectiveness of occupational therapy for cognitive impairment poststroke remains unclear. Occupational therapy may result in little to no clinical difference in BADL immediately after intervention and at three and six months' follow-up. Occupational therapy may slightly improve global cognitive performance of a clinically important difference immediately after intervention, likely improves sustained visual attention slightly, and may slightly increase working memory and flexible thinking after intervention. There is evidence of low or very low certainty or insufficient evidence for effect on other cognitive domains, IADL, and community integration and participation.  Given the low certainty of much of the evidence in our review, more research is needed to support or refute the effectiveness of occupational therapy for cognitive impairment after stroke. Future trials need improved methodology to address issues including risk of bias and to better report the outcome measures and interventions used.

Quasi-Contextualized Speech Treatment in Traumatic Brain Injury Inpatient Rehabilitation: Effects on Outcomes During the First Year After Discharge

OBJECTIVE

To evaluate the effect of providing quasi-contextualized speech therapy, defined as metacognitive, compensatory, or strategy training applied to cognitive and language impairments to facilitate the performance of future real-life activities, on functional outcomes up to 1 year following traumatic brain injury (TBI).

SETTING

Acute inpatient rehabilitation.

PARTICIPANTS

Patients enrolled during the TBI-Practice-Based Evidence (TBI-PBE) study (n = 1760), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, received speech therapy in acute inpatient rehabilitation at one of 9 US sites, and consented to follow-up 3 and 9 months postdischarge from inpatient rehabilitation.

DESIGN

Propensity score methods applied to a database consisting of multisite, prospective, longitudinal observational data.

MAIN MEASURES

Participation Assessment with Recombined Tools-Objective-17, FIM Motor and Cognitive scores, Satisfaction With Life Scale, and Patient Health Questionnaire-9.

RESULTS

When at least 5% of therapy time employed quasi-contextualized treatment, participants reported better community participation during the year following discharge. Quasi-contextualized treatment was also associated with better motor and cognitive function at discharge and during the year after discharge. The benefit, however, may be dependent upon a balance of rehabilitation time that relied on contextualized treatment.

CONCLUSIONS

The use of quasi-contextualized treatment may improve outcomes. Care should be taken, however, to not provide quasi-contextualized treatment at the expense of contextualized treatment.

Activities in Daily Living: The development of a new client-centred ADL intervention for persons with stroke

BACKGROUND

An intervention that contains several interacting components can be defined as a complex intervention. This intervention was developed in accordance with the Medical Research Council (MRC) guidance for complex interventions.

AIM

To describe the development, theoretical framework, and content of a client-centred activities in daily living intervention (CADL) for people with stroke.

MATERIAL AND METHODS

Different steps were used; identifying the evidence base, identifying/developing theory and the modelling process and outcomes in the development of the CADL. The remodelling of the process and content of the intervention that emerged are defined.

RESULTS

Findings from a series of qualitative studies of people with stroke demonstrated the need to develop an ADL intervention based on the clients' lived experiences. The theoretical framework is based on empirical research, theories about human occupation and client-centredness. The CADL is applying an occupational and phenomenological perspective in order to enable agency in daily activities and participation in everyday life among persons with stroke.

CONCLUSIONS AND SIGNIFICANCE

The article can be used as an example of how to present the development and theoretical framework of a new complex intervention in occupational therapy.

Enhancing community participation for stroke survivors with cognitive impairment: study protocol for a randomised controlled trial in Taiwan

INTRODUCTION

Stroke can lead to life-long disability and constitutes a huge financial burden on the family and society. Stroke survivors with cognitive impairment often experience considerable challenges in the process of recovery and returning to society. Interventions that effectively help individuals resume essential daily activities and return to active participation in their communities are lacking. This study examines the efficacy of a newly-developed intervention programme, the Optimising Participation after Stroke through Strategy-training (OPASS) programme, for improving community participation among stroke survivors with cognitive impairment.

METHODS AND ANALYSIS

A single-blind, parallel-group randomised controlled trial with allocation concealment and assessor blinding will be implemented to assess the efficacy of the OPASS programme. An expected 210 adults with cognitive impairment following stroke will be randomly assigned to either the experimental intervention (OPASS) group or the attention control group. In addition to their usual rehabilitation, both groups will receive 45 min sessions, twice weekly for a total of 12-15 sessions. The primary outcome is change in participation performance, which will be measured using the participation measure-three domains, four dimensions scale. Additional measures include the Activity Measure for Post-Acute Care generic outpatient short forms, Montreal Cognitive Assessment, Stroop Test, Trail Making Test and General Self-Efficacy Scale. These scales will be administered at baseline, post-intervention, 3-month follow-up, 6-month follow-up and 12-month follow-up. Their results will be analysed using multiple linear regression models and mixed-effects regression models. Further assessment of feasibility and acceptability of the intervention will be conducted through structured interviews with participants, caregivers and therapists. These interviews will be transcribed and thematically analysed.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of Taipei Medical University (approval number: N201804055). The findings will be disseminated through presentations at scientific conferences and through publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03792061; pre-results.

Cognitive strategy training for adults with neurological conditions: a systematic review and meta-analysis exploring effect on occupational performance

Introduction

The objective of this systematic review was to synthesise the evidence for cognitive strategy training to determine its effectiveness to improve performance of activities of daily living in an adult neurological population.

Method

Medline, CINAHL, EMBASE, PSYCInfo, PsycBITE and Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were searched until August 2019. Studies examining the effect of cognitive strategy training on functional performance were included. Population criteria included adults with non-progressive neurological conditions. External and internal validity of included studies was systematically evaluated using an appropriate methodological quality assessment for each study design. A content analysis was conducted of the methodologies used.

Findings

Forty-one studies met the inclusion criteria and were appraised for content, 16 randomised or quasi-randomised trials were meta-analysed. Trial quality was generally ‘good’, Physiotherapy Evidence Database scale scores ranged from 3 to 8 (out of 10). For activity performance outcomes post-intervention, there was a significant benefit of cognitive strategy training over usual care (standardised mean difference 0.79, 95% confidence interval 0.49–1.09; P < 0.00001).

Conclusion

More high-quality research is needed to strengthen the evidence base for cognitive strategy interventions to improve activity performance outcomes for adults with non-progressive neurological conditions.

Systematic review registration

PROSPERO CRD42016033728

A Need to Activate Lasting Engagement

Occupational therapy practitioners provide interventions to promote activity engagement to multiple clinical populations. They help clients develop restorative, adaptive, and compensatory skills to improve their performance in daily activities. The issue addressed in this article is that current clinical frameworks lack translation of learned skills to consistent everyday performance. There is a gap between what clients can do and what clients actually do in everyday life. Behavioral activation provides an explicit, structured, and practical approach that can translate capacity into long-term engagement. This article presents behavioral activation as a transdiagnostic approach that targets populations experiencing chronic illness to bridge the gap between what the client can do in therapy and what the client could do in everyday life.

WHAT THIS ARTICLE ADDS

People with chronic illness have difficulty translating the skills learned in traditional practice settings to everyday life. Behavioral activation offers occupational therapy practitioners a practical structure to promote the translation of learned skills.

Feasibility and acceptability of the multicontext approach for individuals with acquired brain injury in acute inpatient rehabilitation: A single case series

The Multicontext (MC) approach, a metacognitive intervention designed to improve awareness, strategy use, and executive functioning, may be beneficial for individuals with acquired brain injury (ABI) undergoing acute inpatient rehabilitation. The goal of this study was to provide evidence of feasibility and acceptability of the MC approach and to explore clinical outcomes. A case series of eight individuals with acquired brain injury and at least mild executive functioning impairment were recruited from an acute inpatient rehabilitation unit. The MC approach - involving guided questioning and patient self-generation of strategies practiced across everyday functional cognitive tasks - was implemented within routine occupational therapy. Occupational therapists implemented the MC approach with high adherence to the treatment protocol. Therapists' perceived challenges were the time constraints of inpatient rehabilitation as well as client factors. Participants rated the MC approach as highly satisfying and engaging. They described subjective improvements in their ability to use executive functioning strategies. The MC approach was associated with improvement in awareness, strategy use, and executive functioning at the conclusion of treatment. The MC approach may be a beneficial intervention for individuals with acquired brain injury and executive dysfunction undergoing acute inpatient rehabilitation. Further evaluation with larger samples in controlled trials is warranted.Trial registration: ClinicalTrials.gov identifier: NCT04363645..

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.

Adapting Strategy Training for Adults With Acquired Brain Injury: A Feasibility Study in a Chinese Population

IMPORTANCE

Before introducing strategy training into a cross-cultural (Chinese) context, it is necessary to evaluate its feasibility.

OBJECTIVE

To examine the feasibility of applying strategy training to improve participation outcomes of rehabilitation patients in Taiwan and evaluate the potential intervention effects.

DESIGN

A single-group, repeated-measures study.

SETTING

Rehabilitation outpatient settings.

PARTICIPANTS

A convenience sample of adults (N = 20) with a primary diagnosis of acquired brain injury (ABI) and with cognitive impairment received the intervention and were assessed before and after it.

INTERVENTION

The participation-focused strategy training intervention, a modified version of the strategy training intervention, was provided to participants in 1-2 sessions weekly for a total of 10-20 intervention sessions.

OUTCOMES AND MEASURES

Feasibility indicators, Participation Measure-3 Domains, 4 Dimensions (PM-3D4D), and Canadian Occupational Performance Measure (COPM).

RESULTS

Eighteen participants completed 100% of the scheduled intervention sessions. Participants had very good engagement in the intervention sessions with sufficient comprehension. Participants reported moderate to high satisfaction. Positive score changes were observed for the PM-3D4D (d = 0.46-1.25) and COPM scales (d = 1.82 and 2.12).

CONCLUSIONS AND RELEVANCE

This study demonstrated the feasibility of delivering participation-focused strategy training in Taiwan to people with cognitive impairment after ABI. The preliminary evidence also showed that participants who received the strategy training intervention had positive changes in participation outcomes and in performance of their self-identified goals. On the basis of this study's findings, a larger clinical trial is warranted to evaluate the efficacy of the strategy training intervention.

WHAT THIS ARTICLE ADDS

Participation-focused strategy training is feasible and acceptable for Taiwanese community-dwelling adults with cognitive impairment after ABI. However, because strategy training is quite different from traditional rehabilitation delivered in Taiwan, additional instructions and discussion among the therapist, client, and caregiver may be needed before the intervention is provided.

Assessment of individuals with aphasia: an integrative literature review

ABSTRACT Objective: to analyze which evaluations are used by occupational therapists, speech-language pathologists and physiotherapists on individuals presented with aphasia and what these evaluations address. Methods: the study conducted a national and international documental analysis of evaluations used by professionals working on the neurological rehabilitation of adults and/or elderly individuals with aphasia, published in the last ten years (January 2008/June 2018). This analysis was performed by an integrative review of databases LILACS, SciELO and PubMed, using the descriptors: Health Assessment or Testing, or Protocols, or Psychometrics, or Questionnaires and Rehabilitation, combined with the descriptors: Aphasia, Occupational Therapy, Speech-language Pathology and Physiotherapy. Results: 26 studies were included, most of which were scored as level VI of scientific evidence; the years of 2013 and 2016 presented publication peaks. The studies used 54 evaluation tools, among which 13 were recurrent in the studies, mostly analyzing aspects of communication/language. It is assumed that these data are related to the fact that speech-language pathologists provide care for individuals with aphasia; however, these individuals may present other needs beyond communication, such as those related to human occupation, requiring multiprofessional and integral health care. Among the protocols, the Stroke Impact Scale (SIS) was considered the most complete, since it addresses communication, linguistic, human occupation and psycho-affective aspects. Conclusion: this study identified the use of few instruments dedicated to individuals with aphasia related to all aspects that involve life, with predominance of protocols and evaluations that only address disabilities, highlighting the importance of assessments that address subjectivity, evaluating individuals with aphasia in all dimensions of their lives.

Cognitive rehabilitation for attention deficits following stroke

BACKGROUND

Many survivors of stroke report attentional impairments, such as diminished concentration and distractibility. However, the effectiveness of cognitive rehabilitation for improving these impairments is uncertain.This is an update of the Cochrane Review first published in 2000 and previously updated in 2013.

OBJECTIVES

To determine whether people receiving cognitive rehabilitation for attention problems 1. show better outcomes in their attentional functions than those given no treatment or treatment as usual, and 2. have a better functional recovery, in terms of independence in activities of daily living, mood, and quality of life, than those given no treatment or treatment as usual.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PsycBITE, REHABDATA and ongoing trials registers up to February 2019. We screened reference lists and tracked citations using Scopus.

SELECTION CRITERIA

We included controlled clinical trials (CCTs) and randomised controlled trials (RCTs) of cognitive rehabilitation for impairments of attention for people with stroke. We did not consider listening to music, meditation, yoga, or mindfulness to be a form of cognitive rehabilitation. We only considered trials that selected people with demonstrable or self-reported attentional deficits. The primary outcomes were measures of global attentional functions, and secondary outcomes were measures of attentional domains (i.e. alertness, selective attention, sustained attention, divided attention), functional abilities, mood, and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, and assessed the risk of bias. We used the GRADE approach to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included no new trials in this update. The results are unchanged from the previous review and are based on the data of six RCTs with 223 participants. All six RCTs compared cognitive rehabilitation with a usual care control. Meta-analyses demonstrated no convincing effect of cognitive rehabilitation on subjective measures of attention either immediately after treatment (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) -0.03 to 1.08; P = 0.06; 2 studies, 53 participants; very low-quality evidence) or at follow-up (SMD 0.16, 95% CI -0.23 to 0.56; P = 0.41; 2 studies, 99 participants; very low-quality evidence). People receiving cognitive rehabilitation (when compared with control) showed that measures of divided attention recorded immediately after treatment may improve (SMD 0.67, 95% CI 0.35 to 0.98; P < 0.0001; 4 studies, 165 participants; low-quality evidence), but it is uncertain that these effects persisted (SMD 0.36, 95% CI -0.04 to 0.76; P = 0.08; 2 studies, 99 participants; very low-quality evidence). There was no evidence for immediate or persistent effects of cognitive rehabilitation on alertness, selective attention, and sustained attention. There was no convincing evidence for immediate or long-term effects of cognitive rehabilitation for attentional problems on functional abilities, mood, and quality of life after stroke.

AUTHORS' CONCLUSIONS

The effectiveness of cognitive rehabilitation for attention deficits following stroke remains unconfirmed. The results suggest there may be an immediate effect after treatment on attentional abilities, but future studies need to assess what helps this effect persist and generalise to attentional skills in daily life. Trials also need to have higher methodological quality and better reporting.

A Paradigm Shift: Rehabilitation Robotics, Cognitive Skills Training, and Function After Stroke

Introduction: Robot-assisted therapy for upper extremity (UE) impairments post-stroke has yielded modest gains in motor capacity and little evidence of improved UE performance during activities of daily living. A paradigm shift that embodies principles of motor learning and exercise dependent neuroplasticity may improve robot therapy outcomes by incorporating active problem solving, salience of trained tasks, and strategies to facilitate the transfer of acquired motor skills to use of the paretic arm and hand during everyday activities.

Objective: To pilot and test the feasibility of a novel therapy protocol, the Active Learning Program for Stroke (ALPS), designed to complement repetitive, robot-assisted therapy for the paretic UE. Key ALPS ingredients included training in the use of cognitive strategies (e.g., STOP, THINK, DO, CHECK) and a goal-directed home action plan (HAP) to facilitate UE self-management and skill transfer.

Methods: Ten participants with moderate impairments in UE function >6 months after stroke received eighteen 1-h treatment sessions 2–3/x week over 6–8 weeks. In addition to ALPS training, individuals were randomly assigned to either robot-assisted therapy (RT) or robot therapy and task-oriented training (RT-TOT) to trial whether the inclusion of TOT reinforced participants' understanding and implementation of ALPS strategies.

Results: Statistically significant group differences were found for the upper limb subtest of the Fugl-Meyer Assessment (FMA-UE) at discharge and one-month follow-up favoring the RT group. Analyses to examine overall effects of the ALPS protocol in addition to RT and RT-TOT showed significant and moderate to large effects on the FMA-UE, Motor Activity Log, Wolf Motor Function Test, and hand portion of the Stroke Impact Scale.

Conclusion: The ALPS protocol was the first to extend cognitive strategy training to robot-assisted therapy. The intervention in this development of concept pilot trial was feasible and well-tolerated, with good potential to optimize paretic UE performance following robot-assisted therapy.

Implementing a function-based cognitive strategy intervention within inter-professional stroke rehabilitation teams: Changes in provider knowledge, self-efficacy and practice

BACKGROUND

The Cognitive Orientation to daily Occupational Performance (CO-OP) approach is a complex rehabilitation intervention in which clients are taught to use problem-solving cognitive strategies to acquire personally-meaningful functional skills, and health care providers are required to shift control regarding treatment goals and intervention strategies to their clients. A multi-faceted, supported, knowledge translation (KT) initiative was targeted at the implementation of CO-OP in inpatient stroke rehabilitation teams at five freestanding rehabilitation hospitals. The study objective was to estimate changes in rehabilitation clinicians' knowledge, self-efficacy, and practice related to implementing CO-OP.

METHODS

A single arm pre-post and 6-month follow up study was conducted. CO-OP KT consisted of a 2-day workshop, 4 months of implementation support, a consolidation session, and infrastructure support. In addition, a sustainability plan was implemented. Consistent with CO-OP principles, teams were given control over specific implementation goals and strategies. Multiple choice questions (MCQ) were used to assess knowledge. A self-efficacy questionnaire with 3 subscales (Promoting Cognitive Strategy Use, PCSU; Client-Focused Therapy, CFT; Top-Down Assessment and Treatment, TDAT) was developed for the study. Medical record audits were used to investigate practice change. Data analysis for knowledge and self-efficacy utilized mixed effects models. Medical record audits were analyzed with frequency counts and chi-squares.

RESULTS

Sixty-five health care providers consisting mainly of occupational and physical therapists entered the study. Mixed effects models revealed intervention effects for MCQs, CFT, and PCSU at post intervention and follow-up, but no effect on TDAT. No charts showed any evidence of CO-OP use at baseline, compared to 8/40 (20%) post intervention. Post intervention there was a trend towards reduction in impairment goals and significantly more component goals were set (z = 2.7, p = .007).

Relationship Consensus and Caregiver Burden in Adults with Cognitive Impairments 6 Months Following Stroke

BACKGROUND

Caregiver burden is commonly experienced in caregivers of adults with cognitive impairment after stroke. This burden can be associated with caregiver-centered factors, including caregiver-perceived relationship quality.

OBJECTIVE

To examine the role of caregiver-perceived relationship quality on caregiver burden at 6 months following stroke.

DESIGN

Prospective observational study.

SETTING

Community settings.

PARTICIPANTS

Adults enrolled in two randomized controlled trials after stroke (n = 60) and their caregivers (n = 60).

METHODS

Three constructs of relationship quality (relationship consensus, cohesion, and satisfaction) were examined as predictors of caregiver burden (the Abbreviated Dyadic Adjustment Scale). A hierarchical logistic regression and a Poisson regression with robust standard errors were used to examine the effect of relationship quality on caregiver burden while controlling for characteristics of stroke survivors and caregivers.

MAIN OUTCOME MEASUREMENTS

Caregiver burden was measured with the abridged version of the Zarit Burden Interview.

RESULTS

Poor relationship consensus (odds ratio [OR] = 1.48; 95% confidence interval [CI] = 1.06-2.07; P = .02) increased the odds of high caregiver burden after controlling for characteristics of stroke survivors (age, comorbidity, cognitive fluency) and caregivers (gender, self-reported health). Relationship cohesion (OR  = 1.03; 95% CI = .84-1.25; P = .81) and relationship satisfaction (OR  = 1.53; 95% CI = .75-3.10; P = .24) did not predict caregiver burden.

CONCLUSION

Meaningful and agreeable goals and expectations between dyads are essential to reduce caregiver burden after stroke. Collaborative goal-setting between stroke survivors and their caregivers may be a promising intervention strategy to increase relationship consensus and reduce caregiver burden.

LEVEL OF EVIDENCE

III.

Developing a Non-Pharmacological Intervention for Individuals With Mild Cognitive Impairment

The purpose of this study is to describe one potential intervention model that is designed to slow decline to disability for individuals at-risk for dementia due to Mild Cognitive Impairment. Strategy training is a treatment model that focuses on behavioral activation through addressing barriers to daily activities. Strategy training encourages development of goals and plans to address self-identified impaired processes, and it maintains or improves individuals' ability to perform desired activities. Progression to dementia may be slowed due to the link between engagement in daily activities and production of biological factors associated with neurocognitive health. We demonstrated that an older adult with mild cognitive impairment is able to develop goals, establish effective plans, and engage in daily activities through the strategy training intervention model.

Self-Awareness and Recovery of Independence With Strategy Training

OBJECTIVE

Poor self-awareness co-occurs with cognitive impairments after stroke and may influence independence in daily activities. Strategy training promotes independence after stroke, but poor awareness may attenuate treatment response. We examined the degree to which awareness status affected changes in independence attributed to strategy training.

METHOD

We conducted a secondary analysis of 30 participants with cognitive impairments after acute stroke randomized to strategy training or attention control in addition to typical inpatient rehabilitation. We measured awareness with the Self-Awareness of Deficits Interview and independence with the FIM™. Data were analyzed using general linear models.

RESULTS

Poor awareness attenuated improvements in independence over time, F(3, 55) = 3.04, p = .038. Strategy training promoted greater improvements in independence over time relative to attention control, F(3, 55) = 5.93, p = .002. However, the interaction between awareness and intervention was not significant, F(1, 19) = 0.025, p = .877.

CONCLUSION

Awareness status may not affect the response to strategy training, indicating that strategy training may benefit people with poor awareness.

Measures of fidelity of delivery of, and engagement with, complex, face-to-face health behaviour change interventions: A systematic review of measure quality

PURPOSE

Understanding the effectiveness of complex, face-to-face health behaviour change interventions requires high-quality measures to assess fidelity of delivery and engagement. This systematic review aimed to (1) identify the types of measures used to monitor fidelity of delivery of, and engagement with, complex, face-to-face health behaviour change interventions and (2) describe the reporting of psychometric and implementation qualities.

METHODS

Electronic databases were searched, systematic reviews and reference lists were hand-searched, and 21 experts were contacted to identify articles. Studies that quantitatively measured fidelity of delivery of, and/or engagement with, a complex, face-to-face health behaviour change intervention for adults were included. Data on interventions, measures, and psychometric and implementation qualities were extracted and synthesized using narrative analysis.

RESULTS

Sixty-six studies were included: 24 measured both fidelity of delivery and engagement, 20 measured fidelity of delivery, and 22 measured engagement. Measures of fidelity of delivery included observation (n = 17; 38.6%), self-report (n = 15; 34%), quantitatively rated qualitative interviews (n = 1; 2.3%), or multiple measures (n = 11; 25%). Measures of engagement included self-report (n = 18; 39.1%), intervention records (n = 11; 24%), or multiple measures (n = 17; 37%). Fifty-one studies (77%) reported at least one psychometric or implementation quality; 49 studies (74.2%) reported at least one psychometric quality, and 17 studies (25.8%) reported at least one implementation quality.

CONCLUSION

Fewer than half of the reviewed studies measured both fidelity of delivery of, and engagement with complex, face-to-face health behaviour change interventions. More studies reported psychometric qualities than implementation qualities. Interpretation of intervention outcomes from fidelity of delivery and engagement measurements may be limited due to a lack of reporting of psychometric and implementation qualities. Statement of contribution What is already known on this subject? Evidence of fidelity and engagement is needed to understand effectiveness of complex interventions Evidence of fidelity and engagement are rarely reported High-quality measures are needed to measure fidelity and engagement What does this study add? Evidence that indicators of quality of measures are reported in some studies Evidence that psychometric qualities are reported more frequently than implementation qualities A recommendation for intervention evaluations to report indicators of quality of fidelity and engagement measures.

Incorporating a Cognitive Strategy Approach into an Outpatient Stroke Physiotherapy Programme: Case Report

Purpose: Cognitive Orientation to daily Occupational Performance (CO-OP) has demonstrated an effect on skill performance, compared with the usual outpatient rehabilitation, in people living with stroke when implemented by occupational therapists. This study explored refining CO-OP for delivery by both occupational therapists and physiotherapists. Client Description: Two cases were recruited and treated using the CO-OP approach, which augments task-specific training with cognitive strategies and guided discovery. Intervention: Case 1 was a 79-year-old woman, 31 days after parietal stroke, and Case 2 was a 45-year-old man, 62 days after bilateral brain stem stroke. Case 1 withdrew from the study for medical reasons. Outcome measures applied were the Canadian Occupational Performance Measure, the Stroke Impact Scale (SIS), the Self-Efficacy Gauge, the Berg Balance Scale, the Box and Block Test, and the 2-minute walk test. Measures and Outcomes: After 10 sessions, Case 2 made gains in most measures, including a 22-point gain in the SIS mobility domain. Implications: The therapists reported that the combined delivery required additional communication with the patients but was feasible. Case 2 reported physical and mobility gains larger than the mean changes seen in past CO-OP research. Although these results cannot be generalized, findings suggest that the inter-professional application of CO-OP warrants further investigation.

Guided Training Relative to Direct Skill Training for Individuals With Cognitive Impairments After Stroke: A Pilot Randomized Trial

OBJECTIVE

To examine the effects of direct skill training and guided training for promoting independence after stroke.

DESIGN

Single-blind randomized pilot study.

SETTING

Inpatient rehabilitation facility.

PARTICIPANTS

Participants in inpatient rehabilitation with acute stroke and cognitive impairments (N=43).

INTERVENTIONS

Participants were randomized to receive direct skill training (n=22, 10 sessions as adjunct to usual inpatient rehabilitation) or guided training (n=21, same dose).

MAIN OUTCOME MEASURE

The FIM assessed independence at baseline, rehabilitation discharge, and months 3, 6, and 12.

RESULTS

Linear mixed models (random intercept, other effects fixed) revealed a significant intervention by time interaction (F_4,150=5.11, P<.001), a significant main effect of time (F_4,150=49.25, P<.001), and a significant effect of stroke severity (F_1,150=34.46, P<.001). There was no main effect of intervention (F_1,150=.07, P=.79). Change in FIM scores was greater for the direct group at rehabilitation discharge (effect size of between-group differences, d=.28) and greater for the guide group at months 3 (d=.16), 6 (d=.39), and 12 (d=.53). The difference between groups in mean 12-month change scores was 10.57 points.

CONCLUSIONS

Guided training, provided in addition to usual care, offered a small advantage in the recovery of independence, relative to direct skill training. Future studies examining guided training in combination with other potentially potent intervention elements may further advise best practices in rehabilitation for individuals with cognitive impairments after acute stroke.

Comparison of two cognitive interventions for adults experiencing executive dysfunction post-stroke: a pilot study

Purpose This pilot partially randomised controlled trial compared the feasibility and preliminary efficacy of two promising interventions for persons with executive dysfunction post-stroke: (1) occupation-based strategy training using an adapted version of the Cognitive Orientation to daily Occupational Performance (CO-OP) approach; and (2) Computer-based EF training (COMPUTER training). Method Participants received 16 h of either CO-OP or COMPUTER training. We assessed feasibility and acceptability of each intervention, and change in intervention outcomes at baseline, post-intervention and one-month follow-up. Performance and satisfaction with performance in self-selected everyday life goals were measured by the participant and the significant other-rated Canadian Occupational Performance Measure (COPM). Other intervention outcomes included changes in EF impairment, participation in daily life and self-efficacy. Results Six participants received CO-OP and five received COMPUTER training: one in each group discontinued the intervention for medical reasons unrelated to the intervention. The remaining nine participants completed all 16 sessions. Participants expressed high levels of satisfaction with both interventions. Both treatment groups showed large improvements in self and significant other-rated performance and satisfaction with performance on their goals immediately post-intervention and at follow-up (CO-OP: effect sizes (ES) = 1.6-3.5; COMPUTER: ES = 0.9-4.0), with statistically significant within-group differences in CO-OP (p < 0.05). The COMPUTER group also showed large improvements in some areas of EF impairment targeted by the computerised tasks (ES = 0.9-1.6); the CO-OP group demonstrated large improvements in self-efficacy for performing everyday activities (ES = 1.5). Conclusions Our findings provide preliminary evidence supporting the feasibility of using both CO-OP and COMPUTER training with patients with executive dysfunction post-stroke. Implications for Rehabilitation Computerised executive function training and occupation-based strategy training are feasible to deliver and acceptable to persons with executive dysfunction post-stroke. Preliminary evidence suggests that both interventions have a positive impact on real-world outcomes; and, that CO-OP might have a greater impact on improving self-efficacy for performing everyday activities.

Quality of life of stroke survivors and their informal caregivers: A prospective study

BACKGROUND

Health care improvements have led to increased survival among stroke patients; however, the disability level remains high. These patients require assistance from caregivers, particularly in the first year after stroke. Longitudinal studies of quality of life (QoL) and the factors associated with QoL for both patients and caregivers are limited.

OBJECTIVES

To describe the changes in QoL and determine the factors associated with QoL for both stroke patients and their informal caregivers in the first year after stroke.

METHODS

This multicenter prospective study was conducted in public hospitals in Mongolia. In this study, 155 first-time stroke patients and their 88 informal caregivers were followed up for 1 year. The WHOQOL-BREF questionnaire was used to assess QoL. The Barthel Index was administered to the patients at the baseline and after 1 year. A generalized estimating equation analysis was used to determine the factors associated with QoL.

RESULTS

The QoL of stroke patients in the domains of physical and environmental aspects improved significantly (p < 0.05) after 1 year; however, social relationship and psychological health declined, but the decline was not significant. Among caregivers, psychological health and social relationship domains improved significantly. Factors associated with low QoL among stroke patients were advancing age, male patients, being single and less improvements on BI score, and among caregivers were poor physical health and financial difficulties.

CONCLUSIONS

Efficient rehabilitation therapy for poststroke patients can improve their QoL. Disability training and financial support for caregivers of poststroke patients might be helpful; however, further research is required.

A multi-faceted knowledge translation approach to support persons with stroke and cognitive impairment: evaluation protocol

BACKGROUND

Patients with cognitive impairments following a stroke are often denied access to inpatient rehabilitation. The few patients with cognitive impairment admitted to rehabilitation generally receive services based on outdated impairment-reduction models, rather than recommended function-based approaches. Both reduced access to rehabilitation and the knowledge-to-practice gap stem from a reported lack of skills and knowledge regarding cognitive rehabilitation on the part of inpatient rehabilitation team members. To address these issues, a multi-faceted knowledge translation (KT) initiative will be implemented and evaluated. It will be targeted specifically at the inter-professional application of the cognitive orientation to daily occupational performance (CO-OP). CO-OP training combined with KT support is called CO-OP KT. The long-term objective of CO-OP KT is to optimize functional outcomes for individuals with stroke and cognitive impairments. Three research questions are posed: 1. Is the implementation of CO-OP KT associated with a change in the proportion of patients with cognitive impairment following a stroke accepted to inpatient rehabilitation? 2. Is the implementation of CO-OP KT associated with a change in rehabilitation clinicians' practice, knowledge, and self-efficacy related to implementing the CO-OP approach, immediately following and 1 year later? 3. Is CO-OP KT associated with changes in activity, participation, and self-efficacy to perform daily activities in patients with cognitive impairment following stroke at discharge from inpatient rehabilitation and at 1-, 3-, and 6-month follow-ups?

METHODS/DESIGN

Three interrelated studies will be conducted. Study 1 will be a quasi-experimental, interrupted time series design measuring monthly summaries of stroke unit level data. Study 2, which relates to changes in health care professional practice and self-efficacy, will be a single group pre-post evaluation design incorporating chart audits and a self-report survey. Study 3 will assess patient functional outcomes using a non-randomized design with historical controls. Assessments will occur during admission and discharge from rehabilitation and at 1, 3, and 6 months following discharge from rehabilitation.

DISCUSSION

This project will advance knowledge about the degree to which the implementation of a supported KT initiative can sustainably change health system, knowledge, and patient outcomes.

Strategy Training Shows Promise for Addressing Disability in the First 6 Months After Stroke

BACKGROUND

Cognitive impairments occur frequently after stroke and contribute to significant disability. Strategy training shows promise but has not been examined in the acute phase of recovery.

OBJECTIVE

We conducted a single-blind randomized pilot study estimating the effect of strategy training, relative to reflective listening (attention control), for reducing disability and executive cognitive impairments.

METHODS

Thirty participants with acute stroke who were enrolled in inpatient rehabilitation and had cognitive impairments were randomized to receive strategy training (n = 15, 10 sessions as adjunct to usual inpatient rehabilitation) or reflective listening (n = 15, same dose). The Functional Independence Measure assessed disability at baseline, rehabilitation discharge, 3, and 6 months. The Color Word Interference Test of the Delis-Kaplan Executive Function System assessed selected executive cognitive impairments (inhibition, flexibility) at baseline, 3, and 6 months.

RESULTS

Changes in Functional Independence Measure scores for the 2 groups over 6 months showed significant effects of group (F1,27 = 9.25, P = .005), time (F3,74 = 96.00, P < .001), and group * time interactions (F3,74 = 4.37, P < .007) after controlling for baseline differences in stroke severity (F1,27 = 6.74, P = .015). Color Word Interference Inhibition scores showed significant effects of group (F1,26 = 6.50, P = .017) and time (F2,34 = 4.74, P = .015), but the group * time interaction was not significant (F2,34 = 2.55, P = .093). Color Word Interference Cognitive Flexibility scores showed significant effects of group (F1,26 = 23.41, P < .001), time (F2,34 = 12.77, P < .001), and group * time interactions (F2,34 = 7.83, P < .002). Interaction effects suggested greater improvements were associated with strategy training.

CONCLUSIONS

Strategy training shows promise for addressing disability in the first 6 months after stroke. Lessons from this pilot study may inform future clinical trials.

Strategy Training During Inpatient Rehabilitation May Prevent Apathy Symptoms After Acute Stroke

BACKGROUND

Apathy, or lack of motivation for goal-directed activities, contributes to reduced engagement in and benefit from rehabilitation, impeding recovery from stroke.

OBJECTIVE

To examine the effects of strategy training, a behavioral intervention used to augment usual inpatient rehabilitation, on apathy symptoms over the first 6 months after stroke.

DESIGN

Secondary analysis of randomized controlled trial.

SETTING

Acute inpatient rehabilitation.

PARTICIPANTS

Participants with acute stroke who exhibited cognitive impairments (Quick Executive Interview Scores ≥3) and were admitted for inpatient rehabilitation were randomized to receive strategy training (n = 15, 1 session per day, 5 days per week, in addition to usual inpatient rehabilitation) or reflective listening (n = 15, same dose).

METHODS

Strategy training sessions focused on participant-selected goals and participant-derived strategies to address these goals, using a global strategy training method (Goal-Plan-Do-Check). Reflective listening sessions focused on participant reflections on their rehabilitation goals and experiences, facilitated by open-ended questions and active listening skills (attending, following, and responding).

MAIN OUTCOME MEASURES

Trained raters blinded to group assignment administered the Apathy Evaluation Scale at study admission, 3 months, and 6 months. Data were analyzed with repeated-measures fixed-effects models.

RESULTS

Participants in both groups had similar subsyndromal levels of apathy symptoms at study admission (strategy training, mean = 25.79, standard deviation = 7.62; reflective listening, mean = 25.18, standard deviation = 4.40). A significant group × time interaction (F2,28 = 3.61, P = .040) indicated that changes in apathy symptom levels differed between groups over time. The magnitude of group differences in change scores was large (d = -0.99, t28 = -2.64, P = .013) at month 3 and moderate to large (d = -0.70, t28 = -1.86, P = .073) at month 6.

CONCLUSION

Strategy training shows promise as an adjunct to usual rehabilitation for maintaining low levels of poststroke apathy.

Guided and directed cues: developing a standardized coding scheme for clinical practice

Guided cues facilitate discovery of problems and strategies. Directed cues are instructional statements and commands. Both types of cues are used by therapists to promote learning; yet, little is known about the frequency and effects of these cues in clinical practice. We developed a standardized coding scheme for characterizing training cues. We recorded 27 sessions among 10 participants engaged in inpatient rehabilitation after stroke. Two raters coded type and number of cues on 33% of sessions. We resolved discrepancies between raters and refined the standardized coding scheme, achieving excellent inter-rater reliability (ICC = 0.950, guided cues; ICC = 0.995, directed cues). We applied the final coding scheme to all 27 sessions (10 participants). Average cues per minute ranged from 1 to 13. Guided cues were less frequent than directed cues. This study sets the stage for future, larger studies designed to examine the significance of the number and types of cues in usual practice.

Predictors of poststroke health-related quality of life in Nigerian stroke survivors: a 1-year follow-up study

This study aims to identify the predictors in the different aspects of the health-related quality of life (HRQoL) and to measure the changes of functional status over time in a cohort of Nigerian stroke survivors. A prospective observational study was conducted in three hospitals of Kano state of Nigeria where stroke survivors receive rehabilitation. The linguistic-validated Hausa versions of the stroke impact scale 3.0, modified Rankin scale, Barthel index and Beck depression inventory scales were used. Paired samples t-test was used to calculate the amount of changes that occur over time and the forward stepwise linear regression model was used to identify the predictors. A total of 233 stroke survivors were surveyed at 6 months, and 93% (217/233) were followed at 1 year after stroke. Functional disabilities were significantly reduced during the recovery phase. Motor impairment, disability, and level of depression were independent predictors of HRQoL in the multivariate regression analysis. The involvement of family members as caregivers is the key factor for those survivors with improved functional status. Thus, to enhance the quality of poststroke life, it is proposed that a holistic stroke rehabilitation service and an active involvement of family members are established at every possible level.