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Linkewich E, Rios J, Allen KA, Avery L, Dawson DR, Donald M, Egan M, Hunt A, Jutzi K, McEwen S. The impact of an integrated, interprofessional knowledge translation intervention on access to inpatient rehabilitation for persons with cognitive impairment. PLoS One 2022; 17:e0266651. [PMID: 36048763 PMCID: PMC9436086 DOI: 10.1371/journal.pone.0266651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 03/25/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction Stroke rehabilitation teams’ skills and knowledge in treating persons with cognitive impairment (CI) contribute to their reduced access to inpatient rehabilitation. This study examined stroke inpatient rehabilitation referral acceptance rates for persons with CI before and after the implementation of a multi-faceted integrated knowledge translation (KT) intervention aimed at improving clinicians’ skills in a cognitive-strategy based approach, Cognitive Orientation to daily Occupational Performance (CO-OP), CO-OP KT. Methods CO-OP KT was implemented at five inpatient rehabilitation centres, using an interrupted time series design and data from an electronic referral and database system called E-Stroke. CO-OP KT included a 2-day workshop, 4 months of implementation support, health system support, and a sustainability plan. A mixed effects model was used to model monthly acceptance rates for 12 months prior to the intervention and 6 months post. Results The dataset was comprised of 2604 pre-intervention referrals and 1354 post. In the mixed effects model, those with CI had a lower pre-intervention acceptance rate than those without. Post-intervention the model showed the acceptance rate for those with CI increased by 8.6% (p = 0.02), whereas those with no CI showed a non-significant increase of less than 1%. Conclusions Proportionally more persons with CI gained access to inpatient stroke rehabilitation following an integrated KT intervention.
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Affiliation(s)
- Elizabeth Linkewich
- North & East GTA Stroke Network, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Practice-Based Research, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
| | - Jorge Rios
- St. John’s Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Kay-Ann Allen
- St. John’s Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Lisa Avery
- Avery Information Services Ltd., Orillia, Ontario, Canada
| | - Deirdre R. Dawson
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences, University of Toronto, Toronto, Ontario, Canada
- Rotman Research Institute, Baycrest, Toronto, Ontario, Canada
| | - Michelle Donald
- Central Local Health Integration Network, Markham, Ontario, Canada
| | - Mary Egan
- School of Rehabilitation Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Anne Hunt
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Katelyn Jutzi
- St. John’s Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Sara McEwen
- St. John’s Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Rehabilitation Sciences, University of Toronto, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
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Hunt AW, Allen KA, Dittmann K, Linkewich E, Donald M, Hutter J, Patel A, McEwen S. Clinician perspectives on implementing a team-based metacognitive strategy training approach to stroke rehabilitation. J Eval Clin Pract 2022; 28:201-207. [PMID: 34390294 DOI: 10.1111/jep.13610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/16/2021] [Accepted: 07/26/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The objective of this research study was to explore site and clinician specific experiences, successes and challenges in implementing a complex intervention (cognitive orientation to daily occupational performance approach) to enhance stroke team's ability to address cognitive impairments as part of comprehensive stroke rehabilitation. METHODS A focus group was held with clinicians from five study sites, all rehabilitation stroke hospitals in a large urban setting, to discuss implementation experiences. Participants were clinicians (site champions) from each of the five participating stroke program study sites and included four occupational therapists, three physiotherapists and one speech-language pathologist. Thematic analysis was used to identify themes that represented clinicians' perspectives. RESULTS Implementing this complex team-based intervention was influenced by three themes-organizational support, experiential evidence, and clinicians' perspectives. Continued implementation of the intervention following the withdrawal of study support was represented on a continuum that ranged from not using the approach at all to implementing it with all patients. Sites where managers encouraged and supported use of the intervention within teams (organization support), continued to use it after the study support period as did clinicians who were willing to try new interventions (clinicians' perspectives). Development of iterative conclusions through implementation or attempts to implement the intervention had both positive and negative effects on continued implementation (experiential evidence). CONCLUSIONS Strategies that reinforce development of positive experiential evidence and building organizational support for innovative practice were found to be useful adjuncts in facilitating implementation of complex interprofessional interventions.
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Affiliation(s)
- Anne W Hunt
- Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
| | | | | | | | | | - Jennifer Hutter
- Department of Kinesiology, McMaster University, Hamilton, Canada
| | - Alexandra Patel
- Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Canada
| | - Sara McEwen
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.,Sunnybrook Research Institute, Toronto, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Canada
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Lessons learned and functional outcomes following multifaceted team training in a cognitive strategy-based approach to stroke rehabilitation. JBI Evid Implement 2022; 20:33-43. [PMID: 35165236 DOI: 10.1097/xeb.0000000000000308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To estimate the impact of a multifaceted knowledge translation intervention on patient rehabilitation outcomes in an inpatient stroke setting. METHODS Interprofessional stroke rehabilitation teams were trained in Cognitive Orientation to daily Occupational Performance as part of the larger knowledge translation study. This study describes a two group (historical control vs. post knowledge translation intervention) nonrandomized study. Patient participants with stroke and cognitive impairment were recruited from five rehabilitation hospitals and completed an assessment battery upon admission to and discharge from rehabilitation and at three follow-up times. Data were analyzed using a two-way ANOVA. RESULTS Seventeen historical controls and eight postintervention participants were recruited. The effect for time was significant (P ≤ 0.05) for the majority of outcomes, but there were no significant group × time effects. Small effect sizes for the group × time interaction were noted on several indicators. CONCLUSION Few studies report on patient outcomes following a knowledge translation intervention. Small effect sizes were detected on several patient outcomes, despite study limitations. Lessons learned for future patient-level studies within knowledge translation interventions include the importance of monitoring therapist adherence to implementation protocols and ensuring research designs consider the impact on patient recruitment and retention.
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Moore JL, Mbalilaki JA, Graham ID. Knowledge Translation in Physical Medicine and Rehabilitation: A Citation Analysis of the Knowledge-to-Action Literature. Arch Phys Med Rehabil 2021; 103:S256-S275. [PMID: 33556348 DOI: 10.1016/j.apmr.2020.12.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 12/15/2020] [Accepted: 12/28/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To (1) provide an overview of the use of the Knowledge-to-Action Cycle (KTA) to guide a clinical implementation project; (2) identify activities performed in each phase of the KTA; and (3) provide suggestions to improve KTA activities in physical medicine and rehabilitation. DATA SOURCES Google Scholar and PubMed were searched through December 31, 2019. STUDY SELECTION Two reviewers screened titles, abstracts, and full-text articles to identify published studies that used the KTA to implement a project. DATA EXTRACTION Two reviewers examined full-text articles. Data extraction included activities performed in each phase of the KTA, including measurements used to evaluate the project's effectiveness. DATA SYNTHESIS Commonly performed KTA activities were identified and country of study, area of rehabilitation, and other factors related to the use of the KTA in rehabilitation were described. A total of 46 articles that met the study's inclusion criteria provided an overview of the use of the KTA in rehabilitation. Strengths and weaknesses of the articles are discussed and recommendations for improved KTA use are provided. CONCLUSIONS Implementation of evidence-based practice requires focused engineering and efforts. This review provides an overview of the knowledge translation activities occurring in physical medicine and rehabilitation and considerations to improve knowledge translation research and practice.
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Affiliation(s)
- Jennifer L Moore
- Southeastern Norway Regional Center for Knowledge Translation in Rehabilitation, Oslo, Norway; Institute for Knowledge Translation, Carmel, IN, United States.
| | - Julia A Mbalilaki
- Southeastern Norway Regional Center for Knowledge Translation in Rehabilitation, Oslo, Norway
| | - Ian D Graham
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Cahill LS, Carey LM, Lannin NA, Turville M, Neilson CL, Lynch EA, McKinstry CE, Han JX, O'Connor D. Implementation interventions to promote the uptake of evidence-based practices in stroke rehabilitation. Cochrane Database Syst Rev 2020; 10:CD012575. [PMID: 33058172 PMCID: PMC8095062 DOI: 10.1002/14651858.cd012575.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Rehabilitation based upon research evidence gives stroke survivors the best chance of recovery. There is substantial research to guide practice in stroke rehabilitation, yet uptake of evidence by healthcare professionals is typically slow and patients often do not receive evidence-based care. Implementation interventions are an important means to translate knowledge from research to practice and thus optimise the care and outcomes for stroke survivors. A synthesis of research evidence is required to guide the selection and use of implementation interventions in stroke rehabilitation. OBJECTIVES To assess the effects of implementation interventions to promote the uptake of evidence-based practices (including clinical assessments and treatments recommended in evidence-based guidelines) in stroke rehabilitation and to assess the effects of implementation interventions tailored to address identified barriers to change compared to non-tailored interventions in stroke rehabilitation. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and eight other databases to 17 October 2019. We searched OpenGrey, performed citation tracking and reference checking for included studies and contacted authors of included studies to obtain further information and identify potentially relevant studies. SELECTION CRITERIA We included individual and cluster randomised trials, non-randomised trials, interrupted time series studies and controlled before-after studies comparing an implementation intervention to no intervention or to another implementation approach in stroke rehabilitation. Participants were qualified healthcare professionals working in stroke rehabilitation and the patients they cared for. Studies were considered for inclusion regardless of date, language or publication status. Main outcomes were healthcare professional adherence to recommended treatment, patient adherence to recommended treatment, patient health status and well-being, healthcare professional intention and satisfaction, resource use outcomes and adverse effects. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any implementation intervention compared to no intervention. MAIN RESULTS Nine cluster randomised trials (12,428 patient participants) and three ongoing trials met our selection criteria. Five trials (8865 participants) compared an implementation intervention to no intervention, three trials (3150 participants) compared one implementation intervention to another implementation intervention, and one three-arm trial (413 participants) compared two different implementation interventions to no intervention. Eight trials investigated multifaceted interventions; educational meetings and educational materials were the most common components. Six trials described tailoring the intervention content to identified barriers to change. Two trials focused on evidence-based stroke rehabilitation in the acute setting, four focused on the subacute inpatient setting and three trials focused on stroke rehabilitation in the community setting. We are uncertain if implementation interventions improve healthcare professional adherence to evidence-based practice in stroke rehabilitation compared with no intervention as the certainty of the evidence was very low (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.53 to 2.64; 2 trials, 39 clusters, 1455 patient participants; I2 = 0%). Low-certainty evidence indicates implementation interventions in stroke rehabilitation may lead to little or no difference in patient adherence to recommended treatment (number of recommended performed outdoor journeys adjusted mean difference (MD) 0.5, 95% CI -1.8 to 2.8; 1 trial, 21 clusters, 100 participants) and patient psychological well-being (standardised mean difference (SMD) -0.02, 95% CI -0.54 to 0.50; 2 trials, 65 clusters, 1273 participants; I2 = 0%) compared with no intervention. Moderate-certainty evidence indicates implementation interventions in stroke rehabilitation probably lead to little or no difference in patient health-related quality of life (MD 0.01, 95% CI -0.02 to 0.05; 2 trials, 65 clusters, 1242 participants; I2 = 0%) and activities of daily living (MD 0.29, 95% CI -0.16 to 0.73; 2 trials, 65 clusters, 1272 participants; I2 = 0%) compared with no intervention. No studies reported the effects of implementation interventions in stroke rehabilitation on healthcare professional intention to change behaviour or satisfaction. Five studies reported economic outcomes, with one study reporting cost-effectiveness of the implementation intervention. However, this was assessed at high risk of bias. The other four studies did not demonstrate the cost-effectiveness of interventions. Tailoring interventions to identified barriers did not alter results. We are uncertain of the effect of one implementation intervention versus another given the limited very low-certainty evidence. AUTHORS' CONCLUSIONS We are uncertain if implementation interventions improve healthcare professional adherence to evidence-based practice in stroke rehabilitation compared with no intervention as the certainty of the evidence is very low.
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Affiliation(s)
- Liana S Cahill
- Occupational Therapy, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Melbourne, Australia
- Neurorehabilitation and Recovery, Stroke, Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, Australia
- Department of Occupational Therapy, School of Allied Health, Australian Catholic University, Fitzroy, Australia
| | - Leeanne M Carey
- Occupational Therapy, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Melbourne, Australia
- Neurorehabilitation and Recovery, Stroke, Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, Australia
| | - Natasha A Lannin
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
- Allied Health, Alfred Health, Melbourne, Australia
| | - Megan Turville
- Occupational Therapy, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Melbourne, Australia
- Neurorehabilitation and Recovery, Stroke, Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, Australia
| | - Cheryl L Neilson
- Rural Department of Allied Health, Rural Health School, La Trobe University, Bendigo, Australia
| | - Elizabeth A Lynch
- Adelaide Nursing School, The University of Adelaide, Adelaide, Australia
- NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Florey Institute of Neuroscience and Mental Health & Hunter Medical Research Institute, Melbourne and Newcastle, Australia
| | - Carol E McKinstry
- Rural Department of Allied Health, Rural Health School, La Trobe University, Bendigo, Australia
| | - Jia Xi Han
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Denise O'Connor
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Allen KAM, Dittmann KR, Hutter JA, Chuang C, Donald ML, Enns AL, Hovanec N, Hunt AW, Kellowan RS, Linkewich EA, Patel AS, Rehmtulla A, McEwen SE. Implementing a shared decision-making and cognitive strategy-based intervention: Knowledge user perspectives and recommendations. J Eval Clin Pract 2020; 26:575-581. [PMID: 31828869 DOI: 10.1111/jep.13329] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 11/04/2019] [Accepted: 11/12/2019] [Indexed: 11/30/2022]
Abstract
The aim of this study was to employ knowledge user perspectives to develop recommendations that facilitate implementation of a complex, shared decision-making (SDM)-based intervention in an interprofessional setting. This study was part of a larger knowledge translation (KT) study in which interprofessional teams from five freestanding, academically affiliated, rehabilitation hospitals were tasked with implementing a cognitive strategy-based intervention approach that incorporates SDM known as Cognitive Orientation to daily Occupational Performance (CO-OP) to treat survivors of stroke. At the end of the 4-month CO-OP KT implementation support period, 10 clinicians, two from each site, volunteered as CO-OP site champions. A semi-structured focus group was conducted with 10 site champions 3 months following the implementation support period. To meet the study objective, an exploratory qualitative research design was used. The focus group session was audio-recorded, transcribed verbatim and analyzed through the lens of the integrated promoting action on research implementation in health services (iPARIHS) framework. The focus group participants (n = 8) consisted of occupational therapists, physical therapists, and speech language pathologists. Ten recommendations for CO-OP implementation were extracted and co-constructed from the focus group transcript. The recommendations reflected all four iPARHIS constructs: Facilitation, Context, Innovation, and Recipients. Implementation recommendations, from the knowledge user perspective, highlight that context-specific facilitation is key to integrating a novel, complex intervention into interprofessional practice. Facilitators should lay out a framework for training, communication and implementation that is structured but still provides flexibility for iterative learning and active problem-solving within the relevant practice context.
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Affiliation(s)
- Kay-Ann M Allen
- St. John's Rehab Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Katherine R Dittmann
- St. John's Rehab Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Jennifer A Hutter
- St. John's Rehab Research Program, Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Kinesiology, McMaster University, Toronto, ON, Canada.,Department of Occupational Science & Occupational Therapy, Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | | | - Michelle L Donald
- Health System Planning & Engagement, Central Local Health Integration Network, Toronto, ON, Canada
| | - Amie L Enns
- Neurological Rehabilitation Services, West Park Healthcare Centre, Toronto, ON, Canada
| | - Nina Hovanec
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Anne W Hunt
- Holland Bloorview Kids Rehabilitation Hospital, Bloorview Research Institute, Toronto, ON, Canada.,Department of Occupational Science & Occupational Therapy, Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - Richard S Kellowan
- Bridgepoint Active Healthcare, Sinai Health System, Toronto, ON, Canada.,Stroke & Neuro Rehab, Providence Healthcare, Toronto, ON, Canada.,Department of Occupational Science & Occupational Therapy, Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - Elizabeth A Linkewich
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Occupational Science & Occupational Therapy, Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - Alexandra S Patel
- Holland Bloorview Kids Rehabilitation Hospital, Bloorview Research Institute, Toronto, ON, Canada.,Department of Occupational Science & Occupational Therapy, Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | | | - Sara E McEwen
- St. John's Rehab Research Program, Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Physical Therapy, Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
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Linkewich E, Avery L, Rios J, McEwen SE. Minimal Clinically Important Differences in Functional Independence After a Knowledge Translation Intervention in Stroke Rehabilitation. Arch Phys Med Rehabil 2019; 101:587-591. [PMID: 31738892 DOI: 10.1016/j.apmr.2019.10.185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 10/05/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the odds of persons with stroke achieving minimal clinically important difference (MCID) in functional independence during inpatient rehabilitation relative to cognitive impairment (CI) severity, site, and rehabilitation teams' exposure to a Cognitive Orientation to daily Occupational Performance (CO-OP) knowledge translation (KT) intervention. DESIGN A pre-post observational study was conducted using data from a centralized referral system. Our research team implemented a CO-OP KT intervention as part of a larger study aimed at training teams to use the CO-OP approach. SETTING Five inpatient rehabilitation units. PARTICIPANTS Cases extracted from a centralized referral system from the 5 participating units. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The FIM instrument data from 12 months preintervention and 6 months postintervention were analyzed. A logistic regression was performed to determine the odds ratios (ORs) for achieving MCID based on sample cohort (historical control not exposed to CO-OP KT vs post-CO-OP KT intervention), controlling for site and severity of CI. RESULTS A model that considered the intervention, admission score, CI severity, and site was the best fit for the cases analyzed. Those with severe CI were less likely to achieve FIM total MCID compared to those with no CI (P=<.001; OR=.18; 95% confidence interval, .09-.39). Taking site and CI into account, cases post CO-OP KT intervention were significantly more likely to achieve MCID on FIM motor (P=.048; OR=1.4; 95% confidence interval, 1.00-1.98) than historical controls. CONCLUSION The CO-OP KT intervention is associated with increased odds of achieving MCID in the FIM motor subscale in inpatient stroke rehabilitation.
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Affiliation(s)
- Elizabeth Linkewich
- Regional Stroke Centre, Sunnybrook Health Sciences Centre, Toronto, ON; Practice-Based Research, Sunnybrook Research Institute, Toronto, ON; Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON.
| | - Lisa Avery
- Avery Information Services Ltd., Orillia, ON
| | - Jorge Rios
- St. John's Rehab Research Program, Sunnybrook Research Institute, Toronto, ON
| | - Sara E McEwen
- St. John's Rehab Research Program, Sunnybrook Research Institute, Toronto, ON; Department of Physical Therapy, University of Toronto, Toronto, ON; Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
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McEwen SE, Donald M, Jutzi K, Allen KA, Avery L, Dawson DR, Egan M, Dittmann K, Hunt A, Hutter J, Quant S, Rios J, Linkewich E. Implementing a function-based cognitive strategy intervention within inter-professional stroke rehabilitation teams: Changes in provider knowledge, self-efficacy and practice. PLoS One 2019; 14:e0212988. [PMID: 30856191 PMCID: PMC6411258 DOI: 10.1371/journal.pone.0212988] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/13/2019] [Indexed: 01/22/2023] Open
Abstract
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).
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Affiliation(s)
- Sara E. McEwen
- St. John’s Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Donald
- North & East GTA Stroke Network, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Katelyn Jutzi
- St. John’s Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Kay-Ann Allen
- St. John’s Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Lisa Avery
- Avery Information Services Ltd., Orillia, Ontario, Canada
| | - Deirdre R. Dawson
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Department & Occupational Science & Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
- Rotman Research Institute, Baycrest, Toronto, Ontario, Canada
| | - Mary Egan
- School of Rehabilitation Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Katherine Dittmann
- St. John’s Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Anne Hunt
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Department & Occupational Science & Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Jennifer Hutter
- St. John’s Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Sylvia Quant
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- North & East GTA Stroke Network, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jorge Rios
- St. John’s Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Elizabeth Linkewich
- North & East GTA Stroke Network, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department & Occupational Science & Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
- Practice-Based Research, Sunnybrook Research Institute, Toronto, Ontario, Canada
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Gimeno H, Brown RG, Lin JP, Cornelius V, Polatajko HJ. Cognitive approach to rehabilitation in children with hyperkinetic movement disorders post-DBS. Neurology 2019; 92:e1212-e1224. [PMID: 30796136 DOI: 10.1212/wnl.0000000000007092] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 11/06/2018] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE This proof-of-concept feasibility trial examined the potential of the Cognitive Orientation to daily Occupational Performance Approach (CO-OP) to augment deep brain stimulation (DBS) outcomes in childhood-onset hyperkinetic movement disorders (HMD) including dystonia and dyskinetic cerebral palsy. METHODS This is a single case experimental design using multiple baseline as n-of-1 trial comprising 10 intervention sessions, with replications across participants (n = 10). Treatment focused on 3 participant-selected goals. Transfer was assessed on 2 additional untreated goals. Individuals enrolled were 6-21 years of age and had DBS in situ and sufficient manual ability. Primary outcome was functional performance change on the Performance Quality Rating Scale-Individualized (PQRS-i) measured before, during, and posttreatment, and at 3-month follow-up. Assessors of outcome were blinded to time of assessment, number of intervention session, and treatment allocation. To measure effect size, a nonoverlapping index, Tau-U, was used. Feasibility measures were captured. RESULTS One participant withdrew before baseline assessment. Effect sizes of at least 0.66 were seen at both posttreatment and follow-up with all participants showing improvements in at least one trained goal in PQRS-i. Six participants improved on all 3 goals and 2 improved on 2 trained goals. Two children showed deterioration in one trained goal each. Transfer to untrained goals was observed in 3 participants for a total of 5 goals. CO-OP was feasible and acceptable to all participants. CONCLUSION A cognitive-based, task-oriented approach to support performance of personally relevant functional skills enabling participation is acceptable in childhood-onset HMD post-DBS. Further, preliminary efficacy to improve outcomes and proof of concept with CO-OP has been established in this population. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for children with HMD who had undergone DBS, CO-OP improves performance of personally relevant functional skills.
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Affiliation(s)
- Hortensia Gimeno
- From the Complex Motor Disorders Service (H.G., J.-P.L.), Paediatric Neuroscience, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust; Department of Psychology (H.G., R.G.B.), Institute of Psychiatry, Psychology and Neurosciences, King's College London; South London and Maudsley NHS Foundation Trust (R.G.B.); School of Public Health (V.C.), Imperial Clinical Trials Unit, Imperial College London, UK; and Department of Occupational Science and Occupational Therapy (H.J.P.), University of Toronto, Canada.
| | - Richard G Brown
- From the Complex Motor Disorders Service (H.G., J.-P.L.), Paediatric Neuroscience, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust; Department of Psychology (H.G., R.G.B.), Institute of Psychiatry, Psychology and Neurosciences, King's College London; South London and Maudsley NHS Foundation Trust (R.G.B.); School of Public Health (V.C.), Imperial Clinical Trials Unit, Imperial College London, UK; and Department of Occupational Science and Occupational Therapy (H.J.P.), University of Toronto, Canada
| | - Jean-Pierre Lin
- From the Complex Motor Disorders Service (H.G., J.-P.L.), Paediatric Neuroscience, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust; Department of Psychology (H.G., R.G.B.), Institute of Psychiatry, Psychology and Neurosciences, King's College London; South London and Maudsley NHS Foundation Trust (R.G.B.); School of Public Health (V.C.), Imperial Clinical Trials Unit, Imperial College London, UK; and Department of Occupational Science and Occupational Therapy (H.J.P.), University of Toronto, Canada
| | - Victoria Cornelius
- From the Complex Motor Disorders Service (H.G., J.-P.L.), Paediatric Neuroscience, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust; Department of Psychology (H.G., R.G.B.), Institute of Psychiatry, Psychology and Neurosciences, King's College London; South London and Maudsley NHS Foundation Trust (R.G.B.); School of Public Health (V.C.), Imperial Clinical Trials Unit, Imperial College London, UK; and Department of Occupational Science and Occupational Therapy (H.J.P.), University of Toronto, Canada
| | - Helene J Polatajko
- From the Complex Motor Disorders Service (H.G., J.-P.L.), Paediatric Neuroscience, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust; Department of Psychology (H.G., R.G.B.), Institute of Psychiatry, Psychology and Neurosciences, King's College London; South London and Maudsley NHS Foundation Trust (R.G.B.); School of Public Health (V.C.), Imperial Clinical Trials Unit, Imperial College London, UK; and Department of Occupational Science and Occupational Therapy (H.J.P.), University of Toronto, Canada
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