Using the Cognitive Orientation to daily Occupational Performance ...

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Using the Cognitive Orientation to daily Occupational Performance (CO-OP) Treatment Approach with Adults

with Stroke: Efficacy and Adaptations

by

Sara Elizabeth McEwen

A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy

Graduate Department of Rehabilitation Science University of Toronto

© Copyright by Sara Elizabeth McEwen 2009

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Abstract

Using the Cognitive Orientation to daily Occupational

Performance (CO-OP) Approach with Adults with Stroke:

Efficacy and Adaptations

Sara Elizabeth McEwen

Doctor of Philosophy

Graduate Department of Rehabilitation Science

University of Toronto

2009

This thesis reports on a multi-phased research project conducted to evaluate the use of the

Cognitive Orientation to daily Occupational Performance (CO-OP) approach with adults with

stroke. Current approaches to motor recovery, called systems approaches, suggest that

movement arises from a dynamic interaction among several different systems, including

perception, cognition, and action, all within the context of the individual and his or her

environment. CO-OP is an established treatment approach for children with motor-based

performance problems that takes into account interactions among several systems, as well as

individual needs and environmental factors. CO-OP is a client-centred, problem solving

approach based on the theoretical foundations of learning and motor learning theory. The

objectives of this project were: to examine the efficacy of CO-OP to improve motor skill

acquisition and performance in adults living with chronic stroke; to explore other benefits of the

approach; and to identify adaptations for use with adults with stroke. Two series of single case

experimental studies were conducted, with three participants completing each. In addition, semi-

structured interviews were conducted. Findings from the single case experiments provide

evidence that CO-OP is associated with performance improvements in both trained and untrained

self-selected goals in adults more than one year post stroke. As well, pre-post measures suggest

there may be changes in performance satisfaction, motor control, generalized use of the affected

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upper extremity, and self-efficacy. Interview findings provided valuable information about the

experiences of participants with the approach; the interview respondents enjoyed the increased

sense of responsibility that came with problem solving on their own, but expressed a desire to

have ongoing professional support. Suggestions for modifications to CO-OP for use adults with

stroke are made. CO-OP is a promising approach to improve functional independence in adults

with stroke. Future research is warranted.

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Acknowledgments

“I not only use all of the brains I have, but all I can borrow.” Woodrow Wilson (1856-1924).

I have not only borrowed from the brains of a good number of people to complete this doctoral

thesis, but have also borrowed of their time, patience, good will, good cheer, generosity, and

forgiveness.

Dr. Helene Polatajko, my primary supervisor, was the main reason I decided to return to graduate

school. There isn‟t much I can say about Dr. Polatajko that hasn‟t been said before; she is an

extraordinary person, and I owe her much. During the last four years of graduate school, and in

the preceding years I was in her employ, Dr. Polatajko has enabled me to refine my critical

thinking and problem solving skills, has provided me with the tools and encouragement to move

forward in my academic career, and has done so all in the most enjoyable, delightful,

inconspicuous manner. She is a mentor, and I thank her profusely for all she has done for me.

I have been honoured to have Dr. Maria Huijbregts and Dr. Jennifer Ryan form the rest of my

advisory committee. I thank them both for the time they took to read drafts of proposals,

abstracts, papers, and for their excellent critical thinking around thesis questions, methodology,

analysis, and presentation.

Dr. Huijbregts has long been a role model to me as someone who views physiotherapy, stroke

rehabilitation, and research in a holistic manner. I have enjoyed collaborating with her on this

and other projects, her musings on family life, and her endorsement of skate skiing over classic.

Dr. Ryan is a rare individual who somehow manages to be brilliant, dedicated, focused and over-

achieving while remaining fun, enthusiastic, and approachable. She has a contagious and

inspiring love of being a scientist, and I thank her for that above all.

This project would not have been possible without the research participants. Thank you all so

very much for your time and interest in this project, as well as your thoughts, reflections, and

advice.

Dr. Dina Brooks, the Graduate Coordinator in the Graduate Department of Rehabilitation

Science, has been a helpful, approachable, available guide throughout the PhD process. More

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importantly, she is highly competent and always manages to point out something very crucial of

which no one else has thought.

Thanks to the Occupational and Physical Therapists at Baycrest for sharing their treatment

spaces, equipment, and information. Special thanks to Angela Chan, Lynda Dunal, Carolyn

McCullough, Bianca Stern, and Hedda Zahavi.

My long-time lab mate and good buddy, Jane Davis has been an enormous support throughout

this process. Thanks, Jane, for everything, and thanks especially for teaching me other ways of

knowing.

Thanks very much for all the help I received from many of the people who work or have worked

in Dr. Polatajko‟s lab: Ted Myerscough, Tammy Craig, Melissa Hyland, Diana Kinslikh,

Rajeetha Neminathan, Munirah Quraishi, Aimee Schneiderman, and Randeep Soor.

I was very fortunate to have scholarship funding from the Social Sciences and Humanities

Research Council and the University of Toronto Graduate Department of Rehabilitation Science.

Without this funding, I would absolutely not have been able to return to full-time studies. I was

also fortunate to receive research funding from the Physiotherapy Foundation of Canada, which

assisted greatly with the implementation of the research project and the dissemination of results.

Thanks to my fabulous parents, Joanna and Peter McEwen, for their longstanding support, and

for having fostered free thinking, curiosity and a love of learning from an early age.

Thanks to my smart, beautiful, funny, and mostly perfect daughters, Fiona and Samantha

Johnston, for being yourselves.

And, last, but absolutely not least, thanks to John Johnston, my exceptionally kind, loving, and

supportive husband.

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Table of Contents

Abstract ........................................................................................................................................... ii

Acknowledgments.......................................................................................................................... iv

Table of Contents ........................................................................................................................... vi

List of Tables ................................................................................................................................. xi

List of Figures ............................................................................................................................... xii

List of Appendices ....................................................................................................................... xiii

Chapter 1 Background and rationale................................................................................................1

1 Background and rationale ...........................................................................................................2

1.1 Introduction ..........................................................................................................................2

1.2 The consequences of stroke .................................................................................................2

1.3 Theoretical foundations of stroke rehabilitation ..................................................................4

1.3.1 The International Classification of Functioning, Disability, and Health (ICF) .......7

1.3.2 Neural plasticity .......................................................................................................9

1.3.3 Motor learning .........................................................................................................9

1.3.4 Motor learning and neural plasticity ......................................................................12

1.3.5 The role of motivation in motor learning ...............................................................13

1.3.6 The role of cognition in motor control and motor learning ...................................15

1.3.7 Cognitive strategies ................................................................................................17

1.4 Stroke rehabilitation interventions .....................................................................................18

1.4.1 Therapist-assisted locomotor training ....................................................................19

1.4.2 Constraint-induced movement therapy (CIMT) ....................................................26

1.4.3 Cognitive strategy training .....................................................................................27

1.5 Cognitive Orientation to daily Occupational Performance (CO-OP) ................................29

1.6 Rationale and objectives ....................................................................................................32

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1.7 Methods and thesis overview .............................................................................................33

Chapter 2 Exploring a Cognitive-Based Treatment Approach to Improve Motor Skill

Performance in Chronic Stroke: Results of Three Single Case Experiments. ..........................36

2 Exploring a cognitive-based treatment approach to improve motor skill performance in

chronic stroke: Results of three single case experiments. .........................................................37

2.1 Abstract ..............................................................................................................................37

2.2 Introduction ........................................................................................................................37

2.3 Rationale, objective, and research questions .....................................................................40

2.4 Methods..............................................................................................................................41

2.4.1 Participants .............................................................................................................41

2.4.2 Design ....................................................................................................................42

2.4.3 Ethics......................................................................................................................42

2.4.4 Intervention description .........................................................................................42

2.4.5 Measurement ..........................................................................................................44

2.4.6 Analysis..................................................................................................................46

2.5 Results ................................................................................................................................47

2.5.1 Description of participants .....................................................................................47

2.5.2 Single case experimental design findings: P1 ........................................................47



2.5.5 Quasi experimental findings: Self-reported performance and performance

satisfaction, health status and self-efficacy/confidence .........................................53

2.6 Discussion ..........................................................................................................................55

2.6.1 Limitations and suggestions for future research ....................................................58

2.7 Conclusion .........................................................................................................................58

2.8 Acknowledgements ............................................................................................................59

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Chapter 3 Inter-task transfer following a cognitive-based treatment: Results of three multiple

baseline design experiments in chronic stroke. .........................................................................60

3 Inter-task transfer following a cognitive-based treatment: Results of three multiple

baseline design experiments in chronic stroke. .........................................................................61

3.1 Abstract ..............................................................................................................................61

3.2 Introduction ........................................................................................................................62

3.3 Methods..............................................................................................................................63

3.3.1 Participants .............................................................................................................63

3.3.2 Design ....................................................................................................................64

3.3.3 Instruments .............................................................................................................65

3.3.4 Intervention description .........................................................................................66

3.3.5 Analysis..................................................................................................................67

3.3.6 Ethics......................................................................................................................68

3.4 Results ................................................................................................................................68

3.4.1 Description of participants .....................................................................................68

3.4.2 Comparison of skills across study phases ..............................................................68

3.5 Discussion: .........................................................................................................................75

3.5.1 Advantages and limitations of the multiple baseline design to evaluate transfer ..79

3.6 Conclusion: ........................................................................................................................79

3.7 Acknowledgements ............................................................................................................80

Chapter 4 “There‟s a real plan here and I‟m responsible for that plan.” Participant

experiences with a novel, cognitive-based treatment approach for adults living with

chronic stroke. ...........................................................................................................................81

4 “There‟s a real plan here, and I‟m responsible for that plan.” Participant experiences with

a novel, cognitive-based treatment approach for adults living with chronic stroke..................82

4.1 Abstract ..............................................................................................................................82

4.2 Introduction ........................................................................................................................82

4.2.1 Incorporating client perceptions in stroke rehabilitation research .........................83

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4.2.2 The Cognitive Orientation to daily Occupational Performance treatment

approach .................................................................................................................84

4.3 Methodology ......................................................................................................................86

4.3.1 Study overview and methods .................................................................................86

4.3.2 Participants and recruitment ..................................................................................86

4.3.3 Data collection and management ...........................................................................88

4.3.4 Data analysis ..........................................................................................................88

4.4 Findings..............................................................................................................................89

4.4.1 Learning CO-OP strategies ....................................................................................90

4.4.2 Generalizing and transferring CO-OP strategies ...................................................90

4.4.3 Considerations for modifications ...........................................................................91

4.4.4 Balancing the need for autonomy with the need for support .................................93

4.5 Discussion ..........................................................................................................................97

4.5.1 Methodological Issues .........................................................................................100

4.6 Conclusions ......................................................................................................................100

Chapter 5 Summary of findings, adapting the approach and general concluding remarks .........102

5 Summary of findings, adapting the approach and general concluding remarks. ....................103

5.1 Introduction ......................................................................................................................103

5.2 Summary of findings........................................................................................................103

5.2.1 Performance on trained, self-selected goals.........................................................104

5.2.2 Skill generalization and transfer ..........................................................................106

5.2.3 Motor Control ......................................................................................................107

5.2.4 Participation .........................................................................................................108

5.2.5 Self-efficacy and autonomy .................................................................................110

5.2.6 Concluding remarks about findings .....................................................................111

5.3 Recommendations for adaptations to the approach .........................................................112

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5.3.1 The key features of CO-OP in adults with stroke ................................................112

5.3.2 Summary of recommended adaptations to the approach .....................................116

5.4 Study limitations ..............................................................................................................117

5.5 Clinical relevance.............................................................................................................120

5.6 General concluding remarks ............................................................................................120

References ....................................................................................................................................122

Appendices ...................................................................................................................................145

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List of Tables

Table Title Page

1.1 Working definitions 6

1.2 Recent stroke rehabilitation intervention studies 21-25

1.3 Key features of the CO-OP treatment approach 31

2.1 Transcribed excerpt of an intervention session to illustrate use of the

global cognitive strategy Goal-Plan-Do-Check

43

2.2 Participant descriptions 47

2.3 PQRS baseline mean, standard deviation, and baseline mean plus 2-

standard deviations

53

2.4 Self-selected goals and Canadian Occupational Performance Measure

(COPM) scores

54

2.5 SIS, SEMCD-6, and ABC scores for all participants 54

3.1 Participant demographics and baseline, post-test, and follow-up scores

for quasi-experimental indicators

69

3.2 Self-selected skills and Canadian Occupational Performance Measure

(COPM) scores

70

4.1 Key features of the CO-OP treatment approach 85

4.2 Participant demographics and clinical profile 87

4.3 Semi-structured interview guide 88

4.4 Participants‟ treatment goals and examples of generalization and

transfer from interviews

91

5.1 Types of goals chosen by children with DCD compared to adults with

stroke

113

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List of Figures

Figure Title Page

1.1 International Classification of Functioning, Disability, and Health 8

2.1 P1 PQRS scores with mean and upper 2 SD limits 50



3.1 Study design, instruments, and timing 65

3.2 P5 PQRS charts with baseline mean and upper and lower control

limits

72


limits

73


limits

74

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List of Appendices

Appendix Title Page

A Information letter and consent form for stroke rehabilitation

professionals focus group participants

145

B Information letter and consent form for participants living with stroke 148

C Stroke rehabilitation professionals‟ focus group guide 152

D Stroke rehabilitation professionals‟ focus group findings 155

E Operational definitions for Performance Quality Rating Scale (PQRS)

for Participants 1-3.

156

F Stroke Impact Scale (SIS) 166

G Stanford Self-Efficacy for Managing Chronic Disease 6-Item Scale 172

H Activity-specific Balance Confidence (ABC) Scale 173

I Chedoke-McMaster Stroke Assessment Impairment Inventory 174

J Reintegration to Normal Living (RNL) Index 176

K Motor Activity Log (MAL) 177

L SPSS output for baseline autocorrelations 183

M SPSS output: Normal P-P plots for PQRS scores for all participant 189

N PQRS inter-rater agreement P1-P3, treating therapist SM compared to

research assistant TC

193

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Chapter 1 Background and rationale

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1 Background and rationale

1.1 Introduction

It is well-known that long-term functional outcomes for many people living with the effects of

stroke are not optimal, and novel rehabilitation intervention approaches are required. Current

approaches to motor control, motor recovery, and motor learning, called systems approaches,

suggest that movement arises from a dynamic interaction among several different systems,

including perception, cognition, and action, all within the context of the individual and his or her

environment (Shumway-Cook & Woollacott, 2007, p.16). A number of novel interventions

incorporating aspects of systems approaches have been investigated, such as task-specific

training or constraint-induced movement therapy, but none have been completely satisfactory in

terms of generalizability (Van Peppen et al., 2004), or clinical utility (Sterr, 2004). The

Cognitive Orientation to daily Occupational Performance (CO-OP) is an established treatment

approach for children with motor-based performance problems that takes into account

interactions among several systems, as well as individual needs and environmental factors

(Polatajko & Mandich, 2004). CO-OP is a client-centred, problem solving approach based on

the theoretical foundations of learning and motor learning theory. The author of this thesis, with

a great deal of guidance from her Advisory Committee, conducted a multi-phased, exploratory

study to investigate the utility of the CO-OP treatment approach for use with adults with stroke.

In this chapter, background information relevant to the project is reviewed, including the

consequences of stroke, current theories of motor recovery after a stroke, and stroke

rehabilitation interventions. As well, CO-OP is described, and an overview of relevant literature

is provided. Finally, the rationale and project objectives are outlined.

1.2 The consequences of stroke

Stroke is so-called because it hits suddenly and unexpectedly, and may lead to permanent

cognitive, physical, emotional, and social changes. Strokes are more formally known as

cerebrovascular accidents, and are defined by the World Health Organization (WHO) as

“rapidly developing clinical signs of focal (at times global) disturbance of cerebral function,

lasting more than 24 hours or leading to death with no apparent cause other than that of vascular

origin”(Aho et al., 1980). The WHO definition, while physiologically accurate, does not reflect

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the long-term consequences of the condition, an issue of concern to rehabilitation professionals.

Stroke is one of the most disabling conditions worldwide (Lopez, Mathers, Ezzati, Jamison, &

Murray, 2006), and is the third most disabling condition in the developed world (Murray &

Lopez, 1997). Decreased ability to care for oneself is the most frequent consequence. Data from

a Swedish stroke registry indicated that in 2005 only about half of people living with stroke were

independent in their activities of daily living (ADL) three months after the event (Appelros,

Samuelsson, Karlsson-Tivenius, Lokander, & Terent, 2007). Although half to three-quarters of

people living with stroke are able to walk independently (Dove, Schneider, & Wallace, 1984;

Jorgensen et al., 1995; Wade, Wood, Heller, Maggs, & Langton Hewer, 1987), less than 20%

walk at normal speed (Wade et al., 1987). Endurance has been reported to be approximately 40%

of predicted normal values (Mayo, Wood-Dauphinee, Ahmed, Gordon, Higgins, McEwen, &

Salbach, 1999).

Two Canadian studies have examined longer-term participation* outcomes for people living with

stroke. In a cohort study following more than 400 people with stroke, 39% of those living in the

community 6 months after the event reported limitations in basic ADL and 54% reported

limitations in instrumental activities of daily living (IADL) (Mayo, Wood-Dauphinee, Cote,

Duncan, & Carlton, 2002). In the same study, nearly two-thirds reported limitations in

community participation, citing restrictions in travel, social activities, recreational activities,

moving around the community, and having an important activity to fill the day as the most

common problems (Mayo et al., 2002). Desrosiers and colleagues (2006) followed 66 people for

two to four years after a stroke, and found that further decline in participation was experienced.

Specifically, they noted significant declines in participation related to nutrition, fitness, personal

care, and housing.

Qualitative research has provided a broader and deeper understanding of stroke outcomes. A

2008 synthesis of qualitative studies concluded loss, uncertainty and social isolation were

important themes described by people living with the effects of stroke, but there was a continued

desire to move forward towards recovery (Salter, Hellings, Foley, & Teasell, 2008). According

* Participation means involvement in a life situation, (World Health Organization, 2001) and is discussed in more

detail later in the chapter.

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to Burton (2000) and Folden (1994), recovery should be defined in relation to the social context

and personal goals of the person living with stroke, and the importance of gaining the perspective

of the person living with stroke in determining outcomes and the meaning of recovery has been

reported by several researchers since (Jones, Mandy, & Partridge, 2008; Mangset, Tor Erling,

Forde, & Wyller, 2008; Ownsworth, Turpin, Andrew, & Fleming, 2007).

In parallel with research aimed at gaining a better understanding of the consequences of stroke, a

wide range of both basic science and intervention studies have been conducted. As our

understanding of the mechanisms underlying stroke recovery has grown, interventions have

evolved. In the next two sections, current theories on recovery following stroke and stroke

rehabilitation interventions are discussed.

1.3 Theoretical foundations of stroke rehabilitation

Stroke occurs when there is a disruption in the blood supply to the brain. Tissue in the

immediate area of the disruption dies, and the functions controlled by that area of the brain are

affected. Initially, recovery may occur as edema subsides. As well, there is an area of diaschisis,

or cell shock, around the injury site that may recover in the first few weeks, allowing some

functions to return (Mountz, 2007). In very mild strokes, complete recovery may occur through

these mechanisms, with no rehabilitation needed (Robertson & Murre, 1999). After this initial

period of natural recovery, the person living with the effects of moderate or severe stroke must

actively engage in rehabilitation in order to make further gains (Robertson & Murre, 1999).

Activities that were affected by the stroke must be relearned, and often this relearning must occur

with reduced physical, cognitive, and emotional capacity, potentially along with severe fatigue

and a host of comorbidities, such as diabetes, chronic lung disease, congestive heart failure, and

peripheral vascular disease (Berlowitz, Hoenig, Cowper, Duncan, & Vogel, 2008). In short,

stroke recovery can be an arduous, uphill battle. Even with active rehabilitation, most gains are

seen in the first 6 months following the stroke (Jorgensen et al., 1995), although there is

increasing evidence that people living with stroke can continue to improve for years after the

event, provided their rehabilitation program offers them the right challenges to surmount the

apparent plateau in motor recovery (Page, Gater, & Bach-Y-Rita, 2004).

The factors influencing the process of stroke recovery have been, and continue to be, widely

studied. The specifics of recovery, of course, vary among individuals, and must be viewed in the

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context of personal and environmental factors. The International Classification of Functioning,

Disability, and Health (ICF) provides a framework for classifying the consequences of chronic

conditions, and as such, provides a useful starting point for a discussion about the broad focus of

stroke rehabilitation (World Health Organization, 2001). Moving to the specific mechanisms of

recovery, it is widely accepted that the brain can change and adapt in response to injury and

training (Bach-y-Rita, 1990; Hallett, 2001; Robertson & Murre, 1999). This phenomenon is

called neural plasticity. To activate this mechanism, it has been argued that “learning” must first

occur (Plautz, Milliken, & Nudo, 2000), and neural plasticity and learning are inextricably

linked.

In the subsections below, neural plasticity, motor learning, and the links between the two are

discussed. The role of motivation and cognition in action, and the utility of cognitive strategies

are also explored. The detailed discussion begins, however, with a subsection describing the ICF

and its relationship to stroke rehabilitation, neural plasticity and motor learning. Table 1.1

provides a list of some of the key constructs discussed in this chapter, and their working

definitions.

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Table 1.1 Working definitions

Construct Definition and comments

Cognition All processes by which sensory input is transformed, reduced,

elaborated, stored, recovered and used (Neiser, 1967).

Cognitive processes Also known as mental processes, these are the components of

cognition and include, but are not be limited to memory,

perception, attention, imagery, language, and executive

functions such as planning, problem solving, reasoning, and

decision making (Matlin, 2005, p.2).

Movement Changes in joint angles and/or the position of the entire body

(Schmidt & Lee, 2005, p. 466).

Actions Actions are activities directed towards an intended goal

(Achtziger& Gollwitzer, 2008, p.272).

Motor learning Motor learning is a set of processes associated with practice or

experience leading to relatively permanent changes in the

capacity for movement (R. A. Schmidt & Lee, 2005, p.302).

Motor learning and motor skill acquisition are considered

synonymous. Motor learning is differentiated from motor

control in that motor control focuses on understanding the

control of movement already acquired, whereas motor learning

focuses on understanding the acquisition or modification of

movement (Shumway-Cook & Woollacott, 2007, p.22).

Cognitive rehabilitation A systematically applied set of medical and therapeutic services

designed to reduce cognitive dysfunction or reduce its impact on

daily life (Katz, Ashley, O'Shanick, & Connors, 2006).

Cognitive strategies Goal-directed and consciously controllable processes that

facilitate or support performance as the learner develops internal

procedures that enable them to perform the desired skill

(Rosenshine, 1997).

Global cognitive

strategy

Cognitive strategies that apply to most situations, and have an

evaluative or regulatory component. These are also called

generic cognitive strategies or metacognitive strategies.

Domain-specific

cognitive strategy

Cognitive strategies that apply to a particular situation, and do

not have an evaluative component.

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1.3.1 The International Classification of Functioning, Disability, and Health (ICF)

The ICF is the World Health Organization‟s classification system for the consequences of

chronic conditions (World Health Organization, 2001). It is based on a biopsychosocial model

of disability, in that it views disability through both medical and social lenses. The

consequences of disability, impairments, activity limitations and participation limitations, are

seen as resulting from disruptions to body functions and structures, in the context of personal and

environmental factors (See Figure 1.1).

To examine the ICF model in more detail, take the example of an individual who has had a

stroke. At the top of the figure is the person‟s overall level of function and disability. The area

and size of his or her stroke lesion, and the resulting impairments to body functions and

structures, are clearly associated with the overall level of function. However, it is also apparent

that this is only one component of the equation. At the bottom of the figure, personal and

environmental factors interact with each other, and along with impairment, impact the activities

the individual performs. In turn, all impact overall participation, or involvement in life

situations. Environmental factors include technology, natural and human-made environment,

support, attitudes, and services, systems, and policies (World Health Organization, 2001).

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Figure 1.1 International Classification of Functioning, Disability, and Health (ICF)

Reproduced with permission of the World Health Organization from page 9 of Towards a Common Language for

Functioning, Disability, and Health: ICF (Beginner‟s Guide). Geneva: World Health Organization, 2002. Retrieved

from http://www.who.int/entity/classifications/icf/training/icfbeginnersguide.pdf

Stroke rehabilitation has traditionally focused on impairment-level treatments, such as reducing

muscle tone, improving balance, or improving attention and memory. The belief has been that

altering body functions and structures would eventually translate to improvements in activity and

participation, and subsequently overall improved function. There is little empirical evidence to

suggest this to be true (Cicerone et al., 2005; Van Peppen et al., 2004), and in more recent years,

more holistic theories have emerged. In Shumway-Cook and Woollcott‟s 3rd edition (2007) of

Motor Control: Translating Research into Clinical Practice, their version of the systems

approach to motor control is described (p.16-17). They argue that movement emerges from a

complex interaction among the individual, the task, and the environment. Within person factors

include perception, cognition, and action systems, and movement results from an interplay of

these three systems. Task-based rehabilitation practices have emerged from this and other

similar theories, such as Carr and Shepherd‟s Motor Relearning Programme for Stroke (1987),

arguing that individuals need to learn specific tasks or skills in their own context if they are to

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have optimal stroke recovery. Interventions aimed at reducing impairments are often successful

at reducing the impairment, but these reductions do not often translate into improvements in

activities (Gabr, Levine, & Page, 2005; Gustafsson & McKenna, 2006; Wang et al., 2007). For

changes at either the impairment or activity level to occur, however, it is assumed that the brain

must be able to change. In other words, neural plasticity must occur; this is discussed next.

1.3.2 Neural plasticity

Rehabilitation practitioners working with clients with neuropathology have long believed the

brain to be plastic or changeable, and evidence of this possibility has been accumulating since

the 1960s (Bach-y-Rita, 1990). Neural plasticity refers to the brains ability to change its own

structure and function through thought and activity (Doidge, 2007). Evidence from animal

research, imaging, autopsies, and a variety of other techniques, suggests the human brain

continues to produce functional neurons after birth and long into adulthood, at least in certain

brain areas (Kaneko & Sawamoto, 2009). There is also evidence to suggest that specific

functions of neural pathways can change, or new pathways can be developed (Chen, Cohen, &

Hallett, 2002). Hallet (2001) described four main mechanisms of neural plasticity. Latent

neurons may be disinhibited, or unmasked; there may be a relative strengthening or weakening

of existing synapses, called respectively long-term potentiation or long-term depression; there

may be a change in neuronal membrane excitability; there may be actual anatomical changes,

such as the spouting of new axons or the development of new synapses. The first three

mechanisms can occur relatively quickly, whereas the fourth, anatomical change, needs a longer

period of time, perhaps months or years (Hallett, 2001).

Imaging studies in people with stroke have demonstrated that cortical excitability patterns are

different from controls (Battaglia et al., 2006), and that cortical excitability patterns can change

in response to training regimes, providing evidence of neural plasticity (Liepert, 2006). Plautz,

Milliken, and Nudo (2000) have postulated that motor learning is a prerequisite for neural

plasticity, or at least for changes in the motor cortex. Motor learning is introduced below,

followed by an exploration of the links between motor learning and neural plasticity.

1.3.3 Motor learning

Motor learning has been defined by Schmidt and Lee (2005) as the relatively permanent change

in the capacity for movement (p.302). Motor learning is said to occur through practice and

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repetition of the target movement, task, or skill. The specifics of practice, however, can impact

the efficiency with which the movement is learned and retained; practice variables include

feedback, distribution of practice, and variability of tasks practiced. A motor learning paradox

exists, in which practice variables that improve performance seem to hinder longer-term learning

or retention, and vice versa (Guadagnoli & Lee, 2004). For example, giving feedback after each

trial to a motor learner is likely to improve his or her task performance, compared to summary

feedback, in which feedback is given after several trials. However, upon re-testing task

performance at a later date, it is likely the person who had been given summary feedback would

perform better than the person who had more frequent feedback, indicating better retention with

summary feedback. This paradox does not necessarily hold true as the task gets more complex

(Guadagnoli & Lee, 2004). It has been theorized in the Challenge Point Framework that

manipulating practice variables to provide an optimal challenge during motor skill acquisition

improves the efficiency of learning (Guadagnoli & Lee, 2004). The authors of the Challenge

Point Framework state that learning only occurs in the presence of new information, and that

learning arises from an interaction among the task difficulty, the skill level of the learner, and the

information available to the learner. In the case of motor learning, the new information may be

extrinsic, such as augmented feedback from a video or observer, or intrinsic, such as kinesthetic

feedback. If there is insufficient new information or too much new information, learning does

not occur.

In the context of stroke rehabilitation, Page and colleagues (2004) made a similar argument

regarding the presumed motor plateau experienced by people living with stroke. They argued

there is likely no motor plateau after a stroke, but rather, clients adapt to their therapeutic

regimes. In the language of the Challenge Point Framework, they are unable to make gains

because the optimal challenge point has not been reached, and they aren‟t being provided with

any new information. Exposure to more intense interventions or interventions with a different

focus may enable them to improve.

As the Challenge Point Framework stipulates an “optimal” amount of information to process, too

much information may also be a problem that stalls learning. In the case of stroke recovery,

evidence is accumulating to suggest that there are differences in motor learning in some

individuals living with stroke, depending on the type, severity, and location of injury, and the

type of task being learned. For example, patients with unilateral cerebellar stroke show

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lateralized deficits in motor preparation and motor imagery compared to matched controls

(Battaglia et al., 2006). In more severely impaired individuals, skill learning takes longer and

error correction patterns are atypical, whereas those with mild stroke tend to respond similarly to

the control population (Dancause, Ptito, & Levin, 2002). Dancause and colleagues postulated

that the more severely impaired individuals may be having difficulty rapidly integrating

proprioceptive and visual information. Cirstea and colleagues found associations between better

verbal memory, mental flexibility and planning, and improved retention of performance

components of a reaching task, when knowledge of performance feedback was given, but not

when knowledge of results feedback was given (Cirstea, Ptito, Levin, 2006). Boyd and Winstein

have published a series of articles investigating the impact of explicit information on motor

sequence learning after a stroke. They have demonstrated that explicit information is detrimental

to motor sequence learning in those with middle cerebral artery (Boyd & Winstein, 2003) and

basal ganglia stroke (Boyd & Winstein, 2004b), and to temporal accuracy in those with

cerebellar stroke (Boyd & Winstein, 2004a). Also examining the impact of extrinsic information

on learning a balancing task, Orrell, Eves, and Masters (2006) found that the addition of a

cognitive task impaired balance in a discovery learning group, but not in an implicit, errorless

learning group. These various examples provide evidence that, in some cases, increased

cognitive load is associated with impaired motor performance and learning.

Shumway-Cook and Woollacott (2007) have suggested that making a distinction between motor

learning and motor relearning following an injury may be misleading, and that the issues faced

by someone with impairments learning to reacquire movement skills are similar to issues faced

by an unimpaired person learning or modifying movement (p.22). In a broader context, there is

evidence to suggest people with stroke respond similarly to those without in terms of practice

and feedback (Hanlon, 1996; van Vliet & Wulf, 2006). For example, in van Vliet and Wulf‟s

(2006) review of extrinsic feedback in motor learning after a stroke, many findings paralleled the

findings in the neurologically-intact population, such as providing summary feedback and

feedback inducing an external focus of attention being associated with improved motor learning.

There is also evidence from animal models to suggest that motor relearning following a motor

cortex lesion very closely parallels pre-stroke learning (Gharbawie and Whishaw, 2006).

Motor learning is felt to be a key mechanism by which stroke recovery occurs (Krakauer, 2006),

and as such, the manner in which it is facilitated should be optimized for the particular individual

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recovering from stroke. As mentioned above, some researchers believe that motor learning is a

prerequisite for neural plasticity. The links between these two concepts are explored in more

detail next.

1.3.4 Motor learning and neural plasticity

While Guadagnoli and Lee maintain that an optimal amount of new information is a prerequisite

for optimal motor learning to occur, Plautz, Milliken, and Nudo (2000) have postulated that

motor learning itself is a prerequisite for neural plasticity, or at least for changes in the motor

cortex. Their research found that while the acquisition of a new motor skill produced changes in

the motor cortex in monkeys (Nudo, Milliken, Jenkins, & Merzenich, 1996), simple repetitive

practice in the absence of new skill learning did not (Plautz et al., 2000). This same link between

motor learning and neural plasticity has also been inferred in human studies (Hallett, 2001). For

example, brain representations of the finger muscles used in Braille are significantly enlarged in

Braille readers, compared to blind, non-Braille reading controls (Chen et al., 2002).

It has also been argued that neural plasticity in response to movement or absence of movement

may be maladaptive. After a stroke, functional losses may occur in undamaged brain tissue if no

attempts are made to begin relearning impaired activities (Krakauer, 2006; Nudo et al., 1996).

Compensatory* movement patterns that are learned and retained will, in all likelihood, cause

neural changes, and may make later attempts at recovering pre-stroke movement difficult. In a

recently published article discussing compensation versus recovery, Levin, Kleim, and Wolf

(2008) give the example of a person with stroke executing a previously bimanual task using one

hand and his teeth, rather than two hands. Indeed, this may be considered “maladaptive” by

some clients who strive to regain the use of their hemiplegic hand. However, others may

perceive the effort required to accomplish a task using the hemiplegic hand to be overly

burdensome and time consuming, and they would prefer to use their teeth in the name of

efficiency. In other words, maladaptivity is an individual and subjective concept.

* While the definition of compensation versus recovery is controversial (Levin et al., 2008), for the purposes of this

discussion recovery refers to doing things the way they were done before, whereas compensation refers to doing

them in a new way.

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In stroke rehabilitation, because an area of the brain, to the best of our knowledge, is

permanently damaged, we place a lot of hope in neural plasticity when working to help clients

relearn the tasks and activities they need to do to lead meaningful lives (Bach-y-Rita, 1990).

Regardless of whether people with stroke are working to recover function they had before the

stroke, or to compensate in some way for that lost function, they must learn or relearn skills, and

the central nervous system must adapt. The question becomes how best to maximize both their

capacity to learn and the adaptability of the central nervous system. While maximizing the

capacity to learn can be impacted by a number of variables, wanting or needing to learn, or

motivation, is a factor upon which many others depend. As well, the importance of cognition in

many motor learning situations has been recognized. Motivation and cognition are discussed in

the next two sections.

1.3.5 The role of motivation in motor learning

Motivation can be thought of as the reasons for acting. A number of theories of motivation have

been developed, ranging from earlier theories based on basic biological needs, such as drive

reduction theory (Hull, 1943), to social cognitive theories of motivation, such as self-

determination theory (Deci, 1985). Cognitive neuroscience has also contributed to our

understanding of motivation, in that specific brain areas linked to motivation have been

identified (Schultheiss & Wirth, 2008), and people with lesions in these areas can present with

motivation deficits (Feinstein, 1999).

Overall, motivation, or the reasons for acting, is highly complex, but can be simplified and

thought of as either striving for control or activating/deactivating goals (Heckhausen

&Heckhausen, 2008, p.1). Influences on reasons for acting can be reduced to person factors and

situational factors. The Rubicon model of action phases proposes motivation and action/volition

are inextricably linked, but separate entities (Heckhausen & Gollwitzer, 1987). The Rubicon

model begins with the deliberative phase, proceeds to planning, then action, and finally

evaluation. The deliberative and evaluative phases rely on motivation, whereas the planning and

action phases rely on volition, or the selection of processes to translate goals into actions. In the

deliberative phase, wishes and needs are considered in terms of desirability, feasibility, and

potential positive and negative consequences. When all has been considered, and different

motivational influences exercised, a wish or need may be formulated into a concrete goal, and an

intention is formed. Formulation of a goal/intention marks the transition to the volitional

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planning phase, and as the name of the model suggests, the Rubicon is crossed, and turning back

is unlikely. Planning leads to action, and after the action phase, outcomes are evaluated, and the

person looks forward to future goals.

Goal setting is common in stroke rehabilitation, and is felt to influence adherence to treatment

programs (Levack et al., 2006). However, actual goal achievement rates six months post

rehabilitation discharge have been reported at only 20% (Brock et al., 2008). We can postulate

that people with stroke may have greater difficulty crossing the Rubicon between deliberation

and planning/action. A client-centred approach may help to bridge the divide. A client-centred

approach is one in which therapists actively encourage the participation of the client, family,

significant other, and caregivers (Randall & McEwen, 2000). There is indirect evidence to

suggest that goal achievement is improved if goals have been set in collaboration with the client.

For example, when the client defines goals that then become the focus of intervention,

performance outcomes and satisfaction are improved (Law et al., 1994). If we assume the

Rubicon model to be valid, client definition of goals represents a critical piece in moving from

deliberation to planning/action; it is difficult to image how a health care provider could

accurately weigh, on behalf of a client, the desirability, feasibility, and consequences of various

goals, in order to set a goal that will permit the movement forward to goal striving.

The types of goals selected may also influence how easily an individual moves from goal setting

to goal achievement. Achievement goal theory differentiates between mastery goals and

performance goals (Ames, 1992). In using mastery goals, the learner is engaged for the purpose

of mastering skills and improving competence. In using performance goals, the learner hopes to

demonstrate competence, usually in comparison to others. Performance goals, also called ego

goals, are further subdivided into performance-approach (wanting to demonstrate high ability)

and performance-avoidance (wanting to avoid failure or to avoid demonstration of low ability).

The use of mastery goals rather than performance goals is considered to be more motivating, as it

has been associated with challenge seeking, persistence, positive affect, active cognitive

engagement, and the valuing and using of adaptive cognitive strategies. In a service

provider/service receiver relationship, the service provider can construct a situation to influence

whether the service receiver sets mastery goals or performance goals (Bereby-Meyer & Kaplan,

2005).

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The action perspective of motivation states goal setting and goal striving are separate entities,

and that motivation alone is insufficient to achieve a goal (Heckhausen & Heckhausen, 2008, p.

273). Successful goal achievement relies on specific cognitive processes in each of the action

phases. Action and cognition are closely linked, just as are action and motivation. The role of

cognition in motor control and motor learning is discussed below.

1.3.6 The role of cognition in motor control and motor learning

Cognition refers to all processes by which sensory input is transformed, reduced, elaborated,

stored, recovered and used (Neisser, 1967). The specific processes include memory, attention,

perception, problem-solving, mental imagery, language, problem-solving, reasoning, and

decision-making (Matlin, 2005, p.2). The role of cognition in movement and motor skill

acquisition is, at best, not well understood (Serrien, Ivry, & Swinnen, 2007), and at worst,

neglected (Rosenbaum, 2005); recently, however, efforts to link the two domains have become

more explicit (Ezekiel, Lehto, Marley, Wishart, & Lee, 2001; Guadagnoli & Lee, 2004; T. D.

Lee, Swinnen, & Serrien, 1994; Lee & Wishart, 2005; Lidor, Tennant, & Singer, 1996;

Rosenbaum, 2005; Serrien et al., 2007; Singer, Flora, & Abourezk, 1989; Tennant, Murray, &

Tennant, 2004) .

While it is generally accepted that attention and perception are important to motor skill

acquisition (Shumway-Cook & Woollacott, 2007), research in the last decade has revealed more

specific links between the cognitive and motor domains. In a review article outlining the links

between action and cognition, Serrien and colleagues (2007) conclude that the convergence

between the two domains is particularly prevalent during acquisition of complex motor skills;

with the variation of external factors, such as feedback availability; and the variation of internal

factors, such as the presence of neuropathology. As movement becomes more complex,

neuroimaging data indicate an overall increase in neural activity, including increased

involvement of prefrontal areas, suggesting an increased use of executive functions. After a task

has been mastered, the amount of prefrontal activity is reduced (Doyon, Penhune, & Ungerleider,

2003; Meister et al., 2005; Puttemans, Wenderoth, & Swinnen, 2005), but may increase again if

the task demands change (Jueptner et al., 1997).

The feedback available during a movement task affects the cognitive processing. Most notably,

when the movement intent and sensory outcome are incongruent, considerable cognitive

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resources are engaged beyond what is required to simply correct the movement, and Serrien and

colleagues (2007) write that cognitive guidance is required when “irregular, erroneous, or

ambiguous signals” occur . Internal factors, such as aging and neuropathology, can also impact

cognitive processing during movement, and compensatory processing to support motor function

has been observed (Serrien et al., 2007). While several models have been proposed to explain

this phenomenon, a common feature is the involvement of higher-order processes coordinating

information across brain regions during complex behaviour (Serrien et al., 2007). The cognit is

one such model (Fuster, 2006), described here in more depth to help illustrate the links between

action and cognition. Cognits are neural networks of a particular item of memory or knowledge,

consisting of networks of cortical neurons associated with each other by experience. Perceptual

and executive cognits exist separately in the posterior (sensory) and frontal (motor) cortical

areas, respectively. They can be imagined as inverted cones, with the smaller, apical end

coinciding with deeper, basic sensory or motor brain areas, and the broader ends diverging

towards brain areas representing more abstract functions, such as conceptualizing in perceptual

cognits and planning in executive cognits. However, through the perception-action cycle,

perceptual and executive cognits interact: Sensory information is analyzed in the context of

existing perceptual cognits and processed in the context of existing executive cognits. While

automatic behaviour does not need to engage the highest cortical levels, new behaviours or those

requiring decision-making do. Fuster infers, for example, that working memory is not located in

a specific brain area, but is the temporary activation of cognits of long-term memory, and the

subsequent updating of them for the attainment of a goal in the near future. He further infers that

working memory is maintained through a reverberation between frontal (executive function) and

posterior (sensory percept) areas. As an example from neuroimaging studies, acquiring a

complicated bimanual coordination task showed neural activation concentrated in both frontal

and parietal areas (Ullen, Forssberg, & Ehrsson, 2003).

The manner in which cognitive processes are used while learning a movement or while executing

a previously-learned movement can either enhance or be detrimental to performance. For

example, experiments by Swinnen and colleagues demonstrated better task retention in a group

provided with delayed feedback and asked to self-estimate what the feedback would be while

waiting, compared to a group receiving instantaneous feedback, with no self-estimation

(Swinnen, Schmidt, Nicholson, & Shapiro, 1990). The attentional focus literature indicates when

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thoughts are directed to something outside of the body (external focus) rather than on a specific

body part (internal focus), learning and performance improves (McNevin, Shea, & Wulf, 2003;

Park, Shea, McNevin, & Wulf, 2000; Shea & Wulf, 1999; Wulf, Shea, & Park, 2001). For

example, Park, Shea and Wulf (2000) compared learning to balance a stabilometer focusing

either on their feet (internal focus) or on two markers attached to the stabilometer platform

(external focus) and found learning to be enhanced in the external focus condition (Park et al.,

2000). A related concept, reinvestment, refers to consciously thinking about movements in a

task that is already learned and automatic, usually during stressful performances, such as

competition, or when being observed (Maxwell, Masters, & Poolton, 2006). When reinvestment

occurs, performance worsens. Recent research suggests that reinvestment is more likely to occur

in people living with stroke than age-matched controls, perhaps suggesting increased movement

self-consciousness related to impaired motor control (Orrell, Masters, & Eves, 2009). In the

motor learning section above, several examples of detrimental effects on motor learning under

conditions of extrinsic information provision in people with stroke.

Also in the motor learning section, the Challenge Point Framework was introduced, in which

motor skill acquisition is felt to be closely related to the amount of information a particular

individual is capable of processing under the particular task conditions. Too much or too little

information to process during skill acquisition can hinder the process, thus knowing how to

manage one‟s thoughts during movement can impact the efficiency of learning and the quality of

performance. The use of cognitive strategies has been suggested as a means to this end.

1.3.7 Cognitive strategies

Cognitive strategies have been defined as goal-directed and consciously controllable processes

that facilitate or support performance as learners develop internal procedures that enable them to

perform the desired skill (Rosenshine, 1997). Cognitive strategies have long been used in

education to improve student success in declarative learning (Zimmerman, 2002). Related terms

found in the literature include learning strategies and strategy training (Donkervoort, Dekker,

Stehmann-Saris, & Deelman, 2001; Singer et al., 1989).

Winzer (1999) differentiates between cognitive strategies and learning strategies, but puts them

both under the umbrella of metacognitive processes. She classifies cognitive strategies as

knowledge-based regulation and control processes, such as deciding to use a strategy or knowing

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how to order a series of strategies to solve complex problems, and learning strategies as skill-

based awareness of strategies and resources needed to perform a task. She states that learning

strategies are an individual‟s approach to tasks and they may be either generic or domain

specific. Generic strategies, also known as global or metacognitive strategies, are problem-

solving skills that apply across many areas and have a self-evaluative component (Livingston,

1997; Winzer, 1999), whereas domain-specific strategies are those used only in particular

situations. Table 1.1, presented earlier in this chapter, includes the working definitions of

cognitive strategies, global cognitive strategies, and domain-specific cognitive strategies used in

this thesis.

While cognitive strategies come from the domains of education and declarative learning, they

have been successfully employed in the motor domain (Anderson, 1999; Lidor, 1997; Singer,

1989; Tennant et al., 2004). Examples of specific cognitive strategies mentioned for use in the

motor domain include goal-setting, self-evaluating, self-talk, readying for performance,

attentional focusing, and imagery or mental practice (Anderson, 1999; Tennant et al., 2004). An

example of a global cognitive strategy in the physical education literature is the Five-Step

Approach (5-SA) (Singer & Suwanthada, 1986). The five steps in the strategy are readying,

imaging, focusing, executing, and evaluating. The approach has been associated with improved

motor performance in self-paced tasks in healthy individuals ( Lidor, 1997; Singer, 1989).

The CO-OP treatment approach is a global cognitive strategy-based approach currently being

used in rehabilitation settings to improve skill performance in people with motor-based

impairments. CO-OP is discussed in detail later in this chapter. Prior to the discussion of CO-

OP, an overview of current stroke rehabilitation interventions is provided.

1.4 Stroke rehabilitation interventions

Because the range of stroke sequelae is vast, the scope of stroke rehabilitation interventions is

broad and difficult to classify. Table 1.2 provides examples of recent non-pharmacological

stroke rehabilitation clinical trials investigating interventions aimed at improving functional

activities. The list is, by no means, exhaustive, but is rather meant to provide a broad overview

of the direction that stroke rehabilitation intervention research has taken over the past few years.

While preference has been given to studies targeting activities, some studies targeting

impairments have been included if they have included activity and/or participation outcomes.

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Examples of interventions targeting impairments included progressive resistance training, static

positional stretches for shoulder pain, electromyography-triggered neuromuscular stimulation,

and upper limbs encircling motion. In general, the intensity of these programs was very high,

comprising as many as 80 sessions (Gabr et al., 2005). Changes in participation were either not

measured (Gabr et al., 2005; Gustafsson & McKenna, 2006; Wang et al., 2007), or not found

(Hornby et al., 2008). A notable exception was a study by Flansbjer and colleagues comparing

progressive resistance training for knee muscles to no treatment (Flansbjer, Miller, Downham, &

Lexell, 2008). Participation improvements in the intervention group were maintained at five

month follow up. The intervention group received 20 treatment sessions, and was compared to a

no-treatment group, rather than an alternative treatment group. In a systematic review of

strength training post-stroke, the authors concluded that there was limited long-term follow-up

data, but adequate evidence that resistance training increased strength, gait speed, and functional

outcomes and limited evidence of improved quality of life (Pak & Patten, 2008).

Examples of interventions targeting activities included cognitive strategy training, CIMT,

functional gait activities in community environments, home visits from an occupational therapist

to work collaboratively on client-identified activities, trial-and-error learning, and task-specific

training. Treatment intensity ranged from eight home visits (presumably eight hours or less) to

up to 60 hours of treatment in two of the CIMT studies (Dahl et al., 2008; Wolf et al., 2006). In

general, the interventions studied showed positive post-test improvements, but only three types

of intervention showed retained improvements at follow-up testing (Hornby et al., 2008; Liu,

Chan, Lee, & Hui-Chan, 2004; Wolf et al., 2006; Wolf et al., 2008). The interventions studied

in these cases were therapist-assisted locomotor training, CIMT, and cognitive strategy training;

more information about each intervention type is given below.

1.4.1 Therapist-assisted locomotor training

Hornby and colleagues (2008) tested an assistance-as-needed therapist-assisted locomotor

training (TA) protocol compared to robotic-assisted locomotor training (RA). RA consisted of

consistent and symmetrical mechanical stepping assistance. Participants in the RA group were

provided with 12 sessions of continuous robotic stepping assistance, as well as verbal

encouragement to use maximal effort, and visual feedback with a full-length mirror. Participants

in the TA group were assisted to step by one therapist, who only provided assistance to maintain

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continuous walking, rather than trying to approximate normal kinematics. As with the RA

group, verbal encouragement and visual feedback were provided, and 12 sessions were

conducted. Larger changes were seen in the TA group for some gait parameters, and these were

retained at follow-up. At post-test and six month follow-up, those participants with severe gait

impairment showed significantly greater improvements on the physical domain of the SF-36.

The authors provide suggestions as to why the TA protocol was more effective, including

reduced physical guidance. In terms of improvements on the physical domain of the SF-36, the

authors suggest the most severely impaired participants may have improved their perception of

disability as a result of the intense exercise regime.

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Table 1.2 Recent stroke rehabilitation intervention studies

Interventions targeting impairments

First Author Year Design Population Intervention 1 Intervention 2 Outcomes Findings

Flansbjer 2008 RCT 24 chronic

stroke

Progressive

resistance training

for knee muscles

2/wk for 10 wks

No treatment Muscle strength, tone,

gait speed and

endurance, participation

(SIS), measured pre,

post, and at 5 m f/u.

Muscle strength

improved in

training group,

maintained at f/u.

At f/u, significant

group differences

in gait (TUG) and

participation (SIS).

Gabr 2005 RCT with

crossover

12 people with

chronic stroke

Electromyography-

triggered

neuromuscular

stimulation

(ETMS) 2x/day for

35 mins for 8 wks,

followed by 8 wk

home exs program.

8 wk home

exercise

programme

followed by

use of ETMS

2x/day for 35-

min increments

during an

eight-week

period.

Upper extremity

impairment and activity

measures

After home

exercise, no

changes on any of

the outcome

measures. After

ETMS, modest

impairment

reductions.

Gustafsson 2006 RCT 32 people in

stroke rehab

Static positional

stretches twice

daily and

positioning at

other times

Usual

treatment

Pain, range-of-motion,

functional

No significant

between-group

differences, except

that the treatment

group experienced

increased pain.

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Wang 2007 RCT 44 adults with

stroke, in-

patients

ULEM (upper

limbs encircling

motion) apparatus,

plus conventional

PT for 20 days

Conventional

PT for 20 days

Blood pressure, pulse,

Brunnstrom

stage,(Brunnstrom,

1966) Barthel

(Mahoney & Barthel,

1965)

Improvements in

Brunnstrom stage

in ULEM group,

no other between

group differences

Interventions targeting activities

Dahl 2008 RCT 30 stroke, in-

patient rehab

6 hours CIMT for

10 consecutive

weekdays

Traditional

therapy

WMFT, MAL, FIM,

SIS measured pre, post

and at 6 month f/u.

CIMT group

(n=18) better

WMFT scores

post-test, but not

on other measures.

No between-group

differences were

maintained at f/u.

Egan 2007 RCT 16 chronic

stroke

Up to 8 visits from

an OT to work

collaboratively on

client-identified

activities.

No treatment Perceived satisfaction

and performance in

client-identified

activities, quality of life

Intervention group

had significantly

higher perceived

satisfaction in

activities.

Geusgens 2006 RCT, post-

hoc analysis

113 subacute

stroke, apraxia

Strategy training,

8w

Usual OT, 8w Pre, post, and 5m f/u

standardized ADL,

ARAT, Barthel, apraxia

Strategy group

improved more on

untrained ADL

task, not retained.

Gilmore 2007 RCT 10 stroke Up to 10

treatments focused

on donning socks

and shoes,

reviewing

videotapes of

performance

Up to 10

treatments

focused on

donning socks

and shoes, no

videotape

review

Klein-Bell ADL Scale

and COPM measured

pre and post.

No between group

differences on

Klein-Bell ADL

Scale, but video

group had

significantly higher

COPM scores

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Hornby 2008 RCT 48 chronic

stroke

12 sessions

robotic-assisted

locomotor training

12 sessions

therapist-

assisted (TA)

locomotor

training

Gait speed and

symmetry, activity and

quality of life(SF36),

pre and post

intervention and 6m

follow-up.

Improved speed

and symmetry in

TA group,

improved physical

SF36 domain in

those with severe

gait impairment in

TA group; results

maintained at 6

months.

Langhammer 2007 RCT 75 stroke Intensive exercise,

4 periods over first

year after stroke

Reg. exs with

self-initiated

training

Quality of life (NHP),

BBS, 6MW, Barthel

No between group

differences

Lin 2008 RCT 22 chronic

stroke

CIMT , 2h/day;

5d/wk; 3 wks

Traditional

therapy,

matched

intensity

Motor performance,

functional

independence, and

extended ADL pre and

post intervention. No

f/u reported.

CIMT significantly

greater motor

performance,

functional indep,

and mobility

domain of

extended ADL

Lin 2007 RCT 32 chronic

stroke

Modified CIMT

for 3 wks

Traditional

therapy

Kinematic measures,

MAL, FIM pre and

post.

CIMT group

improved more on

all measures. No

follow-up

assessment.

Liu 2004 RCT 46 stroke, in-

patient

rehabilitation

Global strategy

plus motor

imagery, 15 1-hr

sessions.

TST, 15 1-hr

sessions.

Standardized ADL,

FMA, CTT, measured

pre, post, and

throughout intervention

and 1 m f/u.

Global strategy

improved more on

trained and

untrained ADLs,

retained at f/u. nsd

FMA or CTT

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Lord 2008 Pilot RCT 30 home-

dwelling stroke

Community

intervention:

functional gait

activities in

community

environments,

participant-specific

Hospital-based

physiotherapy

was based

upon a motor

relearning

approach

Gait speed, endurance

(6MW), balance

confidence, physical

and social outcomes,

measured pre, post, and

6 m f/u.

Gains in both

groups, but nsd.

Only 11/30

reported being

indep walkers in

the end.

McDonnell 2007 RCT 20 stroke 9 sessions of TST

over 3 weeks, plus

associative

electrical

stimulation of the

motor point of 2

hand muscles

9 sessions of

TST over 3

weeks, plus

sham

stimulation

Dexterity (grip-lift

task), upper extremity

function, corticospinal

excitability (transcranial

magnetic stimulation),

pre, post, and 3m f/u.

Significant

between group

differences in grip-

lift task at post-

test, but not on

other measures.

No between group

differences at f/u.

Morris 2008 RCT 106 adults with

acute stroke

Bilateral task

training, 20

min/weekday for 6

weeks (30

sessions)

Unilateral task

training, 20

min/weekday

for 6 weeks

(30 sessions)

ARAT, Rivermead

upper extremity

scale,(Collen, Wade,

Robb, & Bradshaw,

1991) and 9-hole peg

test, pre, post and 12

week f/u.

Pinch and 9-hole

peg test changes

were worse for

bilateral training

group at f/u,

otherwise nsd.

Mount 2007 RCT

crossover

33 adults with

acute stroke

Errorless learning,

with and without

explicit memory

impairments –

learning to prepare

a wheelchair for

transfer and use

sock-donning

apparatus.

TEL, with and

without

explicit

memory

impairments -

learning to

prepare a

wheelchair for

transfer and

use sock-

donning

apparatus.

Days until task

retention, and success

or failure of transfer to

similar task.

Nsd in days to

retention for any

group.

Significantly better

transfer in sock-

donning task in

TEL group.

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Wolf 2006 RCT 222 chronic

stroke

CIMT for 2 wks,

including

weekends, with

task training up to

6hrs/day

Usual care,

varied among

individuals

WMFT, MAL, SIS

CIMT showed

greater

improvements in

WMFT

performance time,

MAL, and SIS

hand domain

Wolf 2008 Follow-up

of treatment

arm of RCT

68 chronic

stroke

CIMT n/a WMFT, MAL, SIS Retention of

WMFT strength

improvements and

SIS strength, ADL,

IADL,

participation,

memory and

thinking. Note that

retention was not

compared to

control group.

ADL=activities of daily living; ARAT=Action Research Arm Test (Van der Lee et al., 2001); BBS=Berg Balance Scale (Berg, Wood-Dauphinee, Williams, & Maki,

1992); CIMT=constraint-induced movement therapy; COPM=Canadian Occupational Performance Measure (Law et al., 2005); CTT=Colour Trails Test (D'Elia,

Satz, Uchiyama, & White, 1989); d=day; FIM=Functional Independence Measure (Keith, Granger, Hamilton, & Sherwin, 1987); FMA=Fugl-Meyer Assessment

(Fugl-Meyer, Jaasko, Leyman, Olsson, & Steglind, 1975); f/u=follow-up; h=hour; IADL=instrumental activities of daily living; indep=independent; m=month;

MAL=Motor Assessment Log (Uswatte, Taub, Morris, Light, & Thompson, 2006); nsd=no significant differences; 6MW=6-Minute Walk; OT=occupational therapy;

PT=physiotherapy; RCT=randomized controlled trial; SF36=Medical Outcomes Study 36-item Short-Form Health Survey (Ware & Sherbourne, 1992); SIS=Stroke

Impact Scale (Duncan et al., 1999);TEL=trial and error learning; TST=task-specific training; w=week; TUG=Timed Up and Go (Podsiadlo & Richardson, 1991);

WMFT=Wolf Motor Function Test (Wolf et al., 2001); y=year.

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1.4.2 Constraint-induced movement therapy (CIMT)

CIMT is regarded as a treatment based on learning principles (Krakauer, 2006; Sterr, 2004), has

demonstrated success at improving upper extremity function in numerous studies (Dahl et al.,

2008; Lin et al., 2007; Lin et al., 2008; Wolf et al., 2006; Wolf et al., 2008), and for these

reasons, is discussed in more detail. CIMT was designed for the treatment of upper-extremity

function; it is based on the principles of massed practice, and of reversing or preventing learned

non-use. Learned non-use is a term that was coined by Taub and colleagues to describe the

situation whereby tasks previously done by an impaired arm are taken over by the unimpaired

arm, eventually causing the impaired arm to “forget” how those tasks were done and to cease

doing them permanently (Taub et al., 1994). Massed practice is a term from the motor learning

literature to describe practice periods that are very close together with little or no breaks, and is

in contrast to distributed practice (Schmidt & Lee, 2005, p.332) The degree to which practice is

massed or distributed is relative, and there aren‟t clear definitions as to what constitutes one or

the other, although Schmidt and Lee suggest that in massed practice, rest periods are shorter than

the work periods, and in distributed practice, rest periods are equal to or longer than the work

periods.

While the specifics of constraint-induced therapy vary from study to study, the regime proposed

by Wolf and colleagues has been called the signature CIMT treatment (Sterr, 2004). Participants

in Wolf and colleagues intervention group wore a mitten on their unaffected hand for 90% of

their waking hours for two weeks, including weekends, for a total of 14 days. On weekdays,

they received up to 6 hours of shaping (adaptive task practice) and traditional task training. In

addition, they were asked to perform about 30 minutes of daily practice of activities at home,

monitored by use of a home diary. Participant mitt-wearing compliance was monitored with an

electronic sensor.

Two hundred and twenty-two (222) participants between three and nine months post stroke were

randomized to either CIMT (n=106) or usual care (n=116). The main outcome measures were

the Wolf Motor Function Test (WMFT) (Wolf et al., 2001), and the Motor Activity Log (MAL)

(Uswatte et al., 2006); the Stroke Impact Scale (SIS) (Duncan et al., 1999) was used as a

secondary outcome measure. The WMFT is a laboratory measure of upper extremity motor

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function; the MAL is a self-report log of how often and how well 30 activities are performed

with the affected arm; the SIS is an 8-domain, stroke-specific health status measure. Participants

were assessed at baseline and post intervention, as well as four, eight, and twelve months after

baseline. The CIMT group performed better than the control group in the WMFT performance

time, MAL amount of use, and MAL quality of use, and these results were maintained at the 12

month follow-up. Recently, 24-month follow-up data were reported for this study demonstrating

persistent improvements within the remaining group, however, control group data were not

reported making it impossible to determine whether between-group differences were maintained

(Wolf et al., 2008).

Other CIMT studies have also demonstrated functional improvements (Dahl et al., 2008; Lin et

al., 2007; Lin et al., 2008), however, the regime has not been fully accepted by clients and

clinicians (Sterr, 2004). In a survey of 280 clients, 68% indicated they weren‟t interested in this

type of treatment because of the intense practice schedule and the restraining device (Page,

Levine, Sisto, Bond, & Johnston, 2002). Clinicians and institutions have concerns about

adherance, safety, and resources to administer the intensive treatment (Page et al., 2002; Sterr,

2004). In addition, CIMT in its current form is limited to treating upper extremity recovery in

people who have at least 10 degrees of wrist extension in the affected wrist, along with

additional digit movement (Wolf et al., 2006).

While CIMT is extremely promising for some people living with stroke, it does not represent a

solution for all. Cognitive strategy training, discussed below, is currently less well-studied in

stroke than task-specific training or CIMT, but is a broader approach that may have wider

application.

1.4.3 Cognitive strategy training

As discussed previously, cognitive strategies offer a system for managing one‟s thoughts during

skill acquisition, and for tapping into the links between action and cognition. Global cognitive

strategies, in particular, have been associated with improvements in functional activities, transfer

to untrained activities, and skill retention at follow-up (Geusgens, van Heugten, Cooijmans,

Jolles, & van den Heuvel, 2007; Geusgens et al., 2006; Liu et al., 2004). A recent review article

surveyed the extent to which cognitive strategies have been used to facilitate motor skill

acquisition in stroke, and found only three examples of global cognitive strategy use in stroke

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(McEwen, Huijbregts, Ryan, Polatajko, 2009). Global strategy training was reported to improve

and maintain performance in both trained and untrained ADLs compared to traditional functional

training in people in the early rehabilitation phase after a stroke (Liu et al., 2004), and general

strategy training was reported to improve performance in untrained ADLs compared to

traditional OT in people with apraxia as a result of stroke (Donkervoort et al., 2001). In the RCT

conducted by Liu and colleagues, the efficacy of a global cognitive strategy combined with

motor imagery was investigated, in comparison to traditional functional training. Participants in

the strategy group were trained in Task Analysis, Problem Identification, and Task Performance,

using videotapes to problem solve their own performance issues, and incorporating a motor

imagery component in both the practice sessions and the problem-solving process. Forty-nine

participants were randomized to receive 15 sessions of either strategy training with motor

imagery (n=27) or functional task training (n=22), delivered one hour per day for three weeks.

The functional task training utilized task demonstration followed by practice, and problems

encountered by the participants were rectified by the treating occupational therapists. The main

outcomes were performance of 15 trained daily tasks, five untrained tasks, the Fugl-Meyer

Motor Assessment (FMA) (Fugl-Meyer et al., 1975), and sustained visual attention and visual

scanning. Patients in the strategy training group showed better ability than the functional

training group on the trained daily tasks after the second and third weeks of training and one-

month follow-up. They also performed better on the untrained tasks at post-test, providing

convincing evidence of skill transfer. No significant between-group effects were found for either

the FMA or visual attention and scanning.

While the results of the few global cognitive strategy studies are promising, they have examined

people in the relatively early phases of a stroke, retention was an issue in one (Donkervoort et al.,

2001), and none examined the impact of the approach on participation. In children with motor-

based performance problems, an established global cognitive strategy-based approach has

successfully helped to acquire and maintain skills, and has been associated with improved

participation. We hypothesized that this approach, Cognitive Orientation to daily Occupational

Performance (CO-OP), had potential to do the same for community-dwelling adults living with

chronic stroke.

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1.5 Cognitive Orientation to daily Occupational Performance (CO-OP)

The CO-OP treatment approach evolved from a verbal self-guidance approach to teach motor

skills to children with developmental coordination disorder (DCD) (Mandich, Polatajko, &

Rodger, 2003; Miller, Polatajko, Missiuna, Mandich, & Macnab, 2001; Polatajko, Mandich,

Miller, & Macnab, 2001; Ward & Rodger, 2004). DCD is a childhood condition characterized

by a marked impairment in the development of motor coordination that subsequently interferes

with the child‟s academic performance and/or ability to perform activities of daily living

(Polatajko, Fox, & Missiuna, 1995). The CO-OP treatment approach evolved over several years

in response to evidence that contemporary treatment approaches were not better than control

situations in helping children with DCD to acquire motor skills (Polatajko & Mandich, 2004).

The theoretical foundations of CO-OP encompass all major areas discussed previously in this

chapter, including rehabilitation theory and the ICF; cognitive learning theory, motor learning

theory, and the links between action and cognition; client-centred practice and the associated role

of motivation.

CO-OP is a 10-session treatment approach that has traditionally been conducted by occupational

therapists, although anecdotal evidence indicates the approach has also been employed by

physiotherapists and others. In the first session, the client, guided by the therapist, selects three

goals to be the focus of treatment. Baseline performances of the three goals are assessed, and the

client is then taught a global problem-solving strategy that forms the main framework of the

treatment. The Global problem-solving strategy is “Goal-Plan-Do-Check” adapted from

Meichenbaum (Meichenbaum & Goodman, 1971) and Camp (Camp, Blom, Herbert, &

VanDoorwick, 1976). In subsequent treatment sessions, the therapist and client work together

using the global strategy to find domain-specific strategies (DSS), specific to the individual

client and the particular goal being learned. The therapist uses guided discovery to teach the

client to use the global strategy and to discover DSSs.

The objectives of CO-OP are skill acquisition, cognitive strategy use, and skill generalization

and transfer. CO-OP is an integrated and complex treatment approach which incorporates all

phases of client-therapist interaction from assessment through skill learning consolidation. The

seven key features of CO-OP are: session structure, client-chosen goals, dynamic performance

30

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analysis, global cognitive strategy, domain-specific strategies, parent/caregiver involvement, and

intervention format.

After a number of single case experiments and systematic replications demonstrated an

association between the CO-OP treatment approach and self-selected motor skill acquisition in

children with DCD (Polatajko, Mandich, Miller, & Macnab, 2001), a pilot randomized controlled

trial was undertaken (Miller, Polatajko, Missiuna, Mandich, & Macnab, 2001). Twenty

children, mean age 9, with a diagnosis of DCD, were randomized to either CO-OP treatment or

contemporary therapy. Twenty-two different goals were chosen, the most frequent of which

were: writing, printing, bicycling, keyboarding, organization, basketball, drawing, throwing, and

knife and fork skills. While children in both groups made improvements in their self-selected

goals, those in the CO-OP treatment group had significantly greater improvement than the

control group in their goal performance quality, their self-rated goal performance and

satisfaction, and parent-rated generalized motor behaviours.

Since the initial work with children with DCD, CO-OP has been studied in children with

Asperger‟s syndrome, acquired brain injury (ABI), and cerebral palsy (Cameron, Polatajko,

Missiuna, Schwellnus, 2009; Mandich, Polatajko, & Rodger, 2003; Polatajko, Mandich, Miller,

& Macnab et al., 2001; Rodger, Springfield, & Polatajko, 2007; Samonte, Solish, Delaney, &

Polatajko, 2004), and more recently, preliminary work examining the effectiveness of the

approach with adults with ABI has been conducted (Dawson et al., in press). Rodger and

colleagues have published case report data providing preliminary evidence that CO-OP can

improve social and organizational skills in children with Asperger‟s syndrome, and that these

results were generalized to the home environment (Rodger, Springfield, & Polatajko, 2007). In

data in preparation for publication from Polatajko‟s lab, four single case experiments were

conducted with three children with cerebral palsy and one with ABI (Samonte et al., 2004). All

four children demonstrated improved performance quality in the majority of their self-chosen

goals. Of twelve goals chosen, only two did not improve post intervention. A paper from

Dawson‟s lab, in press, demonstrated that CO-OP is associated with improved performance in a

variety of self-selected goals in adults with ABI (Dawson et al., in press). Taken together, the

results of these studies indicate that the CO-OP treatment approach is promising in a wide range

of pediatric and adult conditions, including those involving a compromised central nervous

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system. The use of DSSs in CO-OP, specific to an individual and the particular skill they are

learning, may explain the approach‟s adaptability to different populations.

Table 1.3 Key features of the CO-OP treatment approach

FEATURE DESCRIPTION

Client- chosen

goals

Goals are set in collaboration with the client. In most cases goals are the specific skills the client wants to

learn to perform or to perform better. The first step in implementing CO-OP is to identify three

goals/skills using the Canadian Occupational Performance Measure (COPM).(Law et al., 2005) The

COPM consists of a semi-structured interview to facilitate the establishment of client-centred goals and a

self-report rating scale to establish the client‟s satisfaction and self-perceived performance with each

goal.

Dynamic

performance

analysis (DPA)

DPA is an observation-based process for identifying performance problems or performance breakdown.

DPA progresses as a flow chart, and begins with a set of questions the therapist asks herself or himself to

establish whether or not the client has the following prerequisites for performance: motivation, task

knowledge and performance competence. If the client has the prerequisites, the therapist proceeds to the

next levels of questioning, beginning with “Is the performance competent?” and then proceeding to

“Where in the performance are the breakdowns” and then “Does the client know what to do?”; “Does the

client want to do it?”; “Can the client do it?”. The final set of questions for each performance breakdown

establishes more specifically why the client is unable to perform the task.

Cognitive

strategy use

In CO-OP, clients make use of both global and domain-specific cognitive strategies. The global

cognitive strategy, GOAL-PLAN-DO-CHECK, forms the framework for the entire treatment approach,

and is used to promote problem-solving, and generalization and transfer.

Domain specific strategies (DSSs) are those that are specific to a particular task and individual, and they

come and go as treatment progresses. Examples of some DSSs are verbal self-guidance, body position,

task specification and feeling the movement.

Guided

discovery

Guided discovery follows in the middle of a teaching spectrum between explicit instruction at one end,

and trial-and-error or discovery learning at the other end, wherein the learner is left largely to their own

devices to learn. As guided discovery falls between these two extremes, it allows for a certain amount of

discovery learning, but it is guided by the therapist, thus allowing the learner to problem solve on his or

her own but curbing excessive frustration or usage of strategies that the therapist doesn‟t expect to work.

The therapist guides the learner by asking questions rather than telling, coaching rather than physically

adjusting, making answers obvious, and working on only one thing at a time.

Enabling

principles

The four enabling principles that have been identified for use in CO-OP are making the intervention fun,

promoting learning, working towards independence and promoting generalization and transfer.

Parent/

significant

other

involvement

Significant others support the client in the acquisition of new skills and facilitate the generalization and

transfer of these to the home environment. They can celebrate the client‟s successes and support use of

newly learned skills and strategies in environments beyond the intervention sessions.

Intervention

format

The first phase of CO-OP is the preparation phase, which is primarily concerned with establishing the

GOALs and the baseline level of performance. The second phase is the acquisition phase where the work

of using strategies to acquire skills is accomplished. There are 10 acquisition sessions in total. The third

and final phase is the verification phase. Typically it consists of one session in which the progress is

reviewed. This session provides an opportunity for the therapist to check and reinforce the client‟s

learning of strategies and skills.

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1.6 Rationale and objectives

Despite the mounting evidence that people living with stroke can make functional gains for many

years after their stroke, long-term stroke outcomes remain poor. While new, promising, task-

oriented stroke rehabilitation approaches based on aspects of systems theory have been

emerging, such as CIMT, none have been completely satisfactory in terms of generalizability

(Van Peppen et al., 2004), or clinical utility (Sterr, 2004). It has been suggested that teaching

cognitive strategies is the key to successful long-term outcomes, as the emphasis is on teaching

clients problem-solving abilities that can be applied to a wide range of tasks, skills, and

situations, rather than on teaching a finite, generic set of skills (Ezekiel et al., 2001; Geusgens et

al., 2006). Three different global cognitive strategy approaches to teach motor skill acquisition

in people with acute or sub-acute stroke have been reported in the literature (Donkervoort et al.,

2001; Liu et al., 2004; O'Callaghan & Couvadelli, 1998). The preliminary, positive results from

these studies hold promise for further investigations of other cognitive-based approaches.

Systems theory suggests that motor control results from a complex interaction among perception,

cognition, and action, all within the context of the individual and his or her environment

(Shumway-Cook and Woollacott, 2007, p. 16) The CO-OP treatment approach is an

individualized, task-oriented, cognitive-based approach that integrates important aspects of

client-centred care and motivational theory with learning and movement science theories. The

main framework for CO-OP is a global cognitive strategy; as well, clients are guided to discover

domain-specific strategies that vary based on the task being learned and the requirements of the

individual. There is strong evidence that the CO-OP treatment approach can improve

performance in motor-based tasked in children with DCD (Miller, Polatajko, Missiuna, Mandich,

& Macnab, 2001), and preliminary evidence of the same in children with Asperger‟s syndrome,

CP, and ABI and adults with ABI (Dawson et al., in press; Mandich, Polatajko, & Rodger, 2003;

Polatajko, Mandich, Miller, & Macnab et al., 2001; Rodger, Springfield, & Polatajko, 2007;

Samonte et al., 2004). The approach is well-established, and has a published protocol (Miller,

Polatajko, Missiuna, Mandich, & Macnab et al., 2001). As it was designed to be delivered over

10-sessions, one to two sessions per week, in an out-patient setting, the format is practical for

adults living in the community with chronic stroke. Approximately 10 hours of intervention over

a period of one or two months may be perceived as a more acceptable time frame and intensity

than some very intensive approaches, such as CIMT (Sterr, 2004).

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Cerebral palsy and ABI are chronic central nervous system conditions more similar to stroke

than the original DCD population. The preliminary evidence of CO-OP‟s effectiveness in these

populations opened the possibility that the approach could also be beneficial to adults with

stroke, as well as evidence of the efficacy of other global cognitive strategies in stroke from

other researchers (Donkervoort et al., 2001; Liu et al., 2004; O'Callaghan & Couvadelli, 1998).

In addition, CO-OP‟s use of domain-specific strategies that vary depending on the stage of

learning, the specific task, and the specific requirements of the learner is theorized to facilitate

the adaptation of the approach to a variety of populations. Therefore, the primary objectives of

this project were to: 1. examine the efficacy of CO-OP to improve motor skill acquisition and

performance in people living with chronic stroke; 2. explore other benefits of the CO-OP

approach beyond skill acquisition and performance, particularly generalization and transfer.

As the CO-OP approach was designed for use with children, there were certain features of the

approach that clearly needed modification for use with adults. For example, in the original

version of CO-OP, the global cognitive strategy, a main tenet of the approach, is taught to

children using a puppet. Notwithstanding that there may be some adults who might enjoy this

feature, it was felt that the puppet would not be a useful teaching tool for adults. Further, it was

considered there might be other features that would also require modification. Therefore, the

secondary objective of this project was to identify adaptations to the CO-OP intervention that

would optimize its utility for adults living with stroke.

1.7 Methods and thesis overview

To address those two broad objectives, a multi-phased, mixed methods project was undertaken.

Mixed methods refer to using a combination of qualitative and quantitative methods; the specific

combinations vary among projects, based on the study objectives and the philosophical

assumptions or beliefs of the researchers (Hesse-Biber & Leavy, 2005, p.316-322). The author of

this thesis tends to be a pragmatist-positivist; that is to say, keen on matching methods to the

study objective, but with a tendency to be looking for “a truth” rather than multiple realities.

Initially, a priori adaptations of the approach were conducted through the application of expert

opinion. Expert opinion included ongoing consultation with one of the CO-OP developers (HP)

as well as an initial focus group with expert stroke rehabilitation practitioners. An overview of

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the findings from the latter is provided in Appendices A, C, and D. Subsequently, a single case

experimental design series was conducted, and in-depth semi-structured interviews were

conducted post-experiment with participants. Below, single case experiments are discussed in

greater detail and an overview of the thesis structure is provided.

To examine the efficacy of the CO-OP approach, a single case experimental AB design with

direct replications was chosen. Single case experiments are a cost effective method of

examining the efficacy of rehabilitation interventions in the development stage (Ottenbacher,

1986a; Zhan & Ottenbacher, 2001), and are considered the design of choice when measuring

behavioral change (Franzen & Harris, 1993). To evaluate the efficacy of an experimental

intervention to alter a particular behaviour using single case experiments, that behaviour‟s

baseline, or pre-intervention state, must first be established (Barlow & Hersen, 1984, p. 71-72).

A minimum of three baseline data points are required. The baseline is considered the “A” phase

of the experiment, and the intervention phase is considered the “B” phase. If the baseline is

stable, then a change in the behaviour being measured after the introduction of the intervention

can be attributed to the intervention.

A major goal in scientific experimentation is the establishment of generality of findings. With

single case experiments, it is difficult to know if the results are relevant to other cases. However,

as proponents of single case experiments point out, it is also difficult to know if the results from

a large group experiment are relevant to an individual client (Barlow & Hersen, 1984, p.54-55).

Single case experiments provide the opportunity to gather a large amount of information about

individual subjects, and to seek sources of intra-subject variability. Replications are used to

increase the generality of findings. In direct replication, the same experiment is repeated, by the

same investigator in the same setting, either on the same subject or on different subjects. Once

several successful direct replications have been conducted, broader generality can be established

through systematic replication. Systematic replication attempts to replicate findings from a

direct replication series in different settings, with different clinicians, or other variations to the

protocol.

In single case experimental design, visual inspection is often used to judge whether or not the

intervention is associated with a significant change in the behaviour of interest, however

statistical analyses are useful when variability is high, at the beginning stages of research to

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identify, and to detect small changes (Kazdin, 1984). The 2 standard deviation (SD) band

method of statistical analysis has been recommended when the number of baseline data points is

small, and variability is high (Ottenbacher, 1986a). This method uses statistical rules of thumb

developed from quality control chart methods (Callahan & Barisa, 2005; Orme & Cox, 2001;

Sideridis & Greenwood, 1996). A significant change is said to have occurred if 2 successive

data points fall outside of 2 SDs on either side of the mean (Ottenbacher, 1986a).

In this project, an initial single case series, (Chapter 2) employing a simple AB design with

retention test, was used to gain preliminary efficacy data and explore other potential benefits of

CO-OP. Each of the three participants self-selected three goals to be the focus of the

intervention. Response-guided experimentation principles were used (Edgington, 1992, p. 134),

and the results of the first single case series guided the experimental question and design

development for a second single case experimental series. The second series (Chapter 3) sought

to further investigate CO-OP‟s effect on skill transfer. In that experimental series, a multiple

baseline design was employed, and a fourth, untrained goal was added to the protocol.

Because this was an exploratory project, qualitative methods were combined with the two single

case experimental series, to elicit greater depth of understanding of the complexities of

participant experiences with the CO-OP treatment approach. Semi-structured interviews were

conducted with five of the six participants in the two single case experimental series. The

participant self-report data was used to capture information about how the protocol was

experienced by participants, how the strategies were learned and used, and to capture additional

and perhaps unintended benefits of the treatment (Chapter 4).

Chapter 5 is a discussion chapter that summarizes the findings as a whole, and provides

recommendations for adapting the CO-OP treatment approach for use with adults with stroke.

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Chapter 2 Exploring a Cognitive-Based Treatment Approach to Improve Motor Skill Performance in Chronic Stroke: Results of Three

Single Case Experiments.

McEwen, S.E., Polatajko, H.J., Huijbregts, M.P.J., Ryan, J.D. Exploring a cognitive-based

treatment approach to improve motor skill performance in chronic stroke: Results of three single

case experiments.

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

2.1 Abstract

Background and purpose: Early evidence suggests the use of cognitive strategies has potential to

improve motor skill performance in people living with the effects of stroke, but no specific

protocol has been identified. This study aimed to explore the potential of using Cognitive

Orientation to daily Occupational Performance (CO-OP) to improve functional performance of

adults with chronic stroke.

Research design and methods: A single case experimental design study with two replications was

conducted. Three community-dwelling participants were recruited. Each selected three

functional goals to be the focus of the CO-OP intervention. Multiple video recorded data points

were collected at baseline, during intervention, post intervention, and at one-month follow-up.

Results: The 9 goals selected varied widely, e.g., using a computer mouse, bicycling, and yoga.

An independent observer used the Performance Quality Rating Scale (PQRS) to rate

performances. Using the 2 standard deviation band method to analyze the data, each participant

showed significant performance improvements in at least 2 goals during intervention. Two

participants had an additional goal show significant improvement at follow-up.

Conclusion: Results provide preliminary evidence that CO-OP is associated with significant

performance improvements in self-selected functional goals.

2.2 Introduction

Long-term stroke outcomes are inadequate, with 39% of community-dwelling people with stroke

reporting ongoing problems with basic activities of daily living (ADL), 20% reporting

difficulties walking 50m or negotiating stairs, and more than half report limitations in

instrumental activities of daily living (Mayo et al., 2002). Novel treatments are required to

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address these issues (Page et al., 2004), and the use of cognitive strategies has been suggested as

a potential means of improving stroke outcomes (Geusgens, Winkens, van Heugten, Jolles, &

van den Heuvel, 2007).

Cognitive strategies have been defined as goal-directed and consciously controllable processes

that support performance as learners develop internal procedures that enable them to perform the

desired skill (Rosenshine, 1997). They may be either global or domain specific (Singer & Chen,

1994; Winzer, 1999). Domain specific cognitive strategies, also known as task-specific, are used

in a specific circumstance, whereas global strategies apply across a wide range of situations.

Global strategies, also referred to as general, generic, metacognitive or executive strategies, are

evaluative or regulatory in nature, including decisions about which particular domain-specific

strategy to use or about actions to take if a goal has not been reached (Livingston, 1997;

Schmidt & Lee, 2005; Winzer, 1999). Global strategies are designed to be applied in almost any

situation, and consist of establishing a goal, developing and implementing a plan, and then

evaluating whether or not the plan worked. The learner revises the plan and re-attempts the

targeted skill if the original plan did not result in goal achievement. Goal-Plan-Do-Check,

adapted from Meichenbaum (Meichenbaum & Goodman, 1971), and used in the Cognitive

Orientation to daily Occupational Performance (CO-OP) treatment approach, is an example of a

global cognitive strategy (Polatajko & Mandich, 2004).

Although cognitive strategies have been used successfully in cognitive rehabilitation (Cicerone

et al., 2005), the two are not synonymous. As defined above, cognitive strategies are consciously

controllable processes that may support many types of learning, including both declarative and

procedural, whereas cognitive rehabilitation is concerned with reducing specific cognitive

process impairments, such as memory or attention deficits. In this project, the intervention focus

was not on impairment reduction, but rather on skill acquisition, and specifically, the use of

cognitive strategies to support functional motor skill acquisition. In using cognitive strategies,

any of the cognitive processes may be invoked; however, the global strategy that forms the

main framework of CO-OP, Goal-Plan-Do-Check, makes use of metacognition or executive

functions, such as planning, problem solving, and decision making.

A recent review article examined the evidence for cognitive strategy use to improve motor skill

acquisition in people with stroke, and concluded that although evidence is preliminary, the

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further development of novel cognitive strategy-based interventions with the intention of

improving long-term stroke outcomes is supported (McEwen et al., 2009). Two randomized,

controlled trials investigated the use of global cognitive-strategy based treatment approaches to

improve functional skill acquisition in people with sub-acute stroke (Geusgens et al., 2006; Liu

et al., 2004). These investigators demonstrated improved skill performance in both trained and

untrained functional skills, however, there have not been any investigations of a cognitive

approach applied as an intervention for people with chronic stroke, nor has a specific protocol

been described.

The intent of the present study was to explore the efficacy of an established cognitive-strategy

based treatment protocol designed for children with developmental coordination disorder (DCD)

for use with adults living in the community with the effects of chronic stroke. The treatment

protocol, CO-OP, has been successful at improving motor -based skill acquisition and

participation outcomes in children with motor-based deficit (Cameron, Polatajko, Missiuna,

Schwellnus, 2009; Mandich, Polatajko, & Rodger, 2003; Miller, Polatajko, Missiuna, Mandich,

& Macnab et al., 2001; Polatajko, Mandich, Miller, & Macnab et al., 2001; Samonte, Solish,

Delaney, Polatajko, 2004; Ward & Rodger, 2004). CO-OP is designed to meet four objectives:

skill acquisition, cognitive strategy use, generalization of learning beyond the treatment session,

and transfer of learning to new tasks in everyday life. A series of 3 published articles have

outlined the theoretical foundations, the protocol, and a summary of the evidence supporting this

approach (Missiuna, Mandich, Polatajko, & Miller-Malloy, 2001; Polatajko et al., 2001;

Polatajko, Mandich, Miller, & Macnab, 2001); as well, a full textbook has expanded on that

information ( Polatajko & Mandich, 2004). In summary, CO-OP is a complex, integrated

approach that fuses elements from behavioral and cognitive psychology, health, human

movement science, and occupational therapy (Missiuna, Mandich, Polatajko, & Miller-Malloy,

2001; Polatajko & Mandich, 2004). Specific theoretical foundations include cognitive-

behavioural learning theory and motor learning theory. A body of research has demonstrated its

ability to improve motor-based skill performance and participation in children with DCD, and

there is preliminary evidence of its effectiveness in children with cerebral palsy, acquired brain

injury, and Asperger Syndrome (Cameron, Polatajko, Missiuna, Schwellnus, 2009; Mandich,

Polatajko, & Rodger, 2003; Polatajko, Mandich, Miller, & Macnab et al., 2001; Rodger,

Springfield, & Polatajko, 2007; Samonte, Solish, Delaney, Polatajko, 2004), and adults with

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acquired brain injury (Dawson et al., in press). Clients select three goals to be the focus of

approximately ten, one hour, intervention sessions. An adaptation of Meichenbaum‟s

(Meichenbaum & Goodman, 1971) global cognitive strategy, Goal-Plan-Do-Check, forms the

main framework for the treatment approach, with domain-specific strategies incorporated as

needed. This global cognitive strategy (Goal-Plan-Do-Check) serves to focus intervention on

problem solving and is reported to be generalizable outside the treatment room and transferable

to other aspects of life (Mandich, Polatajko, & Rodger, 2003; Polatajko & Mandich, 2004;

Rodger, Springfield, & Polatajko, 2007). Skill acquisition is achieved through a combination of

strategy use and a guided discovery process.

In guided discovery, when the learner identifies a problem to solve, he is not given the solution

but is provided with hints, coaching, feedback or modeling to help find a solution to the problem

(Mayer, 2004). Guided discovery has been associated with improved learning outcomes

compared to pure discovery or trial-and-error learning (Mayer, 2004). On a continuum between

explicit instruction and pure discovery or trial-and-error learning, guided discovery can be

thought of as a middle ground between those two extremes. In CO-OP, the therapist is instructed

to work on one thing at a time and “ask, don‟t tell”, thereby providing a minimum amount of

directed, explicit information to the learner. This may be particularly important in stroke, as

explicit information has been shown to be detrimental to some types of motor learning in that

population (Boyd & Winstein, 2003; Boyd & Winstein, 2004b; Orrell, Eves, & Masters, 2006).

The use of guided discovery permits the therapist to regulate the amount of information the client

gets at any given time, and to provide information only as needed.

2.3 Rationale, objective, and research questions

There is a body of evidence that the CO-OP treatment approach can improve performance in

motor-based tasks in a variety of populations. Although originally designed for children with

DCD, CO-OP is not specific to a particular client population, because the treatment focus is not

on reducing impairments, but rather on a manner of therapist-client interaction aimed at

functional skill acquisition. Preliminary evidence of CO-OP‟s effectiveness in populations with

central nervous system impairments, such as cerebral palsy and acquired brain injury (Dawson et

al., in press; Mandich, Polatajko, & Rodger, 2003), provided support for its potential to be

beneficial in adults with stroke.

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The authors of the current study theorized that this integrated, cognitive-based approach would

be associated with improved motor skill performance in people living with the effects of chronic

stroke, and that the improvements would be retained at a one month follow-up. It was also

hypothesized that the CO-OP approach might have secondary benefits, such as improvements in

participation and other stroke-related health status outcomes, and improvements in confidence or

self-efficacy. Two main research questions were explored.

1) Is CO-OP, delivered in an out-patient setting to an individual more than one year post-stroke,

associated with improved performance in self-selected functional goals?

a) Are the results retained at one month follow-up?

b) Can the results be replicated in similar individuals?

2) Are there CO-OP effects on self-rated performance and performance satisfaction, stroke-

related health status, including participation, and self-efficacy/confidence?

2.4 Methods

2.4.1 Participants

The target population for this study was adults living in the community with chronic stroke.

Potential participants were purposely sampled upon discharge from a group out-patient self-

management program with a goal-setting component at a rehabilitation centre in Toronto,

Canada, as individuals who were perceived by the program leader to be motivated to participate

in and contribute to an exploratory research project. Because the CO-OP approach is language-

and cognitive-based, participants were required to have a minimum score of 24/30 on the Mini-

Mental State Exam (MMSE) (Folstein, Folstein, & McHugh, 1975). The MMSE is a quick

cognitive assessment that screens five aspects of cognition: orientation, registration, attention,

recall and language. While the MMSE does not replace a full cognitive assessment battery, it is

effective for separating those with significant cognitive impairment from those without

(Tombaugh & McIntyre, 1992). Participants were required to be at least one year post stroke,

and living in the community. Three individuals were recruited, and were admitted to the study

sequentially.

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2.4.2 Design

To answer the question pertaining to performance on self-selected goals, a single case

experimental AB design with follow-up was conducted, with two replications. Single case

experiments are considered the design of choice when measuring behavioral change (Franzen &

Harris, 1993) and are considered an optimal design in the early stages of establishing a new

intervention (Ottenbacher, 1986a).

To explore preliminary indicators of the generalizability of CO-OP, a quasi-experimental design

was superimposed. Measurements of health status, participation, and self-efficacy were

conducted at baseline, post-test and follow-up.

2.4.3 Ethics

This study was approved by ethics review boards at both the recruiting centre and the University

of Toronto. Informed, written consent was obtained from all participants. A copy of the

information letter and consent form is found in Appendix B.

2.4.4 Intervention description

CO-OP is conducted over approximately 10 sessions, with one or two sessions per week. In the

current study, the total number of intervention sessions and the target goal(s) for a particular

session were negotiated between the treating therapist and the participant. Prior to the first

intervention session, one or two sessions are conducted to establish goals and set the baseline.

The client and the therapist work together, using the Canadian Occupational Performance

Measure (COPM) (Law et al., 2005), to select three goals and establish perceived baseline skill

performance. In subsequent sessions, the intervention is administered. The CO-OP approach is

introduced to the client, the global cognitive strategy (Goal-Plan-Do-Check) is taught and

domain specific strategies are identified, as needed, to acquire the 3 goals. Throughout the

intervention, the therapist uses guided discovery to help the client discover solutions to

performance problems, while ongoing plans for skill acquisition and goal achievement are made

jointly. As part of the guided discovery process, the therapist focuses on “ask, don‟t tell”, which

is a departure from traditional therapist-client interactions in which the therapist provides

directed, explicit task information. An excerpt from an intervention session in this study is

provided in Table 1 to provide a further example description of how the approach works.

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Table 2.1 Transcribed excerpt of an intervention session to illustrate use of the global

cognitive strategy Goal-Plan-Do-Check

Participant 3 (P3) and therapist discussion regarding the goal

to clip finger nails holding clippers in hemiplegic hand

Global Strategy Phase

T: Let‟s make a GOAL to clip the baby finger with this one. That

one baby finger is long. (The therapist picks up one of two pairs

of nail clippers.)

GOAL

P3: Let‟s try it with this one. (The client wants to use the other nail

clipper.)

Start of PLAN formation

T: Okay. Do you have a PLAN? Are you ready to make a PLAN

around this?

Therapist asking for PLAN

P3: Umm yeah. The PLAN is using my right hand. PLAN

T: mhmm

P3 : and with the nail clipper to cut on my nail on the [baby finger].

.. I‟m going to use the nail clipper to try and cut it.

PLAN

T: Okay

P3: Right. (The client tries to cut his nail on his baby finger.) DO

T: Okay, let‟s see where did you get? Where‟s our CHECK? Okay.

So it cut a little bit.

CHECK

P3: Yeah it cut a little. CHECK

T: But it made it worse, now you‟ve got a jagged edge… let‟s just

stop and think for a minute. What is the problem? Is it generating

the force that‟s the problem?

CHECK and T provides

feedback and asks

questions to help P3

problem solve a new PLAN

P3: The force, the force. Guided discovery

T: Now a lever is stronger if you push it closer to the front or closer

to the back?

Guided discovery, “ask

don‟t tell”.

P3: To the back. Alright it should work. Guided discovery

T: So do you have a PLAN based on that information? T asking for PLAN

P3: Yeah. I‟m pushing it further outward. PLAN

T: Okay

P3: Right? So now… (The client uses the new PLAN to clip his nail

and is able to do it.)

DO

T: Yay! (Claps.) Okay, so what did you do that was

different?

CHECK

P3: By extending of the nail clipper where the more force would be

at the back of the nail clipper squeeze, so it could be tightened up

more

CHECK

T=therapist; P=participant

The global cognitive strategy, Goal-Plan-Do-Check, provides the main framework of CO-OP.

Also referred to as an executive, or metacognitive, strategy, the global strategy is used to

problem solve, as well as to generate and coordinate other strategies. The following description

further illustrates the example provided in Table 1. A Goal was established to clip the nail on the

baby finger of the hemiplegic hand. The participant had a vague Plan to use the nail clipper in

his right (unaffected) hand, which he then Did. When he and the therapist then Checked, they

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found he had only cut the nail “a little bit”. The Plan did not fully achieve the Goal, and therefore

a new Plan was required. In this particular case, the Plan needed to be more specific, and the

therapist guided the participant to discover nail clippers have more force when held at the end.

When this Plan was executed, the Check revealed the nail was clipped completely, therefore the

Plan worked and an optimal movement solution had been reached. The participant then

practiced the skill using a Plan that worked best for him.

A second key feature of CO-OP is the use of domain-specific strategies unique to a particular

client, task, skill, or activity. Domain specific strategies previously recorded during CO-OP

interventions include body position, attention to doing, task specification, task modification,

supplementing task knowledge, feeling the movement, verbal motor mnemonic, or verbal rote

script (Sangster, Beninger, Polatajko, & Mandich, 2005).

The intervention was delivered by one of the authors, SM, a physical therapist with

approximately 15 years experience at the time of the study. SM attended a two day CO-OP

workshop to learn the basic intervention techniques and then the use of CO-OP techniques was

monitored throughout the study by reviewing video recordings of intervention sessions with

another of the authors, an experienced CO-OP therapist (HP).

2.4.5 Measurement

The outcome of interest in this study is change in performance of self-selected task-based goals,

and the instrument used was the Performance Quality Rating Scale (PQRS) (Miller, Polatajko,

Missiuna, Mandich, & Macnab et al., 2001). Performances are rated on a 10-point scale, with 1

representing “can‟t do the task at all” and 10 representing “does the task very well”. The PQRS

has previously been employed in CO-OP research (Miller, Polatajko, Missiuna, Mandich, &

Macnab et al., 2001). Operational definitions for PQRS scores were developed for each goal

(Appendix E). Data collection included a minimum of three video recorded baseline trials of

each goal prior to beginning the intervention sessions, as well as a minimum of three trials post

intervention and at one-month follow-up. In addition, performance data were extracted from the

intervention session video recordings. PQRS ratings were conducted by a trained, independent

observer who was presented with all baseline, post-test, and follow-up performances, and a

sample of the intervention performances, in randomized, non-chronological order. Additional

intervention performances were rated separately, also by an independent observer. To rate PQRS

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scores for the handwriting goal, actual handwriting samples were used, rather than video

recorded performances.

A number of standardized measures were used in the quasi-experimental component. Copies of

each are provided in Appendices F through K. The Canadian Occupational Performance Measure

(COPM) (Law et al., 2005) is a standardized instrument for eliciting performance issues from the

client perspective, and for capturing perceived changes in performance over time. The COPM

was used to elicit the participant-selected goals, which became the focus of treatment. It was also

used to rate self-perceived performance and performance satisfaction for each goal, by each

participant. The COPM has demonstrated test-retest reliability of 0.89 in people with stroke

(Cup, Scholte op Reimer, Thijssen, & van Kuyk-Minis, 2003). A change of 2 points or more on

the COPM is considered clinically significant (Law et al., 2005). The COPM was administered

at baseline, post intervention, and at one month follow-up.

The Stroke Impact Scale (SIS) is a stroke-specific health status measure. The scale is comprised

of nine domains: strength, memory, emotion, communication, activities of daily living, mobility,

hand function, participation, and overall recovery. The Cronbach ranges from 0.83 – 0.9

(Duncan et al., 1999) and meets criteria for measuring change over time.

Self-efficacy was measured using the Stanford Self-Efficacy for Managing Chronic Disease 6-

Item Scale (SEMCD-6) (Lorig, Sobel, Ritter, Laurent, & Hobbs, 2001). The SEMCD-6 has

reported internal consistency of 0.91 and a low respondent burden. The Activity-Specific

Balance Confidence Scale (ABC) was included as an additional measure for P3, to capture

mobility-specific confidence (Myers, Fletcher, Myers, & Sherk, 1998). The ABC demonstrates

good internal consistency and reliability as well as being responsive to change and able to

discriminate between elders at various levels of mobility. The ABC has been used with the stroke

population (Huijbregts et al., 2008).

The Chedoke-McMaster Stroke Assessment (CMSA) Impairment Inventory (Gowland et al.,

1995) was used to provide a baseline description of degree of motor control. There are 6

dimensions, of which 4 were used: arm, hand, leg, and foot. Each dimension is rated on a 7-

point scale ranging from Stage 1, in which the limb is completely flaccid and no movement can

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be initiated, to Stage 7, in which movement control is considered to be normal or approaching

normal, and test tasks include aspects of strength, speed and coordination.

2.4.6 Analysis

To evaluate performance in the single case experimental design component, video recorded

performances of each goal were rated using the PQRS, and graphed using Microsoft Excel

2007® . The significance of changes was evaluated using the 2 standard deviation (SD) band

method (Ottenbacher, 1986a). This method of analysis in single case experimental design

improves upon visual inspection by using statistical rules of thumb developed from quality

control chart methods (Callahan & Barisa, 2005; Orme & Cox, 2001; Sideridis & Greenwood,

1996). A significant change is said to have occurred if 2 successive data points fall outside of 2

SDs on either side of the mean (Ottenbacher, 1986a). The PQRS data were examined for normal

distribution, and were verified to ensure no significant degree of autocorrelation in the baseline

data points, using SPSS 15.0†. Significant autocorrelation was seen in one goal, Participant 2‟s

reciprocal stair climbing goal (Lag 1 autocorrelation,-0.6, p=0.05, see Appendix L), thus, for that

goal a variation in the method of calculating the SD was used, incorporating moving ranges. The

moving range is the absolute difference between a data point and the previous one. The SD is

calculated by dividing the mean of moving ranges by a constant (d2=1.128), (Sideridis &

Greenwood, 1996) and results in the SD bands moving up or down to compensate for trends.

Inter-rater reliability for the PQRS was assessed on a sub-sample of data points for each goal

using intraclass correlation coefficients (ICC). ICCs ranged from 0.57 to 0.88, and the average

for all goals was 0.71 (See Appendix N).

The mean and standard deviation of the baseline data points were calculated for each goal using

Microsoft Excel 2007®.

Microsoft Corporation, 1 Microsoft Way, Redmond, WA, 98052-7329

†SPSS Inc Headquarters, 233 S. Wacker Drive, 11

th Floor, Chicago, Illinois, 60606

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For the quasi-experimental component baseline, post-test, and follow-up scores were compiled

for each of the 3 participants for all probe measures.

2.5 Results

2.5.1 Description of participants

Participant descriptions are provided in Table 2.2. All three participants were working-aged men

and all were right-hand dominant. As the participants were recruited from an out-patient

education program, original information about the type, location, and severity of stroke was not

available, however, anecdotally, Participant 1 (P1) reported having had a hemorrhagic stroke,

and Participant 2 (P2) and Participant 3 (P3) reported having had ischemic strokes.

Table 2.2 Participant descriptions

Indicator P1 P2 P3

Age 42 56 52

Gender male male male

Time since stroke 13 months 18 months 40 months

Stroke side left brain left brain left brain

Hand dominance right right right

Years of education post-secondary* 14 15

Comorbidities hypertension none reported diabetes

MMSE 30/30 29/30 29/30

CMSAS-II, arm 6/7 2/7 4/7

CMSAS-II, hand 6/7 2/7 2/7

CMSAS-II, leg 5/7 5/7 4/7

CMSAS-II, foot 5/7 2/7 2/7 MMSE = Mini Mental Status Exam (Folstein et al., 1975); CMSA-II= Chedoke-McMaster Stroke Assessment Scale

Impairment Inventory(Gowland et al., 1985); * years of education not equivalent in P1, as he was educated outside

of North America, however, he did report having post-secondary education.

2.5.2 Single case experimental design findings: P1

P1‟s goals were writing neatly and precisely with his affected right hand, riding a bicycle, and

swimming breaststroke. P1 had a total of 7 one-hour intervention sessions. Three sessions were

dedicated to writing, 1 to biking, and in the remaining 3 sessions he worked on a combination of

2 goals. In total, writing was addressed in 4 sessions, biking in 4, and swimming in 2.

Figure 2.1 provides PQRS scores, baseline means and upper two-standard deviation bands for

each of P1‟s goals. A summary of PQRS baseline means, standard deviations, and mean plus 2

standard deviations, for all participants, is provided in Table 2.3. Significant improvements, as

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noted by 2 successive data points above the 2 standard deviation band, are seen during

intervention and post-test for biking and swimming, and for all goals at one-month follow-up.

Descriptively, at baseline, P1 required assistance to mount the bicycle, and was only able to

peddle for two or three rotations before stopping, swerving off course, or being stopped by the

therapist for other safety reasons. In the 2nd

biking session, through guided discovery, P1came to

a decision to try adding a regular, non-adapted toe cage to the right pedal, and this addition was

made in the 3rd

biking session. During his 4th

and final biking intervention session, he was able

to mount and dismount independently, without stopping, ride two full city blocks, including

turning corners and ascending and descending modest ramps.


P2‟s goals were using the computer mouse with his affected hand, reciprocal stair climbing, and

incorporating the affected hand while reading a book. P2 had 9 intervention sessions of one hour

each. One session was dedicated solely to the use of the computer mouse, while each of the

remaining 8 sessions focused on 2 goals. Use of the computer mouse was addressed in 8

sessions, stairs in 6, and reading in 3.

Figure 2.2 provide PQRS scores, baseline means and upper two-standard deviation bands for

P2‟s goals. Significant improvements, as noted by 2 successive data points above the 2 standard

deviation band, are seen during intervention for all 2 of the 3 goals, for computer mouse at post-

test, and for both computer mouse and stairs at one-month follow-up. P2 developed knee pain

towards the end of the intervention sessions; this made his stair climbing more difficult and the

results more variable, probably explaining the lack of improvement at post-test.

P2‟s original third goal of reading incorporating the affected hand had been to sit in a chair, and

use his right hand to support a book from underneath, while using his left hand for steadying the

book and turning the pages. He achieved the goal to his own satisfaction during the second

session. Subsequently, and unilaterally, he changed the goal to being able to close the book, hold

the closed book with his impaired right hand, stand up from the chair, turn, bend, and place the

book down on the chair. He was reluctant to return to the original goal for post-intervention and

follow-up assessment sessions. His post-test and follow-up performances of the evolved goal

were not included in the PQRS ratings, therefore only 2 data points were available for those

phases.

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The 3 goals selected by P3 were clipping the nails on his left hand by using clippers with his

affected right hand, walking while carrying an object in his affected right hand, and learning

basic yoga/ deep breathing techniques.

P3 had a total of 7 intervention sessions. One session was dedicated to nail clipping, 1 to

walking, and during the remaining 5 sessions he worked on at least 2 of the 3 goals. In total, nail

clipping was addressed in 4 sessions, walking in 5 sessions, and yoga in 3 sessions.

Figure 2.3 provides PQRS scores, baseline means and upper two-standard deviation bands for

each of P3‟s goals. Significant improvements are seen during intervention for walking and yoga,

at post-test for walking, and for walking and nail clipping at one month follow-up. P3 chose to

use a different set of nail clippers at the 1-month follow-up, with widened, easier-to-grip levers.

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Figure 2.1 P1 PQRS charts with means and upper 2 SD control limits

All three bicycling baseline data points were scored at 3, therefore the standard deviation is 0,

and the mean plus two standard deviations is 3, both represented by the solid line.

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Figure 2.2 P2 PQRS charts with means and upper 2 SD control limit

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Figure 2.3 P3 PQRS charts with means and upper 2 SD control limit

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Table 2.3 PQRS baseline mean, standard deviation, and baseline mean plus 2-standard

deviations* P1 Goals Mean SD Mean plus 2 SD

Writing neatly and precisely

with right hand

3.3 1.2 5.7

Riding a bike 3.0 0.0 3.0

Swimming breaststroke 3.7 0.6 4.9

P2 Goals

Using computer mouse with

affected right hand

1.3 0.6 2.5

Incorporating affected right

hand in reading

5.5 0.9 7.3

Reciprocal stair climbing 3.5 0.6 4.8

P3 Goals

Clipping nails on left hand with

affected right hand

2.6 2.1 6.7

Walking carrying item in right

hand

4.0 0.8 5.6

Yoga/meditation 3.8 1.7 7.3 *Mean plus 2 standard deviations is the upper band of the 2 standard deviation band method. SD = Standard

Deviation.

2.5.5 Quasi experimental findings: Self-reported performance and performance satisfaction, health status and self-efficacy/confidence

When considering the three participants together, clinically important changes of two points or

more on the COPM were seen in seven of nine performance scores and eight of nine satisfaction

scores post intervention. At one-month follow-up, all satisfaction improvements were

maintained, and improvements in all but one performance score, nail clipping, were maintained.

COPM scores are provided in Table 2.4.

SIS, SEMCD-6, and ABC probe scores are provided in Table 2.5. Clinically important

improvements of at least 10 points (Duncan et al., 1999) were noted for P1 in the physical, ADL,

hand function, and participation domains, for P2 in communication and overall recovery, and for

P3 in physical, ADL, hand function, and overall recovery. P2 showed changes in self-efficacy,

as measured by the SEMCD-6. To capture any mobility-specific self-efficacy changes, the ABC

was added to the experimental protocol for P3. P3 reported large improvements of 25% at post-

test and 36.2% at 1-month follow-up.

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Table 2.4 Self-selected goals and Canadian Occupational Performance Measure (COPM)

scores T1 COPM T2 COPM T3 COPM

P1 Goals Per Sat Per Sat Per Sat

Writing neatly and precisely

with right hand

3.5 1 7 8 7 9

Riding a bike 1 1 8 8 7 9

Swimming breaststroke 1 1 7 7 7 9

P2 Goals

Using computer mouse with

affected right hand

3 4 5 5 5 5

Incorporating affected right

hand in reading

7 5 4 7 4 7

Reciprocal stair climbing 5 6 6 8 6 8

P3 Goals

Clipping nails on left hand with

affected right hand

3 1 6 6 4 6

Walking carrying item in right

hand

6 4 10 10 10 10

Yoga/meditation 3 1 10 10 10 8 COPM Scores shown for Performance (Per) and Satisfaction (Sat) for T1 (baseline), T2 ( post intervention), and T3

(one-month follow-up). Numbers in bold indicate COPM scores that have increased by at least 2 points from the

T1 (baseline) score, considered to be clinically significant (Law et al., 2005).

Table 2.5 SIS, SEMCD-6, and ABC scores for all participants

P1 P2 P3

Base Post Follow Base Post Follow Base Post Follow

SEMCD-6 28 31 33 32 50 51 58 60 60

ABC (%) n/a n/a n/a n/a n/a n/a 49 74 85

SIS Domains:

Physical 15.0 45.0 35.0 20 20.0 20.0 20.0 35.0 25.0

Cognitive 45.7 45.7 42.8 68.6 71.4 74.3 77.1 77.1 80.0

Emotional 60.0 60.0 44.4 53.3 55.5 57.8 91.1 77.8 80.0

Communication 45.7 40.0 37.1 68.6 77.1 71.4 71.4 77.1 80.0

ADL 28.0 36.0 38.0 52.0 56.0 60.0 62.0 64.0 74.0

Mobility 44.4 42.2 44.4 57.8 66.7 57.8 77.8 75.5 77.8

Hand 15.0 30.0 40.0 15.0 5.0 10.0 10.0 25.0 55.0

Participation 7.5 20.0 27.5 35.0 40.0 47.5 72.5 80.0 80.0

Overall Recovery 60 65.0 68 45.0 56.0 52.0 65.0 70.0 85.0 ABC = Activity-specific Balance Confidence Scale (Meyers Fletcher, Myers, & Sherk, 1998); Base=baseline

assessment; Follow=1-month follow-up assessment; n/a=not assessed; Post=post-test assessment; SEMCD-6=

Stanford Self-Efficacy for Managing Chronic Disease 6-Item Scale (Lorig et al., 2001); SIS = Stroke Impact Scale,

scores in bold indicate an increase of at least 10 points, considered clinically meaningful (Duncan et al., 1999).

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2.6 Discussion

This discussion summarizes the performance improvements associated with the CO-OP

treatment approach, and then elaborates on the relative performances of specific participants and

specific goals in the context of the CO-OP intervention, goal complexity, motivational factors,

and amount of practice. Study limitations related to participant self-selection of goals are

discussed.

Performance in eight of nine self-selected functional goals was significantly improved at one-

month follow-up. Each participant improved in two of their three goals during intervention, and

the improved performance was retained at 1-month follow-up for all but 1 goal, yoga. As well, 2

particularly complex goals, handwriting and finger nail clipping, which did not significantly

improve during intervention, were significantly improved at 1-month follow-up. Clinically

meaningful changes in self-perceived skill performance and performance satisfaction were

reported by P1 and P3 for all 3 goals. P2 self-reported clinically meaningful performance

improvement in only 1 goal, using the computer mouse with his affected hand. As stated

previously, P2‟s reading goal as identified at the outset was achieved very early so he

continuously increase the complexity of his goal, resulting in a final goal that was dramatically

different and much more challenging than his original goal. His self-evaluation likely reflected

his performance on the final, more challenging goal. Also mentioned earlier, P2 developed knee

pain during the intervention, and his stair climbing performance decreased. This was reflected

both in the observed PQRS scores and the self-rated COPM scores. P2 did report clinically

meaningful improvement in satisfaction with performance in both his reading and stair climbing

goals, perhaps indicating that he was satisfied with his overall gains for those goals.

P1‟s handwriting goal and P3‟s nail clipping goal were not significantly improved until 1 month

follow up. While all goals selected by participants in this current study were challenging, the

manual dexterity tasks, handwriting, nail clipping, and using the computer mouse, were probably

the most complex. The task complexity of handwriting and nail clipping may have contributed

to their delayed acquisition. Also, in follow-up testing, P3 used a different set of clippers that

were wider and easier to use, and that likely contributed to his success at that time.

In contrast to the other manual dexterity tasks, significant improvements were seen during

intervention for P2‟s computer mouse task. This may have been because P2‟s specific goal was

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somewhat less complex than the others, in that he wanted to be able to move the mouse

accurately from icon to icon, but not necessarily open and close the computer applications.

Another possible explanation for the earlier achievement of P2‟s computer mouse goal compared

to the manual goals of the other participants is amount of practice. P2 practiced the computer

mouse in 8 sessions, whereas P1 and P3 practiced handwriting and nail clipping respectively in

only 4 sessions. Practice is thought to be the single most important factor in motor skill

acquisition (Schmidt & Lee, 2005, p.322) and outcomes for some of the goals seem to reflect

this. Overall, however, goals were achieved in relatively few sessions, and possible explanations

for that are addressed later in the discussion.

The role of self-selected goals, as well as a certain amount of self-direction in the intervention

may have had a role in how quickly the skill was acquired. Using P1‟s handwriting goal and

P2‟s computer mouse goal again as an example, P2 did two things that likely improved his

success. First, he chose a goal that he perceived to be achievable with his existing level of

impairment. While he knew that using the computer mouse with his hemiplegic hand (CMSA

Impairment Inventory Stage 2) would be extremely challenging, he also knew that it was a long-

term goal, and for the study intervention he selected an interim step of getting to the point where

he could move the mouse in a controlled fashion from icon to icon, but not necessarily open and

close software applications. Second, in keeping with the CO-OP treatment approach he could

direct which goals would be the focus of each treatment sessions. Because the computer mouse

goal was, to him, the most important of the 3 goals, he chose to practice that goal in almost every

session. The computer mouse goal was important to him because it was related to being able to

do his paid work more efficiently; he was self-employed and spent a few hours using the

computer every day. In contrast, P1 was working on refining his handwriting with a CMSA

Impairment Inventory Stage of 6 in the hand, and even though he also chose his own handwriting

goal and partially self-directed his treatments, his motivation to have neat handwriting may have

been less than P2‟s motivation to use the computer mouse.

Amount of practice was mentioned above as a possible reason for seemingly faster acquisition of

some goals over others. However, overall, the amount of formal practice to achieve the self-

selected goals was very small, with a maximum of 8 and as few as 2 sessions on any individual

goal. In some cases, participants practiced informally at home, although the degree to which this

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occurred was not tracked. While a thorough understanding of why the CO-OP approach seems to

work so efficiently is under ongoing investigation, we believe that interactions among some of

the key features of the approach are responsible, namely, global cognitive strategy use, guided

discovery, and self-selection of goals. The role of self-selection of goals and motivation was

addressed briefly above. Global cognitive strategy use and guided discovery require structured

planning and problem solving during goal acquisition. CO-OP‟s imposition of a structure on the

executive cognitive processes implicated in complex skill acquisition may increase the efficiency

of learning. The paragraphs below examine this possibility in more detail.

Lee and colleagues have suggested that motor skill is highly cognitive, and to have successful

motor learning, the cognitive processes associated with movement, such as problem-solving,

planning, attention and perception, require practice as much as the actual movement patterns

themselves (Lee et al., 1994). As well, evidence from motor learning research suggests that a

performance-learning paradox exists, in which there is a tendency for performance-enhancing

practice conditions, such as frequent, continuous feedback, to be detrimental to performance on

learning or retention tests, and concomitantly, in more cognitively-demanding practice

conditions associated with reduced performance, performance on learning/retention tests is

improved (Lee et al., 1994). Thus, in a cognitively-demanding approach such as CO-OP, it is

not unexpected to see variable performance of the goal during the acquisition phase, but

evidence of that the skill was learned and retained at follow-up testing.

The findings from basic research lend additional evidence to the role of cognition, and

specifically executive functions, in motor skill acquisition. In an article reviewing links between

action and cognition, Serrien and colleagues conclude that frontal lobe activity is consistently

seen in complex motor tasks requiring response selection, monitoring, and executive cognitive

control (Serrien et al., 2007). Involvement of cognitive areas is particularly prominent during

initial learning of the task (Debaere, Wenderoth, Sunaert, Van Hecke, & Swinnen, 2004), or

when the brain is compromised through aging or pathology (Murase, Duque, Mazzocchio, &

Cohen, 2004; Wu & Hallett, 2005), or when there are increased external or environmental

demands associated with performing the motor task (Jantzen, Oullier, Marshall, Steinberg, &

Kelso, 2007). The neurophysiological evidence suggests an important cognitive component

exists in tasks that are often considered to be purely motor-based, and lends support to the use of

cognitive-strategy based approaches, such as CO-OP. The global cognitive strategy in CO-OP,

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Goal-Plan-Do-Check, helps to structure cognitive executive functions of planning, problem-

solving, and evaluating, and likely contributes to the increased efficiency of skill acquisition.

2.6.1 Limitations and suggestions for future research

One of the main limitations of this study was the difficulty of measuring performance on self-

selected goals. For example, P3 worked on improving relaxation and deep breathing in two

different positions as the main focus of his yoga goal. His COPM self-reported performance and

performance satisfaction improved by seven and nine points respectively post intervention, and

these large gains were maintained at1 month follow-up. It is likely that his improvements were

greater than noted in the PQRS ratings, but capturing something as subtle as deep breathing and

relaxation on a video recording is difficult. Using a different measurement technique, such as

respiratory or heart rate, or perhaps relying exclusively on participant self-report, may have

captured improvement better on this task, but would have introduced the additional issue of

adding different measurement constructs to the already complex design. While the use of self-

selected goals does present challenges for both treatment and assessment, it is believed that this

component of the CO-OP treatment approach has important implications for participant

motivation and is strongly linked to its success. In future research, exploration of the interactions

among task complexity, motor impairment, and cognitive strategy use, and their impact on motor

skill acquisition should be investigated. Other areas to be investigated are the impact of CO-OP

on skill transfer, the seeming tendency for skills to continue improving after intervention

withdrawal, and the relationships among specific cognitive process impairments and cognitive

strategies learned and used.

2.7 Conclusion

The CO-OP treatment approach was associated with significant improvements in the

performance of the majority of complex, self-selected goals in three single case experiments, and

clinically significant improvements in self-perceived performance and performance satisfaction.

Participants also reported improvements considered clinically important in physical, ADL, hand

function, participation, and overall recovery health status domains. CO-OP is a novel, promising

treatment approach to efficiently improve motor performance in real-life skills in adults living

with the effects of chronic stroke. Further investigation of CO-OP and global cognitive strategies

to facilitate motor skill acquisition is warranted.

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2.8 Acknowledgements

This study was funded by the Physiotherapy Foundation of Canada, and SM received support

from the Social Sciences and Humanities Research Council of Canada.

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Chapter 3 Inter-task transfer following a cognitive-based treatment: Results of three multiple baseline design experiments in chronic stroke.

McEwen SE, Polatajko HJ, Huijbregts MPJ, Ryan JD. Inter-task transfer following a cognitive-

based treatment: Results of three multiple baseline design experiments in chronic stroke.

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3 Inter-task transfer following a cognitive-based treatment: Results of three multiple baseline design experiments in chronic stroke.

3.1 Abstract

Purpose: Transfer of motor-based skills learned in rehabilitation to new skills in the home

setting has hitherto been notoriously difficult to achieve. The Cognitive Orientation to daily

Occupational Performance (CO-OP) treatment approach has been associated with improved

motor performance in people living with chronic stroke, but the specific impact on transfer to

untrained skills has not been investigated. The purpose of this study was to investigate the

capacity of CO-OP treatment to improve performance in both trained and untrained self-selected

skills in community-dwelling adults living with stroke.

Materials and methods: A single case experiment with multiple baselines across skills was

conducted, followed by two replications. The participants self-selected four skills; three were

trained using CO-OP; the fourth was not trained. Using video recording, data points were

collected at multiple baselines, during intervention, post intervention, and at one-month follow-

up.

Analysis: The Performance Quality Rating Scale (PQRS) was used by an independent rater to

score performances. The two-standard deviation band method was used to determine the

significance of improvements.

Results: At one month follow-up, significant performance improvements were seen in all 3

single case experiments in both the trained and untrained skills.

Conclusion: A cognitive-based approach was associated with improved performance in both

trained and untrained skills in adults with chronic stroke. Further investigations into the efficacy

of the approach are warranted.

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3.2 Introduction

To live a full and meaningful life following rehabilitation, it has been argued, transfer of skills

and training to real-life situations is necessary (Ezekiel et al., 2001; Geusgens, Winkens et al.,

2007). While inter-task transfer, or transfer of learning from one task or skill to a very different

one, has been notoriously difficult to achieve in the motor domain (Schmidt & Lee, 2005, p.452),

it is an expectation with cognitive strategy use, as the focus of training is not on learning specific

tasks, but also on learning new ways to solve problems (Geusgens, Winkens et al., 2007;

Geusgens et al., 2006). Preliminary empirical evidence suggests cognitive strategy training can

improve functional skill performance following a stroke, and that the training is associated with

inter-task transfer (Donkervoort et al., 2001; Geusgens et al., 2006; Liu et al., 2004).

Cognitive Orientation to daily Occupational Performance (CO-OP) is a treatment approach that

makes use of both global and domain-specific cognitive strategies. The approach was originally

developed for pediatric use, and a body of research has demonstrated its association with

improved skill performance in children with developmental coordination disorder, cerebral palsy,

acquired brain injury, and Asperger‟s Syndrome (Cameron, Polatajko, Missiuna, Schwellnus,

2009; Miller, Polatajko, Missiuna, Mandich, & Macnab, 2001; Polatajko, Mandich, Miller, &

Macnab et al., 2001; Rodger, Springfield, & Polatajko, 2007; Samonte, Solish, Delaney,

Polatjako, 2004). The approach has also been used successfully with adults with acquired brain

injury (Dawson et al., in press). More recently, our research group has undertaken a multi-phase

research program to evaluate the adaptation of this approach for adults with chronic stroke

(Henshaw, Polatajko, McEwen, Ryan, & Baum, submitted; McEwen, Polatajko, Huijbregts, &

Ryan, submitted; McEwen, Polatajko, Davis, Huijbregts, & Ryan, submitted). The results from

those studies were promising and pointed to the need for a careful evaluation of the approach to

support transfer of skills. Accordingly a transfer study was initiated, the results of which are

reported here.

In CO-OP, clients select three skills to be the focus of approximately ten intervention sessions.

An adaptation of Meichenbaum‟s (Meichenbaum & Goodman, 1971) global cognitive strategy,

Goal-Plan-Do-Check, forms the main framework for the treatment approach, and domain-

specific strategies are identified by the client as needed for skill acquisition, through an iterative

process using guided discovery. The process of learning problem solving strategies in concert

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with meaningful skill acquisition is theorized to enable the transfer of the strategies to novel

situations, allowing the client to eventually acquire skills independently, in the absence of formal

rehabilitation or professional help.

In our initial single case series, we evaluated the effect of CO-OP on self-selected skill

performance in adults living in the community with chronic stroke in three single case

experiments (McEwen, Polatajko, et al., submitted). The CO-OP approach was associated with

improved skill performance in all three cases, as rated by an independent evaluator conducting

ratings from video recorded performances presented in random chronological order. There were

preliminary indications of CO-OP transfer effects from improvements seen in some Stroke

Impact Scale (SIS) domains (Duncan et al., 1999), as well as participant reports that they were

using the newly acquired cognitive strategies independently to improve novel skills beyond those

learned during the intervention. Therefore, a second single case series was developed with the

objective of further exploring the effect of CO-OP on skill performance, and specifically

examining transfer to untrained skills. The specific research questions were:

1. Does the CO-OP treatment approach, administered to an adult living with the effects of

stroke, improve performance in three trained self-selected skills and one untrained self-

selected skill?

a. Can the results be replicated in similar individuals?

2. Are there other indications of transfer or secondary benefits, including changes in health

and functional status, motor control, and self-reported upper extremity use?

3.3 Methods

3.3.1 Participants

The target population for this study was adults living in the community with chronic stroke.

Potential participants were purposefully recruited upon discharge from an out-patient stroke self-

management program at a rehabilitation centre in Toronto, Canada, as individuals who were

perceived by the program leader to be motivated to participate in and contribute to an

exploratory research project. Participants were at least one year post stroke, living in the

community, and had a minimum score of 24/30 on the Mini-Mental State Exam (Folstein et al.,

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1975). Five individuals were recruited. Two participants became ill and withdrew, and, as

required by ethics, their data were withdrawn. Thus, three single case experiments were

completed in this series.

3.3.2 Design

To answer the first question, we conducted a multiple baseline across skills design with follow-

up and two direct replications. Single case experiments are considered the design of choice when

measuring behavioral change (Franzen & Harris, 1993), and are considered an optimal design in

the early stages of establishing a new intervention (Ottenbacher, 1986a). Participants each

selected four personally-meaningful skills: Skills 1-3 were specifically treated with the CO-OP

approach, Skill 4 was not directly addressed. Performance on the fourth, untrained skill was

monitored as a means of evaluating transfer as recommended by Geusgens and colleagues

(2007).

To answer the second question regarding other indicators of transfer and secondary effects, a

quasi-experimental design was superimposed. Single point assessments of health status, self-

efficacy, motor control, and upper extremity activity were conducted at baseline, post-

intervention, and at one-month follow up.

Figure 3.1 provides an overview of study design and timing of assessments for each individual

single case experiment. An initial meeting took place with each participant to explain the study,

obtain informed consent, administer baseline assessments, and to select the skills that would

become the focus of treatment. The following meeting was Baseline 1a, at which point

approximately 3 unaided performances of each of the four skills were executed and video

recorded. At the third meeting, called Baseline 1b, an additional 3 unaided performances of the

4 skills were executed and video recorded. While the researchers strived for 6 baseline

performances combined over Baselines 1a and 1b, in some cases, particularly if acquiring

equipment or fatigue or safety was an issue, fewer performances were recorded.

Following completion of the baseline performances, the CO-OP treatment approach was

introduced to the participant, and treatment of Skill 1 was initiated. Introducing the treatment

approach and beginning the treatment could occur on the same day, immediately following

Baseline 1b performances, or at the subsequent session, depending on time and participant

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fatigue. After 2-3 treatment sessions solely focused on Skill 1, and prior to any interventions

focused on Skill 2, Baseline 2 occurred. The participant performed, unaided, 3 trials of Skills 2-4

prior to beginning the intervention session. Subsequently, the intervention session was initiated,

focused on treatment of Skill 2. Over the next few sessions, treatment continued for Skill 2 and

Skill 1 as needed. Baseline 3 then occurred, prior to introducing treatment for Skill 3. Following

a maximum of 10 intervention sessions, post-intervention performances for all 4 skills were

conducted. A follow-up assessment occurred 1 month later.

Figure 3.1 Study design, instruments, and timing

Initial Meeting

Baseline 1a

Baseline 1b

Intervention Phase 1

Baseline 2


Baseline 3


Post-Intervevntion

1-month Follow-

Up

Consent, SIS, ABC,

SEMCD-6, RNL, COPM,

MAL, CM

PQRS PQRS Treatment of Skill 1

PQRS Treatment of Skill 2, Skill 1 as needed

PQRS Treatment of Skill 3,

Skills 1 and 2 as

needed

SIS, ABC, SEMCD-6,

RNL, COPM,

MAL, CM, PQRS

SIS, ABC,

SEMCD-6, RNL, COPM, MAL, CM,

PQRS

ABC=Activity-Specific Balance Confidence Scale (Myers et al., 1998; CM=Chedoke-McMaster Stroke Assessment

Scale Impairment Inventory (arm, hand, leg, foot only) (Gowland et al., 1995); COPM=Canadian Occupational

Performance Measure (Law et al., 2005); MAL=Motor Activity Log (Uswatte et al., 2006); PQRS=Performance

Quality Rating Scale (Miller et al., 2001); RNL=Reintegration to Normal Living Index (Wood-Daupinee et al.,

1988); SEMCD-6=Stanford Self-Efficacy for Managing Chronic Disease 6-Item Scale (Lorig et al., 2001);

SIS=Stroke Impact Scale (Duncan et al., 1999).

3.3.3 Instruments

The outcome of interest in this study was skill performance on 3 trained skills and 1 untrained

skill. The instrument used to measure participant‟s performance on their self-selected skills was

the Performance Quality Rating Scale (PQRS) (Miller, Polatajko, Missiuna, Mandich, &

Macnab, 2001). Performance is rated on a 10-point scale, with a score of 1 indicating “can‟t do

the skill at all” and 10 indicating “does the skill very well”. Inter-rater reliability has been

estimated using the intraclass correlation coefficient (ICC) at 0.71 (McEwen, Polatajko, et al,

submitted). Data collection included multiple video recorded trials of each skill at each of the

three baselines, post intervention and at one-month follow-up. In addition, performance data

were extracted from video recordings of the intervention sessions. PQRS ratings were conducted

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by a trained, independent observer who was presented with all baseline, post-test, and follow-up

performances, and a sample of the intervention performances, in randomized, non-chronological

order. PQRS ratings for handwriting were conducted using actual handwriting samples provided

in randomized, non-chronological order, rather than using videotaped performances. One

participant was working on increasing gait speed, and for that skill, PQRS ratings were based on

actual gait speed, and randomized video recorded performances were not used.

For the quasi-experimental component, a number of standardized measures were administered

(See Appendices F-K). The Canadian Occupational Performance Measure (COPM) is a semi-

structured interview for eliciting performance issues from the client perspective, and for

capturing perceived changes in performance over time (Law et al., 2005). The COPM is used to

elicit the self-selected, task-based goals or skills which subsequently become the focus of

treatment. Participants use a 10-point visual analogue scale to rate their performance and

satisfaction with performance on each skill.

To capture potential transfer to broader aspects of daily life, the Stroke Impact Scale (SIS)

(Duncan et al., 1999), and the Reintegration to Normal Living Index (RNL) (Wood-Dauphinee,

Opzoomer, Williams, Marchand, & Spitzer, 1988) were used. As an additional indicator of

transfer of upper extremity skills, the Motor Activity Log (MAL) was used (Uswatte et al.,

2006). To measure self-efficacy, the Stanford Self-Efficacy for Managing Chronic Disease 6-

Item Scale (SEMCD-6) (Lorig et al., 2001) and the Activity-specific Balance Confidence Scale

(ABC) (Myers et al., 1998) were used. The Chedoke-McMaster Stroke Assessment Impairment

Inventory (CMSA (II)) provides a description of degree of motor control (Gowland et al., 1995).

CMSA (II) has 6 dimensions, of which 4 were used: arm, hand, leg, and foot.

3.3.4 Intervention description

CO-OP is an individualized intervention, conducted over approximately 10 sessions, with one or

two sessions per week. In the first meeting, prior to beginning the intervention sessions, the

client and the therapist work together, using the COPM (Law et al., 2005), to select 3 skills and

establish baseline skill performance. For the purposes of this particular study, a 4th

skill was

selected to be evaluated, but not trained.

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The CO-OP approach is introduced to the client in the second meeting when the intervention

actually begins; at the outset the global cognitive strategy is learned and in all subsequent

sessions that strategy is used in an iterative fashion to facilitate skill acquisition. Using the global

problem-solving strategy as a framework, the participant is guided to discover domain-specific

strategies that support skill performance and acquisition. As well, the therapist regularly seeks

opportunities to promote generalization of skills and strategies to the home environment and

transfer to novel skills.

The intervention was delivered by one of the authors, SM, a physical therapist with

approximately 15 years experience at the time of the study. Adherence to the CO-OP approach

was monitored throughout the study by reviewing video recordings of intervention sessions with

another of the authors, the creator of the approach (HP).

3.3.5 Analysis

The analysis included descriptive statistics and use of the 2 standard deviation (SD) band method

to compare skill performance (PQRS) scores during baseline to intervention, post-test, and

follow-up phases.

The 2 SD band method is derived from industrial statistical control procedures (Orme & Cox,

2001), and is useful in human single case experiments when the number of data points is

relatively small, and when individual variability is high (Ottenbacher, 1986a). The standard

procedure assumes no significant degree of autocorrelation at baseline (Sideridis & Greenwood,

1996), thus this assumption was verified using SPSS 15.0.3 All PQRS data points for each skill

were graphed on a control chart. The mean and SD of the baseline data points were calculated for

each skill, and then the mean plus and minus 2 SD control limits were established. A set of

accepted decision rules were used for determining non-random conditions: a significant change

was said to have occurred if 2 successive data points are outside of the 2 SD control limits (Orme

& Cox, 2001; Sideridis & Greenwood, 1996).

3 SPSS Inc Headquarters, 233 S. Wacker Drive, 11

th Floor, Chicago, Illinois, 60606

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3.3.6 Ethics

This study was approved by ethics review boards at both the recruiting centre and the University

of Toronto. Informed, written consent was obtained from all participants.

3.4 Results

3.4.1 Description of participants

Participant descriptions are provided in Table 3.1. As the participants were recruited from an out-

patient program, original information about the type, location, and severity of stroke was not

available. Participants (P) were coded as P5, P7, and P8, to distinguish them from the

participants in our initial single case series, reported elsewhere (McEwen, Polatajko, et al.,

submitted). Also provided in Table 3.1 are baseline, post intervention, and follow-up scores for

instruments from the quasi-experimental component of the study. Table 3.2 outlines all

participant-selected skills, and provides baseline, post-test, and one-month follow-up COPM

scores for each.

3.4.2 Comparison of skills across study phases

3.4.2.1 Baseline autocorrelations

Lag 1 autocorrelations were calculated for PQRS baseline scores for each skill. Significant

baseline autocorrelation was found for P5‟s writing skill (Lag 1 autocorrelation=0.52, p=0.05,

see Appendix L), therefore analysis for that skill was conducted using a variation on the 2 SD

band method called the X-moving range-chart (X-mR-Chart). The moving range is the absolute

difference between a data point and the previous one. The SD is calculated by dividing the mean

of moving ranges by a constant (d2=1.128),(Sideridis & Greenwood, 1996) and results in the SD

control limits moving up or down to compensate for trends.

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Table 3.1 Participant demographics and baseline, post-test, and follow-up scores for quasi-

experimental indicators

P5 P7 P8

Age (years) 54 37 47

Gender female male female

Time post stroke (m) 12 25 35

Stroke side left right right

Hand dominance right right right

Education (years) 16 16 16

Comorbidities none none none

MMSE 28 30 30

Base Post Follow Base Post Follow Base Post Follow

SEMCD-6 38 39 27 59 60 60 42 50.5 60

ABC 53.1 57.5 48.8 93.1 96.9 96.9 12.5 21.6 17.5

MAL – AS 41 38 50 54 71 85 0 0 6

MAL - HW 39 38 50.5 58 74 92.5 0 0 6

MAL – count 16 26 28 25 25 27 0 0 3

RNL 7 4 7 1 0 1 11 6 7

SIS Domains:

Physical 30.00 30.00 35.00 60.00 60.00 50.00 5.00 10.00 42.50

Cognitive 62.86 60.00 74.29 80.00 80.00 77.14 77.14 77.14 75.71

Emotional 48.89 57.78 48.89 48.89 51.11 48.89 46.67 53.33 48.89

Communication 71.43 80.00 77.14 80.00 80.00 80.00 80.00 80.00 78.57

ADL 58.00 54.00 44.00 70.00 72.00 70.00 54.00 50.00 57.00

Mobility 60.00 66.67 64.44 77.78 73.33 77.78 44.44 42.22 71.11

Hand 35.00 45.00 45.00 65.00 90.00 85.00 5.00 5.00 36.67

Participation 47.50 52.50 50.00 72.50 67.50 72.50 60.00 52.50 61.25

Overall recovery 45.00 50.00 50.00 85.00 85.00 85.00 40.00 40.00 40.00

CMSA(II) Domains:

Foot 5 6 7 6 7 6 3 3 3

Leg 5 6 6 6 6 6 3 5 5

Hand 3 3 4 5 6 6 2 2 2

Arm 4 5 5 5 7 7 2 3 2

Total 17 20 22 22 26 25 10 13 12

ABC=Activity-Specific Balance Confidence Scale (Myers et al., 1998; CM=Chedoke-McMaster Stroke Assessment

Scale Impairment Inventory (arm, hand, leg, foot only) (Gowland et al., 1995); COPM=Canadian Occupational

Performance Measure (Law et al., 2005); MAL=Motor Activity Log (Uswatte et al., 2006); m=months; MMSE =

Mini Mental Status Exam (Folstein et al., 1975); P= Participant; PQRS=Performance Quality Rating Scale (Miller et

al., 2001); RNL=Reintegration to Normal Living Index (Wood-Daupinee et al., 1988); SEMCD-6=Stanford Self-

Efficacy for Managing Chronic Disease 6-Item Scale (Lorig et al., 2001); SIS=Stroke Impact Scale (Duncan et al.,

1999).

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Table 3.2 Self-selected skills and Canadian Occupational Performance Measure (COPM)

scores

Baseline COPM Post-test COPM Follow-up COPM

P5 Goals Per Sat Per Sat Per Sat Taking focused photographs 1 1 4 5 4 5 Sewing 1 1 3 5 4 5 Cutting with a knife 1 1 3 5 4 5 Handwriting (untrained) 2 1 3 5 3 3

P7 Goals Planting bulbs 2.5 1 10 10 10 10 Walking while carrying with

effected left hand 2 1 9 9 10 9

Buttoning cuffs 4 5 9 10 9 9 Tying tie (untrained) 1 2 10 10 10 10

P8 Goals Walking faster 5 4 8 9 7 7 Putting on coat 1 1 10 10 9 9 Getting in and out of „regular‟

chair 1 1 8 9 9 9

Incorporating effected left hand in

reading (untrained) 1 1 5 5 6 6

COPM Scores shown for Performance (Per) and Satisfaction (Sat) for T1 (baseline), T2 (post intervention), and T3

(one-month follow-up). Numbers in bold indicate COPM scores that have increased by at least 2 points from the

T1 (baseline) score, considered to be clinically significant.(Law et al., 2005)

3.4.2.2 Single case experimental design findings: Skill performance

Figures 3.2, 3.3, and 3.4 provide graphs of PQRS scores across trials, baseline means, and 2 SD

control limits.

For P5 (Figure3.2), the intervention data points remain variable and scattered around the mean

for the first two skills, photography and sewing. The third skill, cutting, demonstrates an upward

trend after the onset of the intervention. Two successive data points beyond the upper 2 SD

control limit were seen for all four skills at one-month follow-up.

For P7 (Figure 3.3), upward trends are seen for all three trained skills after the onset of the

intervention. At least 2 successive data points beyond the 2 SD limits were seen during

intervention for gardening and carrying, at post-test for gardening, carrying, and buttoning cuffs,

and for all four skills at one-month follow-up.

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P8‟s results are provided in Figure 3.4. In P8‟s graph, upward trends for all three skills are seen

after the onset of intervention. As well, at least 2 successive data points beyond the 2 SD limits

are noted in all three trained skills during intervention, at post-test, and at follow-up. The fourth,

untrained skill, incorporating her hemiplegic hand in reading, was significantly improved at

follow-up.

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Figure 3.2 P5 PQRS charts with baseline means and upper and lower control limits

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3.4.2.3 Quasi experimental findings

Clinically important changes of two points or more on the COPM were reported for performance

of all skills except P5‟s handwriting, and in performance satisfaction for all 12 skills (see Table

3.2). These results were retained at 1-month follow-up.

Scores for pre-post measures are provided in Table 3.1. Changes in self-efficacy scores, as

measured by SEMCD-6 and ABC, were variable. Clinically important improvements of at least

10 points (Duncan et al., 1999) were noted in the SIS physical (P8), cognitive (P5), mobility

(P8), and hand (P5, P7, P8) domains. RNL scores decreased, denoting improvement to some

degree for all participants. All participants demonstrated improvements in both MAL domains

and in one or more categories of the CMSA (II).

All instruments used in the quasi-experimental design were single point measures and cannot be

tested statistically in the single case experimental paradigm, but the data are presented to give an

indication of individual improvements in these areas.

3.5 Discussion:

Performance improved significantly for three trained skills at one-month follow up in all three

single case experiments. As well, performance improved significantly in the fourth, untrained

skill at one-month follow up in all participants, providing evidence of inter-task transfer

following treatment with CO-OP. Given the participants were at least one year post stroke, it is

unlikely that improvements in the untrained skill were related to spontaneous recovery. None of

the participants was, to our knowledge, concurrently involved in another rehabilitation program.

It is likely, then, that the improvements in the untrained skill were related to a transfer effect

from treatment with the cognitive-based approach, CO-OP. In the following paragraphs, we

discuss the current study results with reference to studies of skill transfer in the motor and

cognitive domains, and review the conditions that are linked with successful skill transfer.

Finally, we consider the advantages and limitations in using multiple baseline design to evaluate

inter-task transfer.

Clinically meaningful improvements in participant self-report performance and performance

satisfaction scores (COPM) corroborated the independently-rated PQRS scores, with the

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exception of P5‟s handwriting skill. All three participants reported improvements in the SIS hand

domain score and the number of upper extremity tasks they were doing, providing additional

evidence of inter task transfer. Improvements in the CMSA (II) scores suggest that motor

control may have been enhanced. Changes in social participation, as measured by the RNL and

the participation domain of the SIS, and self-efficacy, as measured by the SEMCD-6 and ABC

were variable among the three participants, indicating that transfer did not occur consistently to

these broader aspects of daily life.

The degree of positive4 skill transfer in motor skill acquisition is typically small, and limited to

tasks very similar to the trained task (Schmidt & Lee, 2005, p. 452-453). For example, in an

experiment where participants were required to move at specific speeds, variable practice

facilitated transfer of movement at an untrained speed (Catalano & Kleiner, 1984). In tasks that

are very different from each other, transfer is reportedly negligible (Schmidt & Lee, 2005, p.

452-453). Similar findings exist in the stroke motor rehabilitation literature; for example, in a

study examining progressive resistance training (PRT) in people with stroke, improvements were

noted in muscle strength, power, and endurance for the PRT group, but no far transfer occurred

to walking distance or velocity (Lee et al., 2008). Close transfer has been reported in a controlled

trial comparing errorless learning (EL) to trial-and-error learning (TEL) in people with stroke

(Mount et al., 2007). Both groups were trained to prepare a wheelchair for transfer and to use a

sock-donning apparatus. The TEL group was more likely to successfully transfer the sock-

donning skill to a different sock-donning apparatus, but there was no difference between groups

in a wheelchair transfer task, suggesting that different learning strategies to promote transfer may

be needed for different types of tasks.

While transfer has not been widely reported in the motor domain, in has been demonstrated in

the cognitive rehabilitation literature, in association with cognitive strategy training post stroke

(Donkervoort et al., 2001; Geusgens et al., 2006; Liu et al., 2004), and in the cognitive training

literature (Jaeggi, Buschkuehl, Jonides, & Perrig, 2008). Jaeggi and colleagues trained 70 healthy

young volunteers in a difficult working memory task, and demonstrated post-training transfer to

4 Positive transfer implies an improvement in performance in one skill as a result of practice in another. Negative

transfer has also been reported, in which performance in one skill degrades as a result of practice in another.

(Schmidt and Lee, p. 454)

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fluid intelligence (Jaeggi et al., 2008). In people in the sub acute phase of stroke, two separate

randomized controlled trials have demonstrated improvement in untrained tasks following global

cognitive strategy training, providing evidence of inter-task transfer (Donkervoort et al., 2001;

Geusgens et al., 2006; Liu et al., 2004).

When transfer does occur in the motor domain, a condition strongly associated with that transfer

is variability of practice, rather than blocked practice (Schmidt & Bjork, 1992). Variability of

task practice results in poorer performance during skill acquisition compared to repetitive

practice of a single version of the task, but improved performance at retention testing and in

transfer tasks. Stokes and colleagues have proposed a learned-variability model of skill transfer,

in which they propose that learning a skill involves learning both how to do the skill, and how

differently to do the skill, as well as learning when to alter a skill (Stokes, Lai, Holtz, Rigsbee, &

Cherrick, 2008). With variable practice, the learner is prevented from selecting a single default

strategy, but rather is required to use executive cognitive processes such as planning, rule

identification, action initiation, selection of relevant sensory information, and outcome

evaluation to identify several potential strategies. He or she then learns there are several potential

strategies for a given situation, and can use that information when subsequent learning needs

arise.

Another factor that has been associated with transfer is goal orientation. Mastery goals, i.e. a

goal to master a task, have been more strongly associated with transfer than performance goals,

i.e. goals in which a level of performance is strived for, often in comparison to others (Bereby-

Meyer & Kaplan, 2005).

Geusgens and colleagues summarized six conditions for transfer, from the educational

psychology literature (Geusgens, Winkens et al., 2007).These included requiring the learner to

know what transfer is and how it works, teaching of general rather than specific information, and

addressing transfer during learning rather than expecting it to occur automatically. In this study,

the CO-OP treatment approach was introduced to all participants using a standardized procedure

that described transfer indirectly, by describing the global problem-solving strategy and referring

to its use in other areas of life beyond the three skills being trained. An emphasis on

generalization and transfer is built into the CO-OP treatment approach, and therapists are

encouraged to seek opportunities to discuss use of strategies beyond the treatment session

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(Polatajko & Mandich, 2004). As well, although CO-OP makes use of domain- or task-specific

strategies to support skill learning, the global or general strategy (Goal-Plan-Do-Check) is

consistent throughout, and participants are taught to use it as a problem solving framework

regardless of the specific skill or skill component being learned.

We postulate the 3 participants in this experimental series were able to transfer the global

cognitive strategy learned in CO-OP to begin learning new, untrained skills. We further postulate

they were able to do so because of the transfer mechanisms built into the CO-OP treatment

approach, because of the variability of skill practice that occurs as a result of the guided

discovery process, and because they had self-selected personally meaningful goals. In guided

discovery, the learner is not given the solution to problems, but is provided with hints, coaching,

feedback or modeling to help discover the solution him or herself (Mayer, 2004). Guided

discovery falls in the middle of a continuum between pure discovery, or trial-and-error, learning,

and direct instruction (Mayer, 2004). Learner performance during skill acquisition in CO-OP is

highly variable, because the self-selected tasks are often complex and divergent, and because of

the discovery process. However, because of the guidance that also occurs, participants are

steered towards more successful strategies, are prevented from getting overly frustrated, and are

rewarded for their efforts by achieving sub goals in the skill acquisition process. In the learned-

variability model of skill transfer, variability in practice is thought to be highly important, but

having too much variability early on in the learning process, so that the learner is prevented from

having any successes, is detrimental to transfer (Stokes & Balsam, 2001; Stokes et al., 2008).

Thus, guidance towards more successful strategies may provide the necessary balance in practice

variability.

In at least one study examining transfer in cognitive skill training, it has been demonstrated that

training dosage is an important factor (Jaeggi et al., 2008). Participants in the 3 single case

experiments had between 7 and 10 treatment sessions, a low dosage in stroke rehabilitation

terms. It is possible that the magnitude of transfer may have been greater with more sessions.

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3.5.1 Advantages and limitations of the multiple baseline design to

evaluate transfer

The addition of a multiple baseline component to the single case experiment increases the

validity of attributing changes to the study intervention, when intervention withdrawal or

reversal is not possible (Barlow, 1984, p.209-211). Once a skill was acquired adequately,

withdrawal of the CO-OP treatment approach was not expected to result in losing the skill.

Because the development of this treatment approach was still in the exploratory phases, single

case experiment was considered a good design (Ottenbacher, 1986a), and because withdrawal

was not possible, multiple baselines across skills strengthened the validity.

While we hypothesized a priori that transfer to the later-trained goals and to the fourth untrained

goal may begin during the baseline phases, it was felt that this would provide additional

information about the onset of transfer, rather than compromise the validity of the design. In the

case of P5‟s writing goal, a trend towards performance improvements was seen in the baseline

phases. This reduces the certainty that subsequent performance improvements were related to the

CO-OP intervention, although the other possibilities, spontaneous recovery or covert practice,

seem less likely. The most likely explanation for the gradual baseline improvement is transfer of

the problem-solving strategies learned in the CO-OP approach. Although trends during baseline

can be managed statistically, future research employing alternate study designs is recommended.

Specifically, a controlled design utilizing participants who receive an alternative treatment is

required.

3.6 Conclusion:

Developing stroke rehabilitation approaches that facilitate inter-task transfer are a key

component of optimizing long-term stroke outcomes. Ezekiel and colleagues (2001) wrote,

“When a client is attempting to… relearn a movement, the therapist needs to consider how to

provide feedback to encourage the role of the client as problem-solver… The result of

…dependence on your guidance will be the lack of ability to problem-solve in the real world

when faced with similar or novel challenges” . It is now accepted that people living with stroke

can continue improving for years after the event (Page et al., 2004). However, in the absence of

transfer, this ability is limited by access to professional resources. Teaching cognitive-based

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problem solving approaches associated with improvement in tasks very different from those

trained holds promise for continued recovery in the absence of formal rehabilitation. The CO-OP

approach is a novel, promising treatment approach to improve motor performance in trained and

untrained functional skills in adults living with the effects of chronic stroke, and warrants further

investigation.

3.7 Acknowledgements

The authors of this paper would like to thank Melissa Hyland, BSc, MSc(OT)(Student), for her

extensive help with the graphs. This study was partially funded by the Physiotherapy Foundation

of Canada, and SM received support from the Social Sciences and Humanities Research Council

of Canada.

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Chapter 4 “There’s a real plan here and I’m responsible for that plan.”

Participant experiences with a novel, cognitive-based treatment approach for adults living with chronic stroke.

This chapter is a manuscript that is currently under review by Disability and Rehabilitation:

McEwen, S.E., Polatajko, H.J., Davis, J.A., Huijbregts, M.P.J., Ryan, J.D. (under review)

“There‟s a real plan here and I‟m responsible for that plan.” Participant experiences with a novel,

cognitive-based treatment approach for adults living with chronic stroke. Disabil. Rehabil.

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4 “There’s a real plan here, and I’m responsible for that plan.” Participant experiences with a novel, cognitive-based treatment approach for adults living with chronic stroke.

4.1 Abstract

Purpose: This study was part of a larger mixed methods project aimed at adapting the Cognitive

Orientation to daily Occupational Performance (CO-OP) treatment approach, originally designed

for children with performance problems, for use with adults with stroke. In CO-OP, the client

focuses on learning strategies and skills, rather than on remediating impairments. Therapists use

guided discovery to teach cognitive strategy use. The purpose of this study was to explore

participants‟ experiences with the approach.

Method: Semi-structured interviews were conducted with five participants. Transcriptions were

coded by two members of the research team. Data analysis was conducted in two distinct

phases: Directed content analysis was conducted to apply codes to pre-determined categories;

Thematic analysis was conducted to allow themes grounded in the data to emerge.

Results: Participants reported learning and transferring the strategies taught, and made

suggestions for modifications to the approach, such as increasing the number of sessions. One

theme emerged, Balancing the need for autonomy with the need for support.

Conclusions: The findings suggest the cognitive strategies were well learned and effectively

used. CO-OP was able to provide participants with increased decision-making autonomy, but

may require modifications to better support their transition to higher levels of independence.

4.2 Introduction

Changing understanding of stroke recovery, brain plasticity, and motor learning has lead to novel

treatment approaches (Sterr, 2004), but client perception is often neglected in their development

(Ownsworth et al., 2007). Given marked differences in the way interventions are viewed by

therapists as compared to people living with stroke (Bendz, 2000; Wohlin Wottrich, Stenstrom,

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Engardt, Tham, & von Koch, 2004), incorporating client experience and knowledge in approach

development is important for long-term success and eventual uptake (McKevitt, Redfern, Mold,

& Wolfe, 2004). The study presented here is part of a larger mixed methods project aimed at

adapting an existing client-centred, cognitive-based, treatment approach use with patients with

stroke. The overall objective of the study reported here was to explore participants‟ experiences

with the approach. In this introductory section, the need to incorporate client perceptions in the

development of novel stroke rehabilitation interventions is discussed, and the Cognitive

Orientation to daily Occupational Performance (CO-OP) treatment approach is introduced.

4.2.1 Incorporating client perceptions in stroke rehabilitation research

The potential consequences of stroke include a wide range of mild to severe physical, cognitive,

language, and/or emotional sequelae, and the extent of these consequences have been well-

documented over the years using standardized instruments (Hadidi, Treat-Jacobson, & Lindquist,

2009; Inatomi et al., 2008; Jordan & Hillis, 2005; Jorgensen et al., 1995; Lesniak, Bak, Czepiel,

Seniow, & Czlonkowska, 2008; Mayo, Wood-Dauphinee, Ahmed, Gordon, Higgins, McEwen, &

Salbach, 1999; Mayo et al., 2002; McEwen, Mayo, & Wood-Dauphinee, 2000; Teasdale &

Engberg, 2005; Zinn, Bosworth, Hoenig, & Swartzwelder, 2007). It has been suggested,

however, that stroke recovery should be defined in relation to the social context and personal

goals of the person living with stroke (Burton, 2000; Folden, 1994), and that rehabilitation and

clinical outcomes should include the perspective of people living with stroke (Jones et al., 2008;

Mangset et al., 2008; Ownsworth et al., 2007). In a 2004 review of qualitative stroke research,

the authors concluded that despite flourishing research in all areas from basic science to novel

intervention development, delivery of best-quality stroke care remains problematic (McKevitt et

al., 2004). They suggest that many of these problems, such as unsatisfactory longer-term care,

can be solved through qualitative research, by gaining a deeper understanding of the contributing

processes. While stroke rehabilitation professionals believe they are taking client personal

experiences into account, this view is not always the perception of the clients (Wohlin Wottrich

et al., 2004). Numerous examples of differing perceptions between professionals and clients

exist: professionals tend to believe stroke recovery is limited by the illness trajectory, whereas

clients believe recovery stems from hard work (Becker & Kaufman, 1995; Kaufman & Becker,

1986); professionals and clients have different treatment priorities, and client views can be

excluded (Bendz, 2000); and clients may have a different understanding of goal setting than

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professionals (Holliday, Ballinger, & Playford, 2007). Establishing and incorporating client

experiences in the development stage of an intervention may help to offset potential future

misunderstandings and promise to lead to interventions that are more meaningful to clients,

thereby increasing the likelihood of their uptake.

4.2.2 The Cognitive Orientation to daily Occupational Performance

treatment approach

CO-OP is an established treatment approach for improving functional skill performance in

children with developmental coordination disorder (DCD)(Missiuna, Mandich, Polatajko, &

Malloy-Miller, 2001; Polatajko & Mandich, 2004; Polatajko, Mandich, Miller, & Macnab,

2001). In a randomized controlled trial comparing CO-OP to conventional therapy, children in

the CO-OP group had significantly greater improvement than the conventional treatment group

in the observed quality of their skill performance, their self-rated performance and satisfaction,

and parent-rated generalized motor behaviours (Miller, Polatajko, Missiuna, Mandich, & Macnab

et al., 2001).The approach has also been used with children with Asperger‟s syndrome (Rodger,

Springfield, & Polatajko, 2007), cerebral palsy, and acquired brain injury (Cameron, Polatajko,

Missiuna, Schwellnus, 2009; Samonte et al., 2004), and adults with acquired brain injury

(Dawson et al., in press), and preliminary evidence suggests the approach may be useful in those

populations as well.

CO-OP is designed to meet four objectives: skill acquisition, cognitive strategy use,

generalization of learning beyond the treatment session, and transfer of learning to new tasks in

everyday life. There are seven key features of CO-OP (see Table 4.1). Clients, working together

with the therapist, select three goals to be the focus of approximately ten intervention sessions.

An adaptation of Meichenbaum‟s global cognitive strategy (Meichenbaum & Goodman, 1971),

Goal-Plan-Do-Check, forms the main framework for the treatment approach, with domain-

specific strategies incorporated as needed. The global cognitive strategy focuses the intervention

on problem solving and is reported to be generalizable outside the treatment room and

transferable to other aspects of life (Mandich, Polatajko, & Rodger, 2003; Polatajko & Mandich,

2004; Rodger, Springfield, & Polatajko, 2007). Skill acquisition is achieved through a

combination of strategy use and a guided discovery process.

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Table 4.1 Key features of the CO-OP treatment approach

FEATURE DESCRIPTION

Client- chosen goals Goals are set in collaboration with the client. In most cases goals are specific

skills the client wants to learn to perform or to perform better. The first step in

implementing CO-OP is to identify three goals/skills using the Canadian

Occupational Performance Measure (COPM).(M. Law et al., 1998) The COPM

consists of a semi-structured interview to facilitate the establishment of client-

centred goals and a self-report rating scale to establish the client‟s satisfaction

and self-perceived performance with each goal.

Dynamic performance

analysis (DPA)

DPA is an observation-based process for identifying performance problems or

performance breakdowns. DPA progresses as a flow chart, and begins with a set

of questions the therapist asks herself or himself to establish whether or not the

client has the prerequisites for performance: motivation and task knowledge. If

the client has the prerequisites, the therapist proceeds to the next levels of

questioning, beginning with “Is the performance competent?” and then

proceeding to “Where in the performance are the breakdowns” and then “Does

the client know what to do?”; “Does the client want to do it?”; “Can the client do

it?”. The final set of questions for each performance breakdown establishes more

specifically why the client is unable to perform the task.

Cognitive strategy use In CO-OP, clients make use of both global and domain-specific cognitive

strategies. The global cognitive strategy, GOAL-PLAN-DO-

CHECK,(Meichenbaum & Goodman, 1971) forms the framework for the entire

treatment approach, and is used to promote problem-solving, and generalization

and transfer.

Domain specific strategies (DSSs) are those that are specific to a particular task

and individual, and they come and go as treatment progresses. Examples of some

DSSs are verbal self-guidance, body position, task specification and feeling the

movement.

Guided discovery Guided discovery falls in the middle of a teaching spectrum between explicit

instruction at one end, and trial-and-error or discovery learning at the other end,

wherein the learner is left largely to their own devices to learn. As guided

discovery falls between these two extremes, it allows for a certain amount of

discovery learning, but guided by the therapist, thus allowing the learner to

problem solve on his or her own but curbing excessive frustration or usage of

strategies that the therapist doesn‟t expect to work. The therapist guides the

learner by asking questions rather than telling, coaching rather than physically

adjusting, making answers obvious, and working on only one thing at a time.

Enabling principles The four enabling principles that have been identified for use in CO-OP are

making the intervention fun, promoting learning, working towards independence

and promoting generalization and transfer.

Parent/significant other

involvement

Significant others support the client in the acquisition of new skills and facilitate

the generalization and transfer of these to the home environment. They can

celebrate the client‟s successes and support use of newly learned skills and

strategies in environments beyond the intervention sessions.

Intervention format The first phase of CO-OP is the preparation phase, which is primarily concerned

with establishing the GOALs and the baseline level of performance. The second

phase is the acquisition phase where the work of using strategies to acquire skills

is accomplished. There are 10 acquisition sessions in total. The third and final

phase is the verification phase. Typically it consists of one session in which the

progress is reviewed. This session provides an opportunity for the therapist to

check and reinforce the client‟s learning of strategies and skills.

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4.3 Methodology

This study forms the qualitative component of a larger mixed methods project. Mixed methods

refer to using a combination of qualitative and quantitative methods; the specific combinations

vary among projects, based on the study objectives and the philosophical assumptions or beliefs

of the researchers (Hesse-Biber & Leavy, 2005, p.316-322). The authors of this study are

pragmatist-positivists; that is to say, keen on matching methods to the study objective, but with a

tendency to be looking for “a truth” rather than multiple realities. The overall objective of the

larger project was to adapt the CO-OP treatment approach for use with adults with stroke. The

quantitative component was comprised of two single case experimental series investigating the

efficacy of the approach on observed and self-reported skill performance, amongst other

outcomes. The authors believe the use of qualitative methods is important in this exploratory

project to elicit greater depth of understanding of the complexities of participant experiences

with the CO-OP treatment approach, which will in turn lead to an intervention that is more

meaningful and useful to clients. Three specific research questions were asked:

1. Overall, what were the experiences of participants using the CO-OP treatment approach?

2. What were the experiences of learning and using the CO-OP strategies?

3. What suggestions do the participants offer for modifications to the approach?

4.3.1 Study overview and methods

Interview participants were recruited from the single case experiments. In both single case

experimental series, baseline, treatment, post-test, and follow-up assessments were conducted,

consisting of measures of motor impairment, health status, self-efficacy, community

reintegration, and satisfaction and performance on three self-selected treatment goals.

Participants attended between seven and nine one-on-one CO-OP intervention sessions to

address their three self-selected goals.

4.3.2 Participants and recruitment

Eight community-dwelling people, at least one year post-stroke, started the single case

experiments, and six completed. The eight people were purposefully recruited upon discharge

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from a group out-patient self-management program at a rehabilitation centre in Toronto, Canada,

by the program leader. They were perceived by the leader to be individuals who were motivated

to participate in and contribute to an exploratory research project, and to have adequate cognitive

and communication skills for the intervention. Of the six individuals who completed, five

consented to the semi-structured interviews. The sixth was unable to participate because of

scheduling issues. Each of the five interview participants was interviewed approximately one

month after completion of the post-study testing. Table 4.2 provides a clinical description of

each participant. Mini-Mental Status Exam scores of 24 or higher suggest there is no significant

cognitive impairment (Folstein et al., 1975; Tombaugh & McIntyre, 1992). Chedoke-McMaster

Stroke Assessment (CMSA) Impairment Inventory scores are given for each participant.

(Gowland et al., 1995) CMSA (Impairment Inventory) provides a description of degree of motor

control. There are 6 dimensions, of which 4 were used: arm, hand, leg, and foot. Each dimension

is rated on a 7-point scale ranging from Stage 1, in which the limb is completely flaccid and no

movement can be initiated, to Stage 7, in which movement control is considered to be normal or

approaching normal, and test tasks include aspects of strength, speed and coordination.

Table 4.2 Participant demographics and clinical profile

Indicator P1 P2 P3 P7 P8

Age at admission to study 42 56 52 38 48

Gender male male male male female

Time since stroke 13 months 18 months 40 months 25 months 22 months

Stroke side left brain left brain left brain right brain right brain

Hand dominance right right right right right

Years of education post-

secondary*

14 15 16 16

Comorbidities hypertension none reported diabetes none reported none reported

Mobility walks with

spc

walks with

spc

walks with

spc

walks with no

aid indoors,

spc outdoors

manual w/c,

qc for walking

MMSE 30/30 29/30 29/30 30 30

CMSAS-II, arm 6/7 2/7 4/7 5/7 2/7

CMSAS-II, hand 6/7 2/7 2/7 5/7 2/7

CMSAS-II, leg 5/7 5/7 4/7 6/7 3/7

CMSAS-II, foot 5/7 2/7 2/7 6/7 3/7

MMSE = Mini Mental Status Exam;(Folstein et al., 1975) CMSAS-II= Chedoke-McMaster Stroke Assessment

Scale Impairment Inventory;(Gowland et al., 1995) * years of education not equivalent in P1, as he was educated

outside North America, however, he did report having post-secondary education; spc=single point cane;

w/c=wheelchair; qc=quad cane.

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4.3.3 Data collection and management

The semi-structured interviews were conducted by the first author (SM). The interviews were

conducted in the same rehabilitation hospital as the intervention, and were approximately one

hour in length. All interviews were audio recorded and transcribed verbatim. Since the

interviews were semi-structured, an interview guide (see Table 4.3) was used only as a basic

structure to ensure that all key topics were covered, while still allowing the interviewer to follow

the directions taken by each participant in the discussion.

Table 4.3 Semi-structured interview guide

Preamble Thank you very much for your participation to date in this study to adapt the CO-OP treatment

approach for use with adults who have had a stroke. As well, thank you for agreeing to

participate in this interview. Today, I would like to hear about your experience with the CO-

OP treatment – both pros and cons. Please feel free to be completely open. When I report on

this session, your name will not be used, nor will it appear in any reports related to this project.

You really should feel free to speak your mind.

General

Perceptions

1) Can you begin by telling me about your experience with the CO-OP treatment approach?

2) Do you feel you are better able to manage in your day-to-day life now?

a) What is better?

Modifications 3) What did you like about the CO-OP treatment?

4) Were there things in the treatment sessions that you didn‟t like, or would have done

differently?

Self-Selected

Goals

5) Can you tell me about the goal-setting process?

a) Was it difficult for you?

b) Did you find it useful?

c) Did you set goals for yourself prior to being involved with this research project?

Learning and

Transferring

Global Cognitive

Strategy

6) Is the GOAL-PLAN-DO-CHECK process useful to you?

a) How?

b) Do you think you need more therapy? Why?

c) Do you think you need a different type of therapy? Please explain.

7) Are you able to use the skills you learned in CO-OP in other aspects of your life?

a) Can you give me an example?

Revisiting

Overall

Perceptions

8) Is there anything else you would like to tell me about the treatment approach?

a) Is there anything we have missed in this discussion today?

4.3.4 Data analysis

Data analysis was undertaken in two distinct phases. Directed content analysis was conducted

(Hsieh & Shannon, 2005), in which codes were sorted into predetermined categories: Learning

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CO-OP strategies; Generalizing and transferring CO-OP strategies; and Considerations for

modifications. Subsequently, thematic analysis was conducted, in which the researchers

permitted themes grounded in the data to emerge. The hybrid analysis approach combined

deductive directed content analysis and inductive thematic analysis, and is similar to a process

described by Fereday and Muir-Cochrane (2006). This technique permitted analysis of specific

aspects of the CO-OP approach that are of interest to the researchers, as well as permitting

recognition of patterns in the data.

Independent coding was conducted by two members of the research team (SM and HP), in which

both researchers read the text and indentified meaningful passages. The codes were then

finalized through a consensus process. As part of the directed content analysis, each text was

read at least three times: initially to get an overview of the interview and to develop preliminary

thoughts on codes; subsequent readings to conduct focused coding; and final readings to verify

the thorough application of the codes. The coded segments of text were then, when applicable,

sorted into the above-mentioned pre-determined categories. Subsequently, thematic analysis was

conducted, in which the codes were re-examined independently of the pre-determined

categories, reshuffled, and resorted as the sub-themes emerged. The analysis was an iterative

process that relied largely on the cutting and sorting technique (Ryan & Bernard, 2003). Three

themes emerged; each theme was reviewed and reworked by the primary author and peer review

was conducted with the third author (JD) to ensure dependability. Relationships between the

three themes were discussed and it was decided by the primary and third authors that one

overarching higher level theme best captured the meaning of the three current themes. Those

three themes became sub-themes to the one final theme.

Ethics approval was received from ethics review boards at both the University of Toronto and

the hospital from which the participants were recruited. Written, informed consent was obtained

from all participants prior to their participation in the study.

4.4 Findings

The findings are presented separately for the directed content and thematic analyses. The

findings from the directed content analysis are presented under pre-determined category

headings: Learning CO-OP strategies, Generalizing and transferring CO-OP strategies, and

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Considerations for modifications. One theme emerged, Balancing the need for autonomy with

the need for support, and this is discussed in the last sub-section.

4.4.1 Learning CO-OP strategies

As previously discussed, cognitive strategy use is one of the key features of CO-OP. A global

cognitive strategy, Goal-Plan-Do-Check, is taught as the main problem-solving framework to

enable skill acquisition. In addition, domain-specific strategies are developed by the participant

and/or the therapist in response to specific goals and situations. Participants conveyed that both

the global cognitive strategy and domain-specific strategies were learned. In addition,

participants felt they were able to use the global strategy in the iterative manner in which it was

intended. In CO-OP, therapists strive to have participants attribute an unsuccessful attempt at a

particular skill performance to a problem with their Plan, rather than to personal capacity issues.

The following passage demonstrates P3 understands this.

„…and if your plan doesn‟t work, you try another plan… you remedy the plan until you

accomplish your goal‟. – P3

On further probing, however, the first three participants indicated they had some trouble with the

Check piece of the global strategy. For example, P3 said, „It has to be checked, but I don‟t know

[how].‟ In contrast, P7 and P8 did not experience these issues. For instance, P8 indicated that the

Check seemed obvious, and P7 stated specifically that he liked the idea of the Check, and said „I

think it is good to go back so it reinforces a behavior.‟ –P7

In addition to expressing that CO-OP strategies were learned and used in the context of the

specific treatment goals, participant‟s also discussed generalizing and transferring the strategies

to other aspects of their lives.

4.4.2 Generalizing and transferring CO-OP strategies

Two of the main objectives of the CO-OP approach, beyond self-selected skill acquisition, are

generalization of skills learned in therapy to the real-life environment and transfer of the

strategies learned to learn new skills as needed. Table 4.4 provides a list of each participant‟s

treatment goals, and examples of generalization and transfer gleaned from the interviews. The

interviews indicated some degree of generalization and/or transfer for all participants.

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Table 4.4 Participants’ treatment goals and examples of generalization and transfer from

interviews

P Treatment goals Generalization examples Transfer examples

P1 1. Neat and precise

handwriting

2. Bicycling

3. Swimming breaststroke

Walking better (f)

P2 1. Using hemiplegic hand on

computer mouse

2. Reciprocal stair climbing

3. Using hemiplegic hand to

assist holding a book when

reading

Computer at home

Stairs „differently‟

Washing bathroom floor (a)

„Problem solving sort of in

everything‟

P3 1. Use hemiplegic hand to clip

finger nails

2. Walk while carrying an

object in hemiplegic hand

3. Yoga

Using G-P-D-C worksheets to

practice at home

Taping on the VCR (a)

Using the computer (a)

Taught G-P-D-C to his children

(a)

Public speaking (f)

P7 1. Gardening (planting bulbs)

2. Walk while carrying a laden

tray

3. Buttoning cuff with

hemiplegic hand

Carrying laptop

Typing (a)

Taking the bus (a)

P8 1. Walking faster

2. Putting on jacket

3. Transfer to „regular‟ chair

Using „relax‟ strategy for „pretty

much everything‟

Climbing stairs (f)

Getting in and out of car (f)

P=participant; f=future-planned activity; a=actual activity

The participants described examples of transfer to skills unrelated to the specific treatment goals.

P3‟s self-selected goals were nail clipping, yoga, and walking, but he stated that he used the

global strategy widely at home for, „The things I do... like taping on the VCR or the computer,

the programs, it is because it is intricate, I have a plan set in place…‟ Similarly, P2 said, „But

now, it‟s got me problem solving sort of in everything.‟ P1 and P8 indicated they would use

Goal-Plan-Do-Check in the future.

While the participants expressed having learned, generalized, and transferred the CO-OP

strategies, a number of their considerations for modifications were extracted from the interviews.

4.4.3 Considerations for modifications

All participants endorsed the CO-OP treatment approach, and some endorsed it very strongly.

There was a general acknowledgement that the approach was novel, and represented a true break

from their past experiences with stroke rehabilitation. The participants made numerous direct

suggestions for modifications, as well as considerations that were interpreted as such by the

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researchers. In addition, there were aspects of the program that were perceived by the

participants to be important and should not be altered, such as its individualized nature and the

overall structure. The considerations for modifications were: timing of introducing the CO-OP

approach; pre-requisites for CO-OP; increased emphasis on homework; removing the attendance

of a care partner as a key feature; an increased number of treatment sessions; and blending of

CO-OP with more traditional approaches. We elaborate below on attendance of a care partner,

increased number of sessions, and blending of CO-OP with more traditional approaches.

In the original children‟s version of CO-OP, the attendance of parents at most of the sessions is

considered one of the seven key features of the approach. Having parents understand the global

problem solving strategy is thought to help with generalization and transfer to the home

environment. In the interviews, participants reported family members lack the time to help out

with therapy at home, let alone to attend sessions.

„yeah, the only problem I could see with that is the caregivers already are so busy they

don‟t really have time keep nagging you to do stuff or help you to do things‟. –P8

Four of the five participants indicated they would have liked more CO-OP sessions. P7, who

acquired his three goals to his satisfaction in just seven intervention sessions, did not express a

desire for more CO-OP, but did express the need for ongoing therapy and exercise. On probing

about the reasons for wanting more CO-OP or more therapy, a number of issues emerged from

the participants. P1 suggested that additional CO-OP sessions could focus specifically on the

self-evaluation piece (Check) of the global cognitive strategy (Goal-Plan-Do-Check). Other

participants indicated they continued to need „supervision‟ or some type of expert to tell them

whether or not they were doing things correctly.

„I set a plan but I need supervision because it is the same thing like the cutting of my

nails or the yoga exercise or the walking. I have the ability but I don‟t know whether I am

doing the right thing‟. – P3

There were suggestions that CO-OP could be blended with more traditional approaches. The first

three participants indicated they would have liked more feedback on the skills they were

learning, or more direction from the therapist, but they wanted this to be balanced with their need

to be challenged in their therapy. P2 had a specific and interesting suggestion for modifying the

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CO-OP treatment approach. He described the CO-OP approach as „the way of the future‟, and

stated that „other therapists really have to take this on‟. However, he also repeatedly brought up

an idea to blend CO-OP with more traditional therapy, and specifically suggested „80-20,‟

meaning that 80% of the time should be spent with the CO-OP approach, but 20% of the time

should be devoted to more traditional hands-on, prescriptive therapy.

The expressed desire for ongoing therapeutic support was in marked contrast to appreciation for

having been given more responsibility. The thematic analysis examined that contrast, together

with the interview data as a whole, and one theme emerged, Balancing the need for autonomy

with the need for support.

4.4.4 Balancing the need for autonomy with the need for support

The thematic analysis revealed a dichotomy of participant perceptions and experiences, between

needing greater autonomy to direct their own rehabilitation and needing ongoing outside support.

Overall, there was a desire to balance those two needs. The CO-OP treatment approach

provided the participants with autonomy they had previously been lacking, but participants still

did not feel ready to carry on without some formal therapy. In the next sections, examples are

provided to illustrate the theme of balancing autonomy with support: the experience of increased

autonomy with the CO-OP treatment approach; the need for ongoing outside support; and the

balancing act of transitioning to autonomy.

4.4.4.1 Increased autonomy

In using the CO-OP approach, participants experienced and enjoyed increased autonomy for

managing aspects of their own rehabilitation. Analysis revealed a sense of responsibility,

confidence, and self-attribution of success from the participants, as well as a desire to challenge

themselves. In addition, past experiences of paternalism in the traditional rehabilitation system

were revealed, providing a marked contrast to the autonomy experienced in CO-OP.

P2 stated, „There‟s a real plan here and I‟m responsible for that plan and that [is] good‟,

illustrating an increased sense of responsibility and confidence associated with developing

treatment plans. As is hoped in the CO-OP approach, the interview participants attributed

successes to themselves. P1 noted, „The treatment approach, because it is something we are not

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learning …from outside, is learning something myself”. The following quote from P2

demonstrates he is attributing discovery of a strategy to himself:

„I figured out something, didn‟t quite get it right, and the [next] one, that‟s when I figured

out where I put the cane and from then on it was no problem‟. – P2.

The participants wanted to challenge themselves, and seized the opportunity to do so, including

selecting goals they might not be able to achieve, and likely wouldn‟t have been permitted to set

in a traditional rehabilitation environment.

P1: At the beginning, we don‟t know if you can keep the goal, because… because we

don‟t know if setting the goal is too hard.

SM: Were you worried about that?

P1: Yes, um.. bicycle I think is impossible right? I‟m not learning that.

SM: So, why did you pick it if you thought it was impossible?

P1: Because I want to.

The participants also carried this desire to challenge themselves through setting difficult goals

into the future, after finishing with the study. In the quote below, P3 outlines his next goal as

well as his plan.

„My goal is to speak a half an hour talk to lectures in group session to talk like in the

Toastmasters… the plan is to do little articles and then relate it back to the group‟. – P3

The increased sense of autonomy with the CO-OP treatment approach was accentuated by the

contrast of past experiences of paternalism in the traditional rehabilitation system. P1 expresses

concerns about doing exercises on his own because he has „Safety concerns or… not only safety,

maybe it‟s not [at the right step]‟. P7 was much more explicit about paternalistic experiences

with the traditional rehabilitation system, describing being „yelled at‟ and „scolded‟ for

attempting to practice exercises on his own.

„I was told you cannot stand without assistance and then there was one day I said to

myself why if I want to try? I know my safety and everything but I am going to try to do

it when I have something to hold on to, like a bar, because I was scolded so many

times… Because I was not allowed to stand without anybody help and I did it and I was

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told you are not supposed to do this and this and this and I am like, nothing happened to

me, I am standing, aren‟t you supposed to be happy?‟ – P7

While P7‟s quote illustrates frustration with not having been able to progress his therapy as

quickly as he wanted, other interview excerpts indicated a desire for health care professionals to

continue to be closely involved with the recovery process.

4.4.4.2 Need for ongoing support

All participants expressed a need to have ongoing outside support, and most often this ongoing

support was expressed specifically as the need for therapy or a therapist. Four of the five

participants indicated they would have liked more CO-OP sessions. P7, who acquired his three

goals to his satisfaction in just seven intervention sessions, did not express a desire for more CO-

OP, but he did express the need for ongoing therapy and exercise. The analysis revealed this

need for ongoing therapeutic support came from a lack of confidence that they were „doing the

right thing‟ (P3) and an acknowledgement that bodies work differently after a stroke.

Quotes below suggest participant‟s lacked confidence to proceed with recovery on their own.

„Like what kind of exercise should I follow? Because I cannot go to the gym and do

whatever I want… right? Because some of them… I don‟t know am I appropriate to do

it now, right‟? –P1

„I don‟t know whether I am doing the right thing or I doing the wrong thing and I don‟t

want to do the wrong thing.‟– P3

Part of the need for ongoing professional help came from an acknowledgement by the

participants that their bodies aren‟t working as before. P7 acknowledges the need for ongoing

exercise in the quote below.

„It is just my own theory again, that having a stroke, our muscles are working differently,

right, our nerves or whatever is inside our body, I guess it is not working as before, you

know? If you don‟t do exercise for six months you are ok but for us stroke patients it

different‟. (P7)

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In general, however, it was clear that participants welcomed the increased autonomy, and wanted

a balanced use of additional professional support to support their transition to more optimal

levels of functioning.

4.4.4.3 The balancing act

Participants wanted to balance the concurrent needs for autonomy and support. They expressed

this desire for balance through wanting to have ongoing contact with a therapist, but to work on

self-directed plans in therapy session; through wanting to see a therapist specifically to keep

them challenged and motivated; and through a desire to have a more gradual transition to

autonomy.

P2 expressed a desire to see a therapist on an ongoing basis.

„And then [if I] met with the therapists every two week and she gave me exercises and

stuff and every two weeks they checked on the exercises and what I was trying to

accomplish.‟ – P2

It is illustrative of the balancing act that P2 would like the therapist to give him exercises, but he

would like her to check on what „I was trying to accomplish‟. Similarly, P3 talked about „my

plan‟ in the following quote, but also wants supervision.

„My plan is working, but supervision, or I want to get in contact with a therapist to tell

me you could advance or don‟t do that‟. – P3

The desire to see a therapist for self-directed reasons was also illustrated by the need to be

challenged.

„I think the advantage of having a therapist is that it makes you tend to do things that you

usually wouldn‟t do on your own, presents more of a challenge.‟ – P8

P2 expressed the need for a more gradual transition from support to autonomy to avoid being

discharged before being ready, „It‟s just when you get to start to see results from therapy… They

tell you to leave all the time.‟ P2‟s suggestion of blending CO-OP ‟80-20‟ with more traditional

therapy, as described above in the Considerations for modifications section, is also illustrative of

the desire for a more gradual transition to autonomy.

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The CO-OP treatment approach makes gains towards the balance between autonomy and

support. In the following quote, the balance is seen as P2 discusses with pride discovering the

solution to a problem himself, but goes on to suggest he was assisted to do that through a

challenge by the therapist.

„The third [session], that‟s when I figured out where I put the cane and from then on it

was no problem… So, you know, it gets to a point where [the therapist has] to challenge

someone, I can‟t see it any other way.‟ – P2

4.5 Discussion

The participants interviewed for this study learned, generalized, and transferred CO-OP

strategies, and made suggestions for modifications to the approach. Thematic analysis revealed

the participants were seeking a balance in their ongoing rehabilitation between increased

autonomy and a need for ongoing support. In this discussion, we elaborate on those findings.

A section on methodological issues is included at the end. Recommendations for future

investigations are included throughout the discussion.

Directed content analysis revealed that although participants felt they had learned the global

cognitive strategy, P1, P2, and P3 expressed having difficulty with the Check component,

whereas P7 and P8 did not. P1, P2, and P3 were part of the first single case experimental series;

P7 and P8 were part of the second. It may be that the treating therapist and interviewer (SM)

placed more emphasis on the Check component of the global cognitive strategy during the

second single case series, having been aware of interview responses from the first.

All participants indicated they had either transferred the strategies learned in CO-OP to acquire

new skills in their home environment, or they were planning to do so. Transfer to the home

environment is essential for long-term success (Geusgens, Winkens et al., 2007), and future

longitudinal studies to gain a better understanding of the process and progression of skill transfer

should be conducted. Performance data from the second single case series in the larger project, in

which participants demonstrated skill transfer through improvement on a fourth, untrained goal,

corroborates the interview data presented here.

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Participants made a number of direct suggestions for modifications to the approach; as well,

there were some interpreted as such by the researchers. Participant suggestions, taken together

with the overall theme of balancing autonomy with support, the lack of attendance of a

significant other, and the difficulty that some participants had with the Check phase, all lead to

two general considerations for modifications. The first is to allow for flexibility in the number of

treatment sessions, including the possible addition of several sessions; the second is to tailor the

final few sessions individually as a transition to autonomous use of the CO-OP global cognitive

strategy. The vehicle for teaching the autonomous use of the global strategy could be an

increased emphasis on additional transfer tasks, and an increased emphasis on homework.

Further studies should be conducted to evaluate any modifications to the approach.

Thematic analysis revealed participants were seeking a therapeutic approach that balanced their

need for autonomy with their need for ongoing professional support. CO-OP expressly met their

need for autonomy, but participants felt it could go further in addressing their need for ongoing

professional support. The increased sense of autonomy is an important benefit of the CO-OP

approach that has not, to our knowledge, been described in previous CO-OP research. The

majority of previous research has been with a paediatric population, and it is likely that the desire

for increased autonomy during therapy is specific to adults. In the following paragraphs, the

importance of autonomy in rehabilitation in general and stroke recovery specifically are

discussed. As well, reasons for CO-OP generating an increased sense of autonomy are

postulated.

Autonomy is defined as „independence or freedom, as of the will or one‟s own actions

(Webster's College Dictionary, 1991). In rehabilitation, a distinction is made between decisional

autonomy, the independence to make one‟s own decisions without external constraint or

coercion, and executional autonomy, the capacity to execute those decisions once they are made

(Cardol, De Jong, & Ward, 2002). For example, an individual recovering from stroke may be

autonomous to decide that he or she wants to make dinner, but then may not have the physical

capacity to stand at the kitchen counter long enough to execute the task. It is possible that a

person with a disability can have diminished executional autonomy without having diminished

decisional autonomy. Komrad (1983) argued that the degree of autonomy given to clients in

various stages of health should be flexible; at times, they are unable to be autonomous, because

of illness, and a degree of paternalism is necessary to transition them back to autonomy

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(Komrad, 1983). He argued that practitioners, while being paternalistic out of necessity, should

constantly respect the potential of their clients for full or greater autonomy.

Proot and colleagues wrote specifically about the transition to autonomy in stroke rehabilitation

(Proot, ter Meulen, Abu-Saad, & Crebolder, 2007). Using a grounded theory approach, they

analyzed interviews from 22 clients undergoing stroke rehabilitation, and proposed that people

undergoing stroke rehabilitation desired a progression from paternalism on admission to shared

decision making at discharge, and from full support on admission to reduced supervision at

discharge. The participants viewed initial paternalism as necessary and supportive of their

autonomy, as argued by Komrad (1983). However, Proot and colleagues‟ (2007) findings

suggested that paternalism was sometimes continued too long, and concluded that rehabilitation

professionals need to take clients‟ progress in autonomy into account and gradually reduce

paternalism and support.

In this study, P7‟s reports of being “scolded” and “yelled at” for attempting to do exercises on

his own, in a previous rehabilitation program, provided evidence of paternalism carried on too

long. Other interview participants were not confident to attempt skills on their own in case they

“[did] the wrong thing”. (P3) It may be that this lack of confidence also stems from past

experiences with an overly paternalistic system. An autonomy-fostering approach such as CO-

OP may need to build in extra supports to transition clients to higher levels of autonomy. These

supports may include putting systems in place to help therapists gauge a client‟s readiness to

accept more autonomy or need for more support.

The increased sense of autonomy experienced by participants using the CO-OP approach is

likely due to the large degree of active involvement throughout all aspects of the assessment and

treatment process. Jones and colleagues set out to identify enablers of and challenges to stroke

recovery and found that personal or internal influence was an important enabler of recovery

(Jones et al., 2008). They concluded there is a clear need to understand how practitioners can

both identify preferences and personal goals of people in stroke recovery and subsequently

address these in a planned treatment program. They further concluded that more innovative ways

to actively involve individuals in their own rehabilitation are needed. In the CO-OP treatment

approach, personal goals are identified using the Canadian Occupational Performance Measure

(COPM) (Law et al., 2005). The COPM is a standardized instrument for eliciting performance

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issues from the client perspective, and for capturing perceived changes in performance over time.

In CO-OP, the COPM is used to elicit participant-selected goals, which then become the focus of

treatment. It is also used to rate self-perceived performance and performance satisfaction for

each goal, by each participant. The COPM can assist clients with stroke to identify meaningful

performance goals (Phipps & Richardson, 2007). Once the goals have been selected, each is

specifically addressed through problem solving, cognitive strategy use and guided discovery.

Active participation of the clients is inherent to the CO-OP approach, as they are taught to use

the strategies on their own rather than depending on the therapist to direct them.

4.5.1 Methodological Issues

The sample size was limited by the number of participants who completed the CO-OP

intervention and therefore had experience with the approach. The last interview conducted was

with P7, who brought forth interesting ideas about paternalism in the traditional rehabilitation

system that were not discussed so explicitly in the previous interviews. It would have been ideal

to pursue these ideas in subsequent interviews, and this was not possible. In other words,

theoretical saturation was not reached, meaning that the themes and sub-themes that did emerge

were not saturated with an adequate depth of understanding.

The interviewer, SM, was also the treating therapist who administered the CO-OP intervention to

the participants. While this relationship could be considered advantageous, in that the

participants and the interviewer had developed a rapport over approximately ten treatment

sessions, there may also be disadvantages. The participants may not have wanted to reveal

concerns about the approach to the therapist who administered it, and the therapist-interviewer

may have been biased towards wanting to elicit positive aspects of the approach.

The findings should be interpreted in view of the select group of participants who were

interviewed, a young and predominantly male sample who had been purposefully selected as

“motivated”.

4.6 Conclusions

Interview participants who had previously undergone cognitive strategy training using the CO-

OP treatment approach reported learning and using the treatment strategies to acquire skills. All

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interview participants reported some degree of generalization and/or transfer of the cognitive

strategies. Participants seemed to be searching for a balance between autonomy in decision-

making and ongoing support from rehabilitation professionals. CO-OP was able to provide

participants with increased decision-making, but may require modifications to better support

them to transition them to higher levels of autonomy.

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Chapter 5 Summary of findings, adapting the approach and general

concluding remarks

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5 Summary of findings, adapting the approach and general concluding remarks.

5.1 Introduction

A multi-phased research project was conducted to evaluate the use of the Cognitive Orientation

to daily Occupational Performance Approach (CO-OP) approach with adults with stroke. The

objectives were: to examine the efficacy of CO-OP to improve motor skill acquisition and

performance in people living with chronic stroke; to explore other benefits of the approach; and

to identify adaptations to the intervention that would optimize its utility for adults living with

stroke. In this discussion, a summary of the findings is presented and recommendations for

adaptations are made. Study limitations and clinical relevance are outlined, and general

concluding remarks are made. Throughout, recommendations for future research are suggested.

5.2 Summary of findings

Two series of single case experimental studies were conducted, with three participants

completing each. In addition, semi-structured interviews were conducted with five of the

participants. The first single case experimental series, reported in Chapter 2, was conducted to

explore the efficacy of the CO-OP approach in improving motor performance on self-selected,

task-based goals in adults living with chronic stroke, as well as its impact on stroke-related

health status and self efficacy. The second single case series, reported in Chapter 3, built on

findings from the first and sought to explore skill transfer in CO-OP, primarily by investigating

the impact of the approach on the performance of a fourth, untrained goal. Study participants

from both single case series were invited to participate in a semi-structured interview one month

after having completed the CO-OP treatment, and five of the six did so. The purpose of the

interviews was to gain a greater depth of understanding of the complexities of participant

experiences with the CO-OP treatment approach and to inform the adaptation of the intervention

so that is more meaningful and useful to clients. Findings from the interviews were reported in

Chapter 4.

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5.2.1 Performance on trained, self-selected goals

Participants self-rated their changes in goal performance and satisfaction with performance using

the Canadian Occupational Performance Measure (COPM) (Law et al., 2005). An increase of at

least two points on the COPM is considered clinically meaningful (Law et al., 2005). Of the 18

trained goals, clinically meaningful changes for performance were seen in 16 goals at post test

and for performance satisfaction in 17 goals. At one-month follow-up, meaningful changes were

maintained in 15 goals for performance and in 17 for performance satisfaction. The two COPM

performance post-test scores that did not reach clinically meaningful improvement levels were

P2‟s goals of stair climbing and incorporating the affected hand in reading. P2 felt his stair

climbing performance had suffered because of knee pain he was experiencing. His original goal

to incorporate his affected hand in reading had changed to a more elaborate goal involving

standing up, closing the book, and placing it on the chair. The low performance score likely

reflects P2‟s rating on the newer, more elaborate goal rather than on the original goal. P2‟s goal

to use the computer mouse with his affected hand was the only trained goal not to exhibit

clinically meaningful changes on the COPM performance satisfaction scale. Although this goal

improved dramatically according to independent Performance Quality Rating Scale (PQRS)

ratings, P2 considered moving the mouse from icon to icon to be an interim goal, and eventually

hoped to do more, such as opening and closing software applications with the mouse.

Changes in performance on the 18 participant-selected goals were also measured by an

independent rater using the Performance Quality Rating Scale (PQRS) (Miller, Polatajko,

Missiuna, Mandich, & Macnab, 2001). PQRS ratings were conducted by a trained, independent

observer who was presented with all baseline, post-test, and follow-up performances, and a

sample of the intervention performances, in randomized, non-chronological order. Of 18 trained

goals in six experiments, using the 2 standard deviation method to determine significant

improvement (Ottenbacher, 1986a), 12 were significantly improved during intervention, 11 were

significantly improved at post-test, and 17 were significantly improved at one-month follow-up.

P3‟s yoga goal was not improved at one-month follow-up, possibly because of a measurement

sensitivity issue.

The greater number of improved goals seen with the PQRS at one-month follow-up compared to

post-test warrants discussion. There are a number of possible explanations: spontaneous

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recovery, additional treatment during the month leading up to follow-up, a reinvestment effect at

post-test, or continued independent improvement because of CO-OP treatment effects.

Spontaneous recovery: Because the participants ranged from 12 months to 40 months post-

stroke, it is felt this explanation is unlikely. A recovery plateau is generally seen between 3 and

6 months post-stroke (Gowland, 1982; Mayo, Korner-Bitensky, & Becker, 1991), and

spontaneous recovery is not expected as late as one year after the event. Further, these were all

goals chosen by the participants indicating they were not likely areas that were improving

spontaneously.

Additional treatment: Participants were not asked specifically if they had participated in other

rehabilitation programs in the month since the end of intervention, and it is possible that some of

them may have, but it is unlikely to have been the case in general. In future studies, asking this

question at follow-up would assist in the interpretation of the results.

Reinvestment: the movement science literature refers to reinvestment as reverting to cognitive

processes for a motor task that is largely automatic under a situation of performance pressure,

such as during a competition or an evaluation, such as formal videotaped performances (Jackson,

Ashford, & Norsworthy, 2006; Maxwell et al., 2006). Reinvestment is more likely to occur in

people living with stroke than in an age- and gender-matched non-impaired cohort (Orrell et al.,

2009). However, given that the baseline performances and the follow-up performances were also

formal videotaped assessments, it seems unlikely that reinvestment would have a greater impact

at post-test compared to the other sessions.

The most likely explanation is an ongoing effect of the CO-OP intervention. CO-OP focuses on

teaching cognitive strategies, rather than on teaching the component parts of the target goals.

Cognitive strategies have been associated with continued improvement beyond formal

instruction sessions in other research (Lidor, 2004). Furthermore, in motor skill acquisition,

there is thought to be a performance-learning paradox, in which practice techniques that initially

degrade performance are associated with overall improved learning and retention (Guadagnoli &

Lee, 2004). Goal performance in the CO-OP intervention sessions was highly variable,

presumably because the goals were varied and participants were problem-solving partially

independently, trying a variety of different movement solutions, and were being permitted to

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make mistakes as part of the guided discovery process. Variable performance during skill

acquisition is associated with ongoing improvements and improved skill retention (Stokes et al.,

2008).

Overall, it is concluded that CO-OP was associated with significantly improved performance in

motor performance in at least one goal for each single case experiment participant at post-test,

and for the vast majority of goals at one-month follow-up. The observed tendency for

performance to continue improving after the conclusion of treatment should be further

investigated.

5.2.2 Skill generalization and transfer

Two of the main objectives of the CO-OP approach are generalization of skills learned in therapy

to the real-life environment and transfer of the strategies to learn new skills as needed. Evidence

of skill generalization and transfer was gleaned from interview data and from formal

investigation of a fourth, untrained goal in the second single case series.

Five semi-structured interviews were conducted, in which participants were specifically asked if

they were able to use aspects of the CO-OP treatment approach in other aspects of their lives.

Four of the five gave examples of generalization, and all five gave examples of either actual or

future-planned transfer. (Chapter 4, Table 4.4)

In the second single case series, two methods were added specifically to investigate skill transfer.

The first was the addition of a fourth, untrained goal that was monitored at multiple baselines,

post-test, and one-month follow-up. The second was the addition of baseline, post-test, and

follow-up administration of the Motor Activity Log (MAL) to specifically identify increases in

functional use of participants‟ upper extremity (Uswatte et al., 2006).

In all three single case experiments in series two, performance in the fourth, untrained goal was

significantly improved at one-month follow-up, suggesting either that the CO-OP treatment

effect had enabled participants to transfer the cognitive strategies learned to the acquisition of an

untrained skill, or that they had spontaneously improved in the fourth skill. As discussed above,

spontaneous recovery is unlikely in chronic stroke, and it seems more likely that a treatment

effect occurred. Transfer to untrained skills following a cognitive-based treatment has

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previously been demonstrated in two separate research projects in sub-acute stroke (Donkervoort

et al., 2001; Liu et al., 2004), corroborating the current findings.

In the second single case series focusing on transfer of skills, all three participants reported

increases in the number of upper extremity activities they were doing at one-month follow-up.

P5 reported 12 more activities, P7 reported two more, and P8 increased from zero activities with

her more affected hand to three. These participant reports of using the affected upper extremity

for additional activities provide some additional evidence of transfer.

Geusgens and colleagues state that transfer is necessary if rehabilitation clients are to be restored

to their greatest potential and maximal independent functioning (Geusgens, Winkens et al.,

2007). Inter-task transfer has rarely been demonstrated in the motor domain in the past (Schmidt

& Lee, 2005, p.425), thus this preliminary evidence is important and warrants considerable

future investigation.

5.2.3 Motor Control

The Chedoke-McMaster Stroke Assessment Impairment Inventory (CMSA(II)) was used in these

studies as a description of degree of motor control (Gowland et al., 1995). There are 6

dimensions, of which 4 were used: arm, hand, leg, and foot. Each dimension is rated on a 7-

point scale ranging from Stage 1, in which the limb is completely flaccid and no movement can

be initiated, to Stage 7, in which movement control is considered to be normal or approaching

normal, and test tasks include aspects of strength, speed and coordination. Initially, the

CMSA(II) was used only at baseline to provide a description of the participants‟ level of motor

control. However, based on therapist observation that changes may have occurred, it was

administered to P2 at post-test, and since improvements were noted, it was subsequently

administered at post-test and follow-up for all remaining participants. The maximum score on

the four dimensions is 28, and scores at baseline ranged from a low of 10 points (P8) to a high of

22 points (P7). Of the five participants re-assessed at post-test and follow-up, only P3 showed

no changes. P5 improved by 5 points at one-month follow-up, going from 17 to 22. Combined

average CMSA(II) scores for P2, P3, P5, P7, and P8 were compared for pre-post differences

using a paired-samples t-test, and improvements were significant both baseline to post-test

(p=0.007) and baseline to follow-up (p=0.011).

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Spontaneous changes in motor control are not expected in people living with chronic stroke

(Krakauer, 2006), and it is possible that these statistically significant improvements were

associated with the CO-OP treatment. Further research examining the impact of the approach on

motor control should be conducted.

5.2.4 Participation

Participation was measured in all participants using the participation domain of the Stroke

Impact Scale (SIS) (Duncan et al., 1999), and with the Reintegration to Normal Living (RNL)

Index (Wood-Dauphinee et al., 1988), in P3, P5, P7, and P8. Changes in participation were

variable. In the SIS participation domain, P1 and P2 showed improvements of more than 10

points, indicating clinically meaningful change (Duncan et al., 1999). However, none of the other

participants had equally large changes. P7 had a nearly perfect score on the RNL at baseline,

suggesting a ceiling effect. P3‟s RNL score decreased, denoting improvement, by nine points at

post-test, and P8‟s decreased by five points. P5‟s RNL score decreased by three points at post-

test, but the result was not maintained at follow-up. Oddly, P8‟s participation level appears to

have decreased according to the SIS participation domain, but to have increased according to the

RNL.

Overall, the participation findings were inconsistent. It is of interest that some participants with

improved community reintegration according to the RNL did not demonstrate clinically

meaningful improvements in the SIS participation domain. It is possible that the two instruments

are measuring different constructs, although RNL has been considered a measure of participation

(Noonan, Miller, & Noreau, 2009). It may be that the RNL is more sensitive than the SIS,

although, a literature search did not reveal any sensitivity research on the RNL, or any studies

comparing the two instruments. Another possible explanation for the inconsistent findings is

response shift (Ahmed et al., 2005; Osborne, Hawkins, & Sprangers, 2006). Below, response

shift is discussed briefly, followed by problems with the way participation has been

operationalized.

Response shift refers to a change in the meaning an individual assigns to self-evaluation in a

target construct, as a result of changes in their internal standards of measurement, a change in life

priorities, or a change in their definition of a construct, such as quality of life (Osborne,

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Hawkins, Sprangers, 2006). Response shift is a concern when collecting self-report data in

individuals with chronic conditions, and it may be negative (respondents realize they were worse

than they thought), positive (respondents realize they were better than they thought), or absent

(no change in interpretation). A recent study examining response shift in self-reported overall

health in people living with stroke found 15% lowered their health and 13% raised their health

over time (Mayo, Scott, Dendukuri, Ahmed, Wood-Dauphinee, 2008). Response shift was not

evaluated in these studies, but should be considered in future work.

Participation, or involvement in a life situation, is a main component of the International

Classification of Functioning, Disability, and Health (ICF) (World Health Organization, 2001),

and the ICF is one of the main theoretical foundations of CO-OP (Polatajko & Mandich,

2004).The ICF has been criticized as having poorly operationalized the participation component

(Badley, 2008; Schuntermann, 2005), although rehabilitation researchers have called for its

increased inclusion (Cicerone et al., 2005; Jette, 2005). Examining the participation results in

detail in these six single case experiments has raised questions about measurement of the

construct.

Badley published a paper attempting to enhance the conceptual clarity of the ICF participation

domain, particularly with respect to its relationship to the activity domain (Badley, 2008). She

reminds readers that ICF developers purposefully did not explicitly distinguish between activity

and participation feeling the need to have more research and experience prior to distinguishing

them. As well, details about coding of environmental factors and further specifications about

linking components of the model were also left open. Badley suggests that activity and

participation together are comprised of acts, tasks, and societal involvement, and suggests that

participation may be comprised of both tasks and societal involvement or societal involvement

alone. She also suggests that environmental and personal contextual factors as a priori scene-

setters have a direct impact on societal involvement, and should be incorporated in future

iterations of the model.

In summary, optimal participation, or involvement in a life situation, represents the pinnacle of

rehabilitation. However, the construct has not been clearly operationalized, thereby making its

measurement challenging. To determine any associations between treatment with the CO-OP

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approach and improvements in participation, a clear understanding of the participation construct

and a valid means of assessment must be established.

5.2.5 Self-efficacy and autonomy

Self-efficacy is belief in one‟s ability to behave in a particular way or achieve certain goals

(Gage & Polatajko, 1994), and is differentiated from self-esteem, or general feelings of self-

worth. Self-efficacy is specific to a particular situation, so the same individual may have low

self-efficacy with respect to a task that he or she is not trained in, such as alpine skiing, but high

self-efficacy in another familiar task, such as using a computer software program. Self-esteem,

on the other hand, tends to pervade all aspects of one‟s life.

Autonomy is the capacity to make one‟s own decisions, and in health care, because of the power

relationship between health care providers and clients, the degree of autonomy is not controlled

by the client, but given or taken away by the providers (Komrad, 1983; Proot et al., 2007),

although clients have some agency in this matter if they strive for more autonomy.

Pre and post measures of self-efficacy were conducted in all six single case experiments, using

the Stanford Self-Efficacy for Managing Chronic Disease 6-Item Scale (SEMCD-6) (Lorig et al.,

2001). Five of the participants reported increases, and one, P5, reported a decrease in self-

efficacy. There was a ceiling effect on the scale for three participants, P3, P7, and P8. An

additional mobility-specific self-efficacy scale, the Activity-Specific Balance Confidence Scale

(ABC) (Myers et al., 1998), was added to the assessment protocol for P3, P5, P7, and P8, and

improvements were reported for all except P5, who reported a decline. P7‟s scores on the ABC

were nearly at the maximum possible 100, suggesting a possible ceiling effect on that scale as

well.

The semi-structured interviews revealed that the participants had an increased sense autonomy

following the CO-OP treatment approach. The qualitative analysis, reported in Chapter 4,

revealed autonomy through a sense of responsibility, confidence, and self-attribution of success,

as well as a desire to challenge themselves. In addition, past experiences of paternalism in the

traditional rehabilitation system were revealed, providing a marked contrast to the autonomy

experienced in CO-OP. P7 had high baseline levels of self-efficacy, based on the instruments

used. A more sensitive measure would have been required to detect any potential additional

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increases in self-efficacy. P5 reported a decline in self-efficacy on both measures, not at post-

test, but at one-month follow-up. Unfortunately, P5 was unable to participate in the semi-

structured interview, and it is not known why these declines occurred. Interestingly, her one

month follow-up SIS scores are generally improved from post-test, with more than 10 point

improvements in cognitive, emotion, hand, and overall recovery domains. The improved SIS

results, particularly emotion and cognition, seem contradictory to a decline in self-efficacy. P5

spoke English as a second language, and anecdotally, had the most difficulty of all the

participants in communicating. It is possible the questionnaires were less valid with her because

of her decreased English comprehension. However, the consistent decline of both the SEMCD-6

and the ABC would indicate differently, and an alternate explanation may be related to personal

or environmental factors unknown to the researcher. It is also possible that a response shift

occurred.

Overall, there seem to have been small, positive changes in self-efficacy. It is theorized that

providing participants with greater decisional autonomy, combined with teaching them to

attribute failures to a problem with their Plan, rather than personal capacity, may have lead to

increased levels of self-efficacy. In addition, skill mastery is known to be an important

contributor to self-efficacy (Mann & Eland, 2005). The acquisition and mastery of the self-

selected skills post intervention likely contributed to the improved self-efficacy. Both constructs,

self-efficacy and autonomy, warrant further investigation with respect to their association with

the CO-OP treatment approach.

5.2.6 Concluding remarks about findings

Results of the two single case experimental series provide evidence that CO-OP was associated

with self-rated and independently-rated performance improvements in trained and untrained task-

based goals. Further, findings from quasi-experimental pre-post assessments and semi-structured

interviews suggest that CO-OP may be associated with significant, improvements in motor

control, participation, self-efficacy, and an increased sense of autonomy. Participation

improvements as measured by the SIS participation domain and the RNL were inconsistent,

suggesting either that broader participation was not impacted by the CO-OP approach, or that

measurement of this construct requires some further development in the chronic stroke

population. Interview findings suggested that participants, while enjoying an increased sense of

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autonomy, needed more support to reach optimal levels of autonomy and self-efficacy. The

following section, Recommendations for Adaptations to the Approach, interprets these findings

and other process findings in the context of adapting the approach to optimize its utility for use

with adults with stroke.

5.3 Recommendations for adaptations to the approach

The CO-OP treatment approach was originally designed for use with children with

Developmental Coordination Disorder (DCD). At the outset of this project, a number of

decisions were made regarding the use of CO-OP with the adult stroke population, based largely

on expert opinion. For example, a decision was made to begin this exploratory work with

community-dwelling people with stroke, as the consensus was that this group would be more

likely to be ready for a self-directed approach than would people undergoing in-patient

rehabilitation, and it would control for any problems associated with administering a new

approach in a team-based, institutional setting. A major adaptation made at the outset was to

eliminate the use of a puppet to teach the global problem solving strategy, Goal-Plan-Do-Check,

and rather to use a computer-generated slide presentation.

It was assumed other adaptations to the approach would be required, but without having used and

tested the approach, it would be impossible to determine what those may be. The secondary

objective of the project was to identify these potential adaptations. In the section below, each of

the key features of the approach is discussed in the context of its use in adults with stroke;

adaptations are suggested when warranted.

5.3.1 The key features of CO-OP in adults with stroke

CO-OP is comprised of seven key features: client-chosen goals, dynamic performance analysis,

cognitive strategy use, guided discovery, enabling principles, parent/significant other

involvement, and intervention format. See Table 1.1 in Chapter 1 for a description of each key

feature.

The first key feature of CO-OP, client-chosen goals, was well received by the participants. They

chose a wide variety of goals which, for the purposes of comparison with the child CO-OP

literature have been classified as: personal ADL activities (such as chopping vegetables with a

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knife or nail clipping), basic gross motor activities (such as walking faster or reciprocal stair

climbing), leisure activities (such as incorporating affected hand while reading a book or

bicycling), and school or work activities (such as handwriting or using a computer mouse).

Goals that were reported by Mandich and colleagues for 9 children with DCD were similarly

classified for the purposes of comparison (Mandich, Polatajko, & Rodger, 2003). The proportion

of goals in each category for adults with stroke and children with DCD are provided in Table 5.1.

It is of interest that the largest proportion of children‟s goals were school or work activities

(mostly cursive writing or printing), whereas this category formed the smallest percentage for

adults. This may be largely due to the nature of DCD, where handwriting difficulties are the

primary reason for referral (Miller, Polatajko, Missiuna, Mandich, & Macnab, 2001), albeit

parental influence may also have played a role. Another explanation may be that only two of the

six adults in these current experiments were working outside the home, despite all of them being

of working age. No recommendations for adaptations to this particular key feature are made,

although therapists should note the wide variety of challenging, complex goals selected by adults

living in the community with chronic stroke.

Table 5.1 Types of goals chosen by children with DCD compared to adults with stroke

Children’s Goals* Adult’s Goals

Types of Goals Chosen

15% personal ADL activities

0% basic gross motor activities

22% leisure activities

63 % school /work activities

Goals established with COPM interview, but identified

through negotiation between parent and child

Types of Goals Chosen

33% personal ADL activities

24% basic gross motor activities

29% leisure activities

14% school/work activities

Goals established in COPM interview, but without

significant other involvement.

*Adapted from list of goals in Mandich et al, 2003.

The second key feature of CO-OP is Dynamic Performance Analysis (DPA). DPA is an

observation-based process for use by therapists to identify performance breakdowns and sources

of those breakdowns (Polatajko & Mandich, 2004). In a secondary analysis of a random sample

of intervention session transcripts from the first three single cases in this project, Schneiderman,

McEwen, Kinslikh and Polatajko (2008) identified that participants themselves, in addition to the

treating therapist, were using DPA as part of the problem solving process to identify their own

performance problems. This has not been reported in children with DCD. In adults with stroke,

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Schneiderman argued that DPA was being used as a cognitive strategy by the participants. It is

suggested that this finding should be built on as a recommended adaptation to the approach for

stroke and that additional emphasis be placed on DPA. DPA could be explicitly taught to the

adults with stroke, in the same way that the global strategy, Goal-Plan-Do-Check is taught.

Cognitive strategy use, both global and domain-specific, is the third key feature of CO-OP.

Findings from the semi-structured interviews, as well as Schneiderman‟s secondary analysis of

some of the intervention sessions, indicates that cognitive strategies were learned and used

efficiently by the adults with stroke. Beyond the a priori adaption to teach the global cognitive

strategy, Goal-Plan-Do-Check, with a computer generated slide show rather than a puppet, no

adaptations to this feature are recommended.

Guided discovery, in which the learner is not given the solution to a problem, but is asked

questions and provided instead with hints, is the fourth key feature of CO-OP. In a secondary

analysis of intervention transcripts from first single case series, Kinslikh, McEwen,

Schneiderman, and Polatajko (2008) concluded that the therapist facilitation techniques that took

on a more supportive, guiding role led to more active engagement of the participants in the CO-

OP process, whereas when the therapist was more directive, the participants became more

passive. In the interview findings presented in Chapter 4 of this thesis, participants revealed they

weren‟t always comfortable with the more active role they were expected to take, and sought a

balance between autonomy in rehabilitation decision-making, and outside support, preferably

from a professional. So, while Kinslikh‟s analysis concluded that techniques compatible with

guided discovery were effective at engaging the participants in active problem solving, and the

participant‟s themselves reported enjoying this increased level of responsibility and autonomy,

they also reported that they continued to require some support, and on occasion, some direction.

In terms of adapting the CO-OP treatment approach, no significant changes are required in the

key feature of guided discovery, as the nature of guided discovery allows for a balance between

more directive or more guiding techniques. However, therapists using the CO-OP treatment

approach with adults with stroke should be aware that transition to higher levels of autonomy in

rehabilitation decision making should be gradual, and therapists should be taking cues from

clients as to when greater or lesser levels of independence in problem solving and decision

making are appropriate.

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In terms of the fifth key feature, enabling principles, no adaptations are required, although for the

same reasons as cited in the guided discovery paragraph above, moving towards independence

should be done gradually.

The sixth key feature of CO-OP, parent or significant other involvement, requires re-thinking for

adults with stroke, based on the experience with these six participants. The attendance of a

parent, or significant other at 3 or more CO-OP sessions is considered of paramount importance

for children, as this feature aids in generalization of the treatment to the everyday environment,

and transfer of strategies. Of the six adults with stroke who participated in the CO-OP treatment

approach, only one (P1) had a significant other attend. In the interviews, some participants

indicated that significant others don‟t have time to attend treatment sessions, let alone to help

implement new strategies at home. Some other findings may have been related to the lack of

participation by a significant other, namely, the general consensus among interviewed

participants that more CO-OP treatment sessions are necessary; the need for ongoing

professional support; the inconsistent participation scores; and the lack of conscious awareness

of actual, current transfer of cognitive strategies to other aspects of their life by P1 and P8. The

recommendation is to remove this key feature for adults with stroke, because of the apparent

difficulty for significant others to attend, but also with the recognition that the relationship

between spouses is a different relationship than that between parent and child. It is hoped that

enhancements to the seventh key feature, intervention format, will compensate for the lack of

attendance of a significant other.

The seventh key feature of CO-OP is the intervention format. The intervention format prescribes

a preparation phase, in which assessments are conducted and goals are established, an acquisition

phase, in which the goals or skills are learned, and a final assessment, in which all goals are re-

assessed to ensure they have been learned. The preparation phase is one or two sessions,

followed by ten acquisition sessions, and one re-assessment session. In the six single case

experiments with adults with stroke conducted as part of this project, the number of total

acquisition sessions ranged from 7 to 10. Reduced numbers of sessions were related to time

constraints of the participants, cancellations, and perceived necessity of additional sessions.

Although the number of sessions was reached by consensus between therapist and client, semi-

structured interviews one month later indicated that participants, in general, wanted more

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sessions. The participants with the lowest levels of motor control, P2 and P8, had the most

intervention sessions, 9 and 10 respectively, whereas P7, who had the highest level of motor

control, had only 7 sessions. It is suggested that the approach be adapted to have flexibility in the

number of sessions for adults with stroke, as was the practice in this set of single case

experiments. It is also recommended that an additional transfer phase, of approximately one to

three sessions, be added. It is theorized that the addition of a transfer phase will help to

compensate for the lack of significant other, will address the need for more gradual support to

autonomous decision making sessions, and may help to address the inconsistency in participation

outcomes. The focus during the transfer phase should be on explicit transfer of the cognitive

strategies learned to new goals or skills at home and in the community, and specific goals or

skills would be selected for that phase. At the beginning of the transfer phase, participants

would be taught about the importance of transfer and how it is thought to occur. Specifically

teaching transfer as part of the intervention, and ensuring that participants know how transfer

works and when to apply it have been identified as prerequisites for transfer in the educational

psychology literature (Geusgens, Winkens et al., 2007).

5.3.2 Summary of recommended adaptations to the approach

Based on the findings of these two single case experimental series, the semi-structured

interviews, and supported by secondary analysis of intervention transcripts by other students in

our laboratory, a number of recommendations for adaptations to the approach have been made.

In addition, there are aspects of the existing approach that do not need to be modified, but may

require special emphasis in adults with stroke.

The recommendations for modifications to the approach follow:

1. Design and add a segment to the CO-OP approach that explicitly teaches DPA.

2. Remove parent/significant other as a key feature of the approach when it is used with

adults with stroke.

3. Adapt the intervention format to allow for more flexibility in the number of intervention

sessions, so that fewer or more sessions occur based on the needs of the individual with

stroke.

4. Design and add a transfer phase to the intervention format.

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Overall, the existing CO-OP approach works well for adults with stroke. It is suggested that

therapists carefully weigh the amount of support they are giving during guided discovery and

moving towards independence (within enabling principles) (H. J. Polatajko & Mandich, 2004).

The therapist should take cues from the client as to how much autonomy they are able/willing to

take at that time, and transition them to higher levels of autonomy as the client is able.

5.4 Study limitations

In this section, limitations with the single case experiments and semi-structured interviews are

discussed. Specifically, concerns with single case experimental design, instrumentation, bias,

and the general collaborative nature of CO-OP are discussed.

Single case experimental design is based on repeated measures at baseline, thereby allowing the

participant to be his own control. It is considered the design of choice during the exploratory

phases of a new intervention, as it allows for a large amount of detailed information to be

collected about each participant in the series, identifies functional relationships, allows for

exploration of intersubject and intrasubject variability, and allows for continuous monitoring of

change (Barlow, 1984; Callahan & Barisa, 2005). However, without substantial replication, it

does not allow for immediate generalization to the population as a whole (Barlow & Hersen,

1984, p.325-371). Further, rules for interpretation and analysis of single subject design data are

“shockingly vague” (Callahan & Barisa, 2005).

In this project, six single case experiments were conducted, and replication of improved

performance in self-selected goals occurred consistently. The six participants represented a

range of stroke severity, stroke side, gender, and socio-economic status. However, they were all

recruited from the same out-patient stroke self management program, Moving On after Stroke

(MOST) (Huijbregts et al., 2008), and through that program had been introduced to goal setting

and self-management principles. Further, all participants were referred to the CO-OP research

project because they were perceived by the MOST program leader to be bright, keen, motivated

individuals, and were felt to have unmet rehabilitation goals. Given these individuals were

purposefully selected as those perceived to be keen and motivated, it may reduce the likelihood

that the results are generalizable to the general stroke population. In addition, the participants

were all young, working-aged adults, which is not typical of the general stroke population. A

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more widespread, controlled, clinical trial is warranted to test the efficacy of the approach in the

broader stroke population.

Interpretation and analysis of results in single case experimental design is controversial

(Bobrovitz & Ottenbacher, 1998; Callahan & Barisa, 2005; Harbst, Ottenbacher, & Harris, 1991;

Kazdin, 1984; Orme & Cox, 2001; Ottenbacher, 1986b; Ottenbacher, 1990; Ottenbacher, 1993).

Bobrovitz and Ottenbacher demonstrated 86% agreement between visual analysis and statistical

significance (Bobrovitz & Ottenbacher, 1998), although Ottenbacher had previously

demonstrated much lower agreement (Harbst et al., 1991; Ottenbacher, 1986b; Ottenbacher,

1990). Use of statistical methods is recommended in a number of circumstances, including when

there is a trend in baseline, and when testing a new intervention (Kazdin, 1984). In this study,

the two-standard deviation band method was used, and was selected as a method that is robust to

variable data, and useful with a small number of baseline data points (Ottenbacher, 1986a). The

two-standard deviation band method is derived from industrial quality control techniques, and

there are several variations on its use in health care research (Callahan & Barisa, 2005; Orme &

Cox, 2001; Sideridis & Greenwood, 1996). The technique assumes no significant degree of

autocorrelation, or serial dependency, in baseline (Ottenbacher, 1986a). Two goals displayed

significant autocorrelation in baseline, and this was dealt with using an alternate calculation of

standard deviation, using „moving range‟ to account for the trend (Sideridis & Greenwood,

1996). The data in single case experimental design are clearly not independent, regardless of

autocorrelation figures, and it is possible that either Type I (overestimation of differences) or

Type II (underestimation of differences) errors have been committed. Overall, given the

variability of the data, the small number of baseline data points and the general lack of

significant autocorrelation in baseline, the two standard deviation band method seemed the most

appropriate statistical analysis for the data.

As discussed in Chapter 2, using the PQRS to rate performance from video recorded samples

may not be sensitive enough for certain subtle activities, such as deep breathing during yoga or

taking focused pictures. However, the inherent client-focus of CO-OP dictates that goals be

client-chosen, and using the PQRS allows for a homogenous outcome measure despite the

heterogeneity of the treatment goals. Reliability of the PQRS scores between the rater and the

treating therapist were calculated for a sub-sample of data points for each goal in the first 3

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single cases, and Interclass Correlation Coefficients (ICC) ranged from 0.58 to 0.88 (Appendix

N), representing moderate to good reliability.

Bias is not a term used in qualitative research, but instead reflexivity is discussed. Reflexivity is

widely accepted by qualitative researchers as crucial to the trustworthiness of their studies

(Finlay, 2002; Morrow, 2005; Rennie, 2004). It is defined as “self-awareness and agency within

that self-awareness” (Rennie, 2004). Cutcliffe disputes the idea that reflexivity increases the

credibility of the findings, citing an inability to ever be completely self-aware and the influence

of tacit knowledge (Cutcliffe, 2003). Cutcliffe cautions against being overly-reflexive,

suggesting that too much of the practice may hinder the researcher‟s ability to create bold and

innovative theories. Patton (1990) takes a more moderate view, with which this author agrees:

“Evaluators should strive neither to overestimate nor to underestimate their effects but to take

seriously their responsibility to describe and study what those effects are (p.474).”

Reflexivity is a tool that can examine the positionality of the researcher and its impact (Finlay,

2002). With respect to positionality, Finlay recommends reflecting on the topic and one‟s

relationship to it, one‟s relationship to the study participants, and one‟s own motivations and

interests .The author of this thesis was also the treating therapist who administered the CO-OP

intervention to the participants and conducted the semi-structured interviews. While that

relationship could be considered advantageous, in that the participants and the interviewer had

developed a rapport over approximately ten treatment sessions, there may also be disadvantages.

The participants may not have wanted to reveal concerns about the approach to the therapist who

administered it, and the therapist-interviewer may have been biased towards wanting to elicit

positive aspects of the approach. So, the positionality of the researcher has pros and cons in this

case, and the interview findings should be viewed in that context.

The general collaborative nature of CO-OP approach is at odds to some degree with

experimental methods, although more in line with “real-world” clinical applications. For

example, the variable numbers of intervention sessions among participants and the ongoing

changes to P2‟s reading goal are a reflection of the collaborative CO-OP process, but also

represent increased experimental noise. It is recommended that, in parallel with future CO-OP

clinical trials, some of the components of the approach be examined in a more controlled

laboratory setting, so that the relative contribution of each can be examined.

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5.5 Clinical relevance

The CO-OP treatment approach is highly relevant to people living with stroke. Long-term stroke

outcomes are poor, with approximately half of people living at home after a stroke reporting

decreased independence in activities of daily living (Appelros et al., 2007; Mayo et al., 2002).

Shumway-Cook and Woollacott (2007, p.16-17) have proposed that neurological recovery be

viewed from a systems perspective, in which an individual‟s perception, cognition, and action

systems interact with the task being learned and the environment. Very recently, Vanhook

(2009) categorized aspects of stroke recovery as cognition, function, health perception, self-

concept, relationships, and role change. She concluded that the individual aspects of stroke

recovery cannot be separated from one another, and that research into the interactions among

categories should be conducted. CO-OP is a complex, integrated approach that shows promise to

improve real-life functioning in people living with chronic stroke.

Preliminary evidence presented in this thesis suggests CO-OP is effective in improving

functional performance in tasks that are personally meaningful to clients; the approach is

associated with inter task transfer; and it may also be associated with improvements in motor

control and self-efficacy. Furthermore, the approach is efficient, with changes appearing after

approximately 10 intervention sessions, compared to as many as 80 in other stroke rehabilitation

interventions (Gabr et al., 2005). Participants reported enjoying the increased sense of

responsibility and engagement with the CO-OP approach.

People with stroke are seeking approaches that engage them more in both goal setting and goal

attainment (Jones et al., 2008). CO-OP engages clients in all aspects of the process, and seems

to do so effectively and efficiently. CO-OP participants, who are people living with stroke, have

contributed to the recommendations for adaptations to the approach made in this chapter. It is

hoped that future iterations of the approach will continue to be relevant to clients, and that

participant perceptions continue to be a valued aspect of the adaptation process.

5.6 General concluding remarks

This exploratory, multi-phased, mixed methods project has provided strong preliminary evidence

that CO-OP, a cognitive-based treatment approach, is associated with performance

improvements in both trained and untrained self-selected goals in community dwelling adults

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more than one year post stroke. As well, pre-post measures suggest there may be changes in

performance satisfaction, motor control, generalized use of the more affected upper extremity,

and self-efficacy. Interview findings have provided valuable information about the experiences

of participants with this type of self-directed, problem-solving approach; the interview

respondents enjoyed the increased sense of responsibility that came with problem solving on

their own, but also expressed a desire to have ongoing professional support.

Based on the findings reported in the three manuscripts in this thesis, and supported by

secondary analysis done by other students in our laboratory, recommendations for adaptations to

the approach have been made. In addition to adaptations, recommendations have been made to

increase the emphasis on certain existing aspects of the approach. It is recommended that, for

adults with stroke, CO-OP be modified to include a segment that explicitly teaches dynamic

performance analysis (DPA), that the parent/significant other involvement be removed as a key

feature, and that the intervention format be modified so that the number of intervention sessions

is more flexible and a transfer phase be added to the overall intervention format.

CO-OP is a promising approach to improve long-term functional independence in adults living

with stroke, and represents a significant break from conventional stroke rehabilitation. Future

applied and clinical research is warranted.

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Appendices

Appendix A: Information letter and consent form for stroke rehabilitation professionals

focus group participants

Adapting the CO-OP Treatment Approach for Use with Adults with Stroke

Investigators:

Sara McEwen, BSc(PT), MSc

Doctoral Candidate



416-946-7130

Email: [email protected]

Helene Polatajko, PhD, OT (Reg. Ont.)

Professor and Chair

Department of Occupational Science and Occupational Therapy



416-978-5936


Maria Huijbregts, PhD, PT

Coordinator Evaluation and Outcome

Physiotherapy Department

Baycrest

Tel: 416 785 2500 ext.2677


Jennifer Ryan, PhD

Rotman Research Institute

Baycrest

Tel: 416-785-2500 ext. 3550


mailto:[email protected]




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University of Toronto Graduate Department of Rehabilitation Science Letterhead

Date

Dear ___________________________,

Thank you for your interest in the CO-OP/S project, a project to adapt the Cognitive Orientation

to daily Occupational Performance (CO-OP) treatment approach for use with adults with stroke.

CO-OP was designed for treatment of children with motor-based performance problems. A body

of research has demonstrated its ability to improve participation in that population. The CO-OP

treatment is an integrated approach to skill acquisition that includes elements critical for the

generalization and transfer of skills from the clinical setting to real life and is derived from the

knowledge and theories of movement science, psychology, health, neuroplasticity, and

rehabilitation sciences. Skill acquisition is viewed from a learning perspective and the emphasis

is on integrating activities into the larger context of life participation. The client selects and is

taught a finite number of specific skills, however, the problem-solving strategies central to the

intervention are generalizable to other aspects of life, and result in improved participation levels.

As well, a care partner is instructed in the techniques, further increasing the approach‟s

generalizability and transferability.

We are planning two focus groups with occupational and physical therapists who are experts in

stroke rehabilitation. Prior to Focus Group 1, we will conduct a workshop to introduce the

participants to the CO-OP approach. Following the workshop we will solicit your ideas about

how best to adapt CO-OP for use with adults with stroke, in a focus group format. We will then

use a first version of the adapted CO-OP approach (CO-OP/S1) in a series of single case

experiments. Once those are completed, we will conduct Focus Group 2 with the same experts.

The results of the experiments with CO-OP/S1 will be presented, and ideas for the final

adaptation will be solicited.

If you wish to participate, the time commitment from you will be a full day for the workshop and

Focus Group1, and approximately 3 hours for Focus Group 2. Focus Group 1 is planned for

{date}, and will be held at the Rehabilitation Sciences Building, University of Toronto, 500

University Avenue.

Please be advised that we require the focus groups be audiotaped to ensure we benefit from all of

the information provided. You can withdraw from the study at any time, with no negative

consequences to withdrawing.

The focus groups will be conducted by our Sara McEwen, the principle investigator on this

study, and a doctoral student in the Graduate Department of Rehabilitation Science.

The focus group transcripts will be confidential. All identifying information from the interview

will be removed prior to its use in presentations and publications resulting from this study.

Audiotapes of interviews will be transcribed and then destroyed. The transcripts, both paper and

electronic copies, will be stored in locked files. No information will be shared with your

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supervisors. There are no known risks to your involvement. As a benefit, you will gain a

professional development day, in that you will have attended an introductory CO-OP workshop.

Furthermore, your participation will contribute to the development of a new treatment approach

for adults with stroke, which may lead to improved community participation for them.

Please feel free to direct any questions about this study to Sara McEwen at the University of

Toronto Graduate Department of Rehabilitation Science (416-946-7130) or Maria Huijbregts,

Baycrest Physiotherapy Department (416-785-2500, ext. 2677).

CONSENT:

I agree to participate in the CO-OP/S Study by: 1) Attending a CO-OP Workshop on, at the

University of Toronto, on [date]; 2) Participating in a focus group following the workshop, on

the same day 3) Participating in a second focus group several months later. I understand that the

CO-OP Workshop and first focus group will, combined, require a full 8-hour day, and the second

focus group will require approximately 3 hours of my time.

I can withdraw from the process at any time and be assured that there will be no adverse personal

or employment consequences I am free not to answer any questions I am uncomfortable with.

The CO-OP/S project is covering the cost of the workshop and meals on that day. Travel and

parking costs at the University of Toronto will not be reimbursed.

All information will be confidential, and will be kept in a locked filing cabinet until the

completion of the study, and then will be destroyed. All identifying information will be coded as

soon as possible, and will not appear on any presentations or publications resulting from this

pilot testing.

I understand the nature of this study, including its risks and benefits, and have had an opportunity

to ask questions about the study.

________________________________________________________________________

Name of Participant Signature

___________________________________

Date

Sincerely,

Sara McEwen, BSc(PT), MSc Helene Polatajko, PhD, OT (Reg. Ont.)

Maria Huijbregts, PhD, PT Jennifer Ryan, PhD

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Appendix B: Information letter and consent form for participants living with stroke

(Baycrest Letterhead) Adapting the CO-OP Treatment Approach for Use with Adults with Stroke

Investigators:

Sara McEwen, BSc(PT), MSc

Doctoral Candidate



416-946-7130


Helene Polatajko, PhD, OT (Reg. Ont.)

Professor and Chair

Department of Occupational Science and Occupational Therapy



416-978-5936


Maria Huijbregts, PhD, PT

Coordinator Evaluation and Outcome

Physiotherapy Department

Baycrest

Tel: 416 785 2500 ext.2677


Jennifer Ryan, PhD

Rotman Research Institute

Baycrest

Tel: 416-785-2500 ext. 3550






149

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(Baycrest Letterhead) Date

Dear Participant,

You are invited to participate in a study looking at the usefulness of adapting a treatment program

designed for children with movement problems for use with adults who have had a stroke. In the

Cognitive Orientation to daily Occupational Performance (CO-OP) program, you work individually with

a physical therapist for 10 sessions, learning how to do skills you have selected as treatment goals. The

first session consists of an assessment, and selecting the goals that you would like to meet during the 10

sessions. In the next sessions, you will practice the skills you have selected as treatment goals, and,

assisted by the therapist, you will use strategies to help you better learn the skills. Your care partner

(spouse, friend, son or daughter, or other person closely involved in your care) is encouraged to attend

some of the sessions with you, to learn the CO-OP strategies, in order to help you continue learning skills

once the therapy sessions have finished.

In addition to attending the sessions, you will be asked to participate in three assessment sessions before

the treatment starts, and two assessments after the treatment is over. This involves the completion of some

written questionnaires and some physical assessments, and will take about one and a half hours. The

research physiotherapist will be able to assist you if you have questions. If you become tired during the

assessment, you will be able to take a break. Each assessment will be explained and completion is

voluntary.

Sample Assessment and Treatment Schedule

Date Time Session Description

Mar 4 tbd Assessment session approximately one and a half hours long.

Combination of questionnaires and physical tasks.

tbd Assessment session, approximately one hour long. Goal-setting

interview and baseline testing of three goals, one and a half hrs.

tbd Baseline testing of three goals, and also begin treatment session 1.

Approximately one and a half hrs long.

tbd Treatment session 2, approximately one hour long.








tbd Treatment session 10, followed by first post-intervention assessments,

approximately 2 hours long.

tbd One month follow-up, approximately one and a half hours long.


tbd One month follow-up (2) , approximately one and a half hours long.


The treatment sessions will take place at Baycrest, in the physiotherapy department. You will be

reimbursed $10 each session to offset the travel or parking costs you may incur to get to these sessions.

We will provide you with detailed information about getting to our location on an individual basis.

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During a part of each assessment session, and during the entire treatment sessions, you will be

videotaped. This method will be help us to collect the research data, and will also help to ensure the

quality of the intervention sessions. The videotape will be reviewed on a regular basis by the research

supervisor to ensure adherence with the study protocol.

You may be contacted by the treating therapist (Sara McEwen) towards the end of the study to invite you

participate in some additional interviews to learn more about your experiences with CO-OP. These

additional interviews are optional, and you may decline to participate in them without affecting your

participation in the CO-OP treatment project, or the services you receive from Baycrest.

Research is required because right now we do not know the best way to deliver therapy once a person

who has had a stroke is trying to resume his or her normal community life. This study may answer some

questions.

There may be additional research questions that arise during the process of adapting the CO-OP treatment

approach that may require secondary analysis of the data at some point in the future.

Whether you participate in the study or not will not affect the services you are receiving or will receive at

Baycrest in any way. Also, if at any time you wish to stop your participation that will not affect the

services you receive at Baycrest.

No personal information about you will be released to anyone, and all your results will be kept

confidential. All assessment forms, videotapes, and other information we learn about you will be stored

in a locked cupboard. Findings will be presented in such a way that no individual participant can be

identified. The only risk we foresee in you participating is a potential for increased fatigue during the

assessments or treatments. There may be benefits to you in participating, in that you may learn how to do

new skills.

Please feel free to direct any questions about this study to Sara McEwen at the University of Toronto

Graduate Department of Rehabilitation Science (416-946-7130) or Maria Huijbregts, Baycrest

Physiotherapy Department (416-785-2500, ext. 2677). If you wish to contact someone not connected

with the project about your rights as a research participant, feel free to call the Dr. Ron Heslegrave, Chair

of the Research Ethics Board at (416) 785-2500 ext. 2190

I agree to participate in the CO-OP/S Study by: 1) Attending 10 CO-OP treatment sessions at the

Baycrest; 2) Attending 6 assessment sessions, three before I begin the CO-OP treatment, one

immediately after I finish the CO-OP treatment, one a month later, and one three months following my

last treatment session. I understand that each treatment and assessment session will take about an hour of

my time. I understand that I will be given breaks as needed during the assessment and treatment

sessions.

I will be videotaped throughout the study. This method will be used to collect some of the research data.

As well, the videotape will be reviewed on a regular basis by the research supervisor to ensure adherence

with the study protocol.

I can withdraw from the process at any time and be assured that there will be no adverse personal

consequences I am free not to answer any questions I am uncomfortable with.

The CO-OP/S project will reimburse me $10 for each treatment and assessment session I attend, in order

to offset the cost of travel to Baycrest.

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All information will be confidential, and will be kept in a locked filing cabinet until it is no longer

needed, and then will be destroyed. All identifying information will be coded as soon as possible, and will

not appear on any presentations or publications resulting from this pilot testing.

I understand that there may be secondary analysis of this data at some point in the future, should

additional research questions arise in the process of adapting the CO-OP treatment approach.

I understand the nature of this study, including its risks and benefits, and have had an opportunity to ask

questions about the study.

________________________________________________________________________

Name of Participant Signature

___________________________________

Date

Sincerely,

Sara McEwen, BSc(PT), MSc Helene Polatajko, PhD, OT (Reg. Ont.)

Maria Huijbregts, PhD, PT Jennifer Ryan, PhD

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Appendix C: Stroke rehabilitation professionals focus group guide

INTRODUCTORY REMARKS:

I am _____________. I will facilitate the session today. _____________will be making notes, to

make sure that we remember everything that is being said.

We are holding discussion groups with a group of expert stroke rehabilitation occupational and

physical therapists. This morning, you were introduced to the CO-OP treatment approach. CO-

OP was designed for use with children with motor problems, but, as you know, we feel it has

potential to be used with adults with stroke. We need your feedback to help us determine how

best to adapt the CO-OP treatment approach for use with adults with stroke. We would like your

impressions about whether the approach is applicable to the adult stroke population, and we

would like to generate some ideas about how to adapt it. Please feel free to be completely open.

When we report on this session, none of your names will be used. Your names will not appear in

any reports related to this project. You really should feel free to speak your mind.

GROUND RULES:

1. Please speak one at a time so we do not miss anything, and so that the tape can pick up your

comments.

2. There are no right or wrong answers, all comments are important.

3. It is OK to disagree, because we want to hear all perspectives.

4. Most importantly everything you say in this group is confidential and we ask that you do not

discuss this outside of the group.

1. Ice Breaker:

a. Let‟s begin by going around the table: please tell me your name and a little bit

about your background experience.

2. Transition Questions:

a. What are your initial impressions about the CO-OP approach?

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b. Do you have any questions about the approach, or would you like clarification

about any aspects of the approach?

3. General Impressions:

a. What is your initial impression about the applicability of the CO-OP approach to

adults with stroke?

4. Assessment:

a. During the first CO-OP session, work is done between the client and the therapist

to select three client goals and establish baseline motor performance, using the

COPM and the PQRS, as described this morning. Do you have any comments or

suggestions about this assessment session with respect to using the approach with

adults with stroke?

5. Cognitive Strategies:

a. In the subsequent sessions, cognitive strategies are learned to acquire skills to

meet the goals, including a global problem-solving strategy and domain-specific

strategies. In each session, the therapist and the client work together to make

plans for skill acquisition and goal achievement, and during skill practice, the

therapist uses a dynamic performance analysis process and guided discovery

techniques to work towards independence and promote generalizability and

transfer. In addition, care partner involvement is strongly encouraged to reinforce

all aspects of learning. Do you have any specific comments about this aspect of

the approach with respect to its use with adults with stroke?

6. Global Problem-Solving Strategy:

a. The global problem-solving strategy is one of the most important features in CO-

OP. Also referred to as an executive strategy, the global cognitive strategy is used

to control and coordinate other strategies. CO-OP makes use of a strategy called

GOAL-PLAN-DO-CHECK. It helps to structure the conversation about skill

performance and promotes metacognitive functions, allowing clients to learn to

regulate their own behaviour by instructing themselves in goal selection,

implementation, and evaluation. GOAL-PLAN-DO-CHECK is used throughout

the intervention and after as a framework for the acquisition of any new skills. Do

you have any specific comments about the global problem-solving strategy with

respect to its use with adults with stroke?

7. Commander GOAL-PLAN-DO-CHECK:

a. When using this approach with children, using a puppet called “Commander

GOAL-PLAN-DO-CHECK” has been used successfully to teach and implement

the global problem-solving strategy. What are your impressions about using a

puppet with adults?

b. What alternatives would you suggest to teach this strategy to adults?

8. Domain Specific Strategies:

a. A second key feature of CO-OP is the use of domain-specific strategies that are

specific to a particular task, skill, or activity. Domain specific strategies used in

CO-OP have included body position, attention to doing, task

specification/modification, supplementing task knowledge, feeling the movement,

verbal motor mnemonic, and verbal rote script. The therapist determines which

domain-specific strategies are needed for a particular task and client based on

dynamic performance analysis.

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b. Ask Focus Group participants to comment on each domain-specific strategy

individually.

c. Are there additional domain-specific strategies that might be used by adults with

stroke?

9. Care Partner Involvement: a. Using this approach with children, another key component has been training

parents in order to reinforce learning and increase the generalizability of the

learning to additional skills outside the therapeutic setting. How can we capture

this aspect of the approach with adults?

10. Goal-Setting: a. Any thoughts on the goal setting process?

11. Who will benefit? a. Which people with stroke would benefit most from this approach?

b. Are there people with stroke who would not benefit from this approach? Why?

c. Do you have thoughts on when in the stroke rehabilitation process to introduce

this approach?

12. Other Comments?

13. Summary Questions: a. These are the main points I believe came out of the discussion today…..

b. Do you agree?

c. Is there anything you would like to add?

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Appendix D: Stroke rehabilitation professionals’ focus group findings

Adapting the CO-OP Treatment Approach for use with Adults with Stroke: Phase 1,

Expert Opinion

McEwen, S.; Polatajko, H; Birkenmeier, R; Huijbregts, M., Ryan, J.

Paper presentation at the World Congress of Physical Therapy, Vancouver, June, 2007.

Background: The Cognitive Orientation to daily Occupational Performance (CO-OP) treatment

approach was designed for treatment of children with motor skills deficits, and a body of

research has demonstrated its ability to improve participation in that population. In stroke

rehabilitation, however, there is little evidence or agreement on how to improve participation.

CO-OP is an integrated approach to skill acquisition that includes elements critical for the

generalization and transfer of skills from structured rehabilitation programs to real life. It is

hypothesized that CO-OP will be more effective in improving participation in adults post-stroke

as compared to traditional rehabilitation approaches.

Objective: The objective of this multi-phased project is to determine how best to adapt the CO-

OP approach for use with adults with stroke. The specific Phase 1 research questions were:

1. How do expert stroke rehabilitation clinicians perceive the utility of the CO-OP approach

for use with adults with stroke?

2. What adaptations do they recommend?

Methods: In a half-day workshop, expert stroke rehabilitation occupational therapists (OTs)

and physical therapists (PTs) were introduced to CO-OP. Subsequently, they participated in a

focus group to determine their perceptions of the applicability of the approach for adults with

stroke, and to elicit recommendations for adaptations.

Results: Seven clinicians (3 PTs and 4 OTs) with an average of 16 years work experience

participated in the focus group. The participants had, on average, 5 years of experience in stroke

rehabilitation. They represented acute care, in-patient rehabilitation, day hospital, and

community. They perceived CO-OP to be a novel, promising, and exciting approach for stroke

rehabilitation. While not unanimous, the general consensus among focus group participants was

that CO-OP would be more feasible in community-dwelling adults with stroke. Some

participants had concerns about using the approach in clients with cognitive impairments,

particularly impairments in executive functions.

Conclusions: Expert stroke rehabilitation therapists perceived CO-OP to be a promising new

approach for stroke rehabilitation. Specific recommendations about using the approach in adults

were made.

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Appendix E: Operational definitions for Performance Quality Rating Scale (PQRS)

scoring for Participant 1, Participant 2, and Participant 3.

P1 Operational Definitions for PQRS Ratings

Participant Goal PQRS

Score

Description

P1 Cycling 1 Does not mount the bike, or falls while attempting to

mount the bike.

2 Mounts the bike with hands-on assistance, but does

not pedal the bike.

3 Mounts the bike with hands-on assistance, and pedals

less than 2 metres before stopping or being stopped

because of an error, such as foot coming off the

pedal, or swerving off the path.

4 Mounts the bike and pedals between 2 and 5 metres

before stopping or being stopped because of an error,

such as foot coming off the pedal or swerving off the

path. Riding is very wobbly. Stops with some hands-

on assistance.

6 Mounts the bike independently, and rides the bike in

a straight line between 5 and 10 metres with only

minimal wobbling or swerving. Stops the bike

independently. May require some hands-on

assistance for dismounting.

8 Mounts the bike independently. Rides in a smooth

straight line with no wobbling or swerving, for more

than 10 metres. Stops the bike independently, and

dismounts independently.

10 Mounts the bike independently, smoothly, and

efficiently. Rides the bike straight and around

corners smoothly, with no wobbling or swerving.

Rides at least 20 metres. Stops the bike independently

and smoothly. Dismounts independently, smoothly,

and efficiently.

P1 Swimming 1 Does not lie down in the water, or lies down in the

water but floats for less than a second.

2 Floats very briefly, less than 5 seconds, but does not

propel self forward.

3 Propels self forward, but uses floatation device.

4 Propels self forward less than the width of the pool,

or touches a leg down partway across.

5 Swims across the width of the pool, but in a diagonal

or crooked path, or body is not horizontal in the water

(feet appear to be 6 inches or more below the

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surface), or arm pull/leg kick ineffective and not even

bilaterally.

6 Swims in a straight line across the width of the pool

with body mostly horizontal in the water (feet 3

inches or less below the surface of the water) using

either arms OR legs, but not both coordinated

together. Arm pull or kick must be generally

effective and even bilaterally.

8 Swims in a straight line across the width of the pool,

with body horizontal in the water (feet at surface of

water) using both arms and legs. Arm pull and leg

kick are effective and even bilaterally, arms pull first

and then legs kick.

10 Swims in a straight line across the length of the

pool, with arms, legs, and breathing properly

coordinated. (Arms pull, head lifts up to breath, legs

kick, glide with arms straight out in front and legs

straight together). Arm pull and leg kick are

effective and even bilaterally.

P1 Handwriting

with

affected

hand

1 Marks on paper are not recognizable as letters

2 Letters are large, inconsistent, and illegible.

4 Letters are legible, but large and inconsistent, and

nearly all (three-quarters or more) the letters have

deviations from proper formation.

6 Letters are legible, but large and/or inconsistent, with

occasional (a quarter to a half of letters formed)


8 Letters are legible, consistent, and properly sized to

fit on a regular lined sheet, with very few deviations

(<10%) from proper formation.

10 Letters are well-formed, sized to fit on a regular lined

sheet, and writing is consistent, with no deviations

from proper formation.


Participant Goal PQRS Score Description

P2 Computer

Mouse

1 Does not put open hand around mouse.

2 Hand grasps mouse, but does not move the

mouse.

4 Hand grasps mouse and moves the mouse

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on the mouse pad, but does not move the

mouse to targets, or does not land accurately

on a target.

6 Hand grasps mouse, lands the mouse on a

target accurately, but gets there with a

crooked trajectory.

8 Hand grasps mouse and moves the mouse to

targets with a smooth trajectory, and lands

accurately on targets.

10 Moves the mouse with a smooth trajectory

to targets, lands accurately on the target,

and clicks the mouse to open and close

applications.

P2 Reciprocal

Stairs

1 Does not put a foot up/or down on a stair.

2 Walks up or down one step with feet not

alternating.

3 Walks up or down several stairs, feet not

alternating.

4 Walks up or down several stairs, feet

alternating, but unsteady and having

difficulty clearing the steps. Toes are

catching on the lip of the step going up, or

heel catching on the way down, on most

(75%-100% more) of the steps.

6 Walks up or down several stairs with feet

alternating, with occasional difficulty

clearing the stair – toes catching going up,

or heel catching on the way down (50%)

8 Walks up or down full flight of stairs

alternating feet, right foot clearing the stair

smoothly on most steps (25% or less) using

the railing.

9 Walks up or down full flight of stairs

alternating feet, right foot clearing the stair

smoothly (0 %), using a cane, but no railing.

10 Walks up or down a full flight of stairs

without stopping, alternating feet, using no

cane or railing, and right foot smoothly

clears 100% of the steps.

P2 Using right

hand to hold

book while

reading

1 Does not put the open book on or in the

right hand

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2 Open book sits on top of right hand (right

hand is supporting the book for a few

seconds, but not grasping it ) and the book

falls off after one or two seconds


hand is supporting the book, but not

grasping) for several seconds, and appears

to be stable.

6 Right hand grasps and stabilizes open book

but no pages are turned.


while left hand is turning pages.


while left hand is turning pages. Right hand

closes the book.



Score

Description Additional

Notes

P3 Nail

Clipping

1 Does not hold the clippers with

right hand

May use

adapted or

ordinary

clippers

2 Holds the clippers in the right

hand after several attempts at

positioning, but does not bring the

clippers and the left hand together

to attempt cutting fingernails.

May use

adapted or

ordinary

clippers


hand, and makes movements

towards clipping left fingernails,

but the clippers are not held

securely or are not in a functional

position, and no nails are clipped.

May use

adapted or

ordinary

clippers


hand, securely, and in a functional

position, and makes places

clippers over at least one left

fingernails, but insufficient force

is generated, and no nails are

clipped.

May use

adapted or

ordinary

clippers

8 As above, but is able to clip

fingernails, although more than

one attempt is required, or the

attempt takes several seconds.

May use

adapted or

ordinary

clippers

10 Using ordinary clippers, as above,

but the fingernails are clipped

Must use

ordinary

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easily and quickly on the first

attempt.

clippers

P3 Yoga –

Deep

Breathing

1 Attempts but does not achieve

sitting position and does not

attempt deep breathing

2 Gets into sitting position with

arms bent at elbows and forearms

resting on or beside legs. Inhales

with short intakes, with significant

upper chest expansion and right

arm and hand flexing strongly up

out of resting position.

4 Takes slow inhalations, but with

some upper chest expansion

AND right arm and hand are

flexing out of resting position.

6 Takes slow breaths with some

upper chest expansion OR some

right arm/hand flexion out of

resting position.

8 Takes long, slow inhalations with

only minimal evidence of upper

chest expansion and/or tension in

right arm/hand

10 Takes long, slow inhalations, with

no evidence of chest expansion

and right arm and hand appear

relaxed and do not move out of

resting position.

P3 Walking

w/ object

in right

hand

1 Despite attempts, does not hold an

object in right hand and walk with

it.

2 Puts an object in right hand, hand

grasp it and client walks one or

two steps before object drops from

hand.

4 Client grasps and holds object

with right hand and walks for

several steps carrying object in

right hand, but object is banging

into leg or body.

6 Walks for several steps (~ 5m)

carrying object in right hand, and

object does not bang into leg or

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body. Gait is slow and unsteady.

8 Walks ~ 10m carrying object in

right hand, held away from the

body so it is not banging into his

leg, but gait is slow and unsteady.

10 Walks > 10m carrying object in

right hand, held away from the

body so it is not banging into his

leg, with steady gait and normal

walking speed.



Score

Description

P5 Photography 1 Does not take a picture, or picture is unviewable.

2 Takes picture, but it is out of focus, poorly

composed, and either under or over-lit (all 3

conditions).

4 Takes picture, but it has 2 of the following 3

conditions: out of focus, poorly composed, or poor

lighting.

6 Takes picture, but it has 1 of the following

conditions: out of focus, poorly composed, or poor

lighting.

8 Takes focused, composed picture with good

lighting.

10 Takes focused, composed picture with good

lighting, of interesting subject matter.

P5 Sewing 1 Does not pass needle through fabric.

2 Needle pierces fabric but stitch is not completed.

4 Stitch is completed with left hand and/or table;

readjustment of forearm position or needle position

occurs several times.

6 Stitch is completed with help of left hand;

readjustment of forearm position or needle position

occurs minimally.

8 Stitch is completed entirely with right hand on

needle and left hand on fabric, but movement may

not be entirely smooth, or other errors may occur.

10 Stitch is completed in one smooth motion, with

right hand on needle and left hand holding fabric.

P5 Cutting fruits

and

vegetables

1 Does not bring knife in contact with object to be

cut.

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with a knife

2 Brings knife in contact with object to be cut, but

does not cut through.

4 Cuts through object: cut is crooked, and takes a

very long time to accomplish, and does not appear

entirely safe.

6 Makes a straight cut through object, but knife is

pulled back up or readjusted and cut takes a long

time to accomplish.

8 Makes a smooth, safe, straight cut through object.

Cut piece is thick or chunky.

10 Makes a smooth, safe, straight, thin cut through

object in one motion.

P5 Handwriting 1 Marks on paper are not recognizable as letters

2 Letters are large, inconsistent, and illegible.

4 Letters are legible, but large and inconsistent, and

nearly all (three-quarters or more) the letters have


6 Letters are legible, but large and/or inconsistent,

with occasional (a quarter to a half of letters

formed) deviations from proper formation.

8 Letters are legible, consistent, and properly sized to

fit on a regular lined sheet, with very few

deviations (<10%) from proper formation.

10 Letters are well-formed, sized to fit on a regular

lined sheet, and writing is consistent, with no



P7 Gardening –

plant bulbs

1 Does not crouch down to ground and

attempt to dig a hole.

2 Crouches down to ground, but falls forward

and steadies self by putting hand on the

ground. Does not dig a hole for the bulb.

4 Crouches down to ground, digs a hole and

plants a bulb. During the process he falls

forward and steadies self by putting hand

on the ground. Requires use of hands to

stand back up.

6 Crouches down to ground, digs a hole and

plants a bulb. During the process he

appears unsteady, but doesn‟t put hand on

the ground. Requires use of hands to stand

back up.

8 Crouches down, digs a hole, places bulb in

root side down, fills in hole, all without

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losing balance. Participant then stands up

by straightening legs, without using hands

on tree or other nearby object to steady self.

10 Crouches down, digs a hole, places bulb in

root side down, fills in hole, and repeats

process with a second bulb, all without

losing balance. Participant then stands up

by straightening legs, without using hands

on tree or other nearby object to steady self.

P7 Walk

carrying

heavy

objects with

left hand

1 Does not use left hand to pick up tray to be

carried.

2 Picks up object to be carried, incorporating

left hand, but does not walk anywhere.

4 Picks up tray to be carried incorporating

left hand, and walks to second table. Tray is

not steady, and objects shift or fall over.

6 Incorporating left hand, carries a tray to

second table. Tray is steady enough that

objects do not shift or fall over.

8 Incorporating the left hand, carries a tray

with liquids from one table to another table,

spilling only a drop.

10 Incorporating the left hand, carries a tray

with liquids from one table to another table,

without spilling.

P7 Buttoning

right cuff

1 Hands do not grasp cuff to attempt

buttoning.

2 Hands grasp cuff to attempt buttoning, but

in one minute, the cuff is still not buttoned.

4 Buttoned in 30s-60s.



10 Cuff is buttoned in less than 5 seconds.

P7 Tieing a tie 1 Hands do not grasp tie and attempt to tie it.

2 Knot is partially completed.

4 Knot is completed, but loosely. Uses teeth

for part of the process, and/or bottom tail of

tie is longer than top tail, and/or tie bottom

is not sitting at belt.(3/3 or 2/3)

6 Knot is completed loosely. Uses teeth for

part of the process OR top tail of tie is

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longer than bottom tail OR tie bottom is

NOT sitting at belt. (1/3)

8 Knot is completed loosely. Top tail of tie is

longer than bottom tail, and tie sits roughly

at belt.

10 Tie is tied with quickly, with no errors or

false starts. Knot is taut, top tail of tie is

longer than bottom tail, and tie bottom sits

roughly at belt.


P8 Improve

walking

speed

1 Does not walk

2 Walks 5 metres at 90 seconds or slower

4 Walks 5 metres in 75 -90 seconds.

6 Walks 5 metres in 60 – 75 seconds

8 Walks 5 metres in 45-60 seconds

10 Walks 5 metres in less than 45 seconds

P8 Put on jacket 1 Does not put on jacket.

2 Puts jacket on, but left arm is twisted and

not completely in sleeve, and jacket is

bunched up at the back of her neck. (all 3

conditions)

4 Puts jacket on with 2 of the following 3

conditions: left arm is twisted or not

completely in sleeve or jacket is bunched

up at the back of the neck.

6 Puts jacket on so that left arm is twisted OR

not completely in sleeve OR jacket is

bunched up at the back of neck (1 of 3

conditions)

8 Puts jacket on so that both arms are

completely in sleeves and back of jacket is

pulled down on back with only minor

bunching.

10 Puts jacket on so that both arms are

completely in sleeves, and jacket is lying

flat on her back.

P8 Transferring

to and from

regular chair

1 Does not attempt to sit in a regular chair.

2 Requires backing up/repositioning prior to

sitting in a regular chair; plunks down; is

unable to get back up from regular chair

without assistance (3/3)

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4 Requires backing up prior to sitting in

regular chair and/or plunks down; requires

several attempts to get back up from chair.

(2/3)

6 Requires backing up prior to sitting in

regular chair and/or plunks down; requires

several attempts to get back up from chair.

(1/3)

8 Approaches regular chair in such a way that

backing up/repositioning not required

before sitting down; lowers self down

gently (no “plunking”); gets up smoothly

first try, but rocks back and forth to gain

momentum before getting up.

10 Approaches regular chair in such a way that

backing up/repositioning not required

before sitting down; lowers self down

gently (no “plunking”); gets up smoothly

first try.

P8 Incorporating

left hand in

reading

1 Does not put the open book on or in the

right hand


hand is supporting the book for a few

seconds, but not grasping it ) and the book

falls off after one or two seconds


hand is supporting the book, but not

grasping) for several seconds, and appears

to be stable.


but no pages are turned.


while left hand is turning pages.


while left hand is turning pages. Right

hand closes the book.

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Appendix F: Stroke Impact Scale (SIS)

Duncan, P. W., Wallace, D., Lai, S. M., Johnson, D., Embretson, S., & Laster, L. J. (1999). The

Stroke Impact Scale version 2.0. evaluation of reliability, validity, and sensitivity to change.

Stroke; a Journal of Cerebral Circulation, 30(10), 2131-2140.

The purpose of this questionnaire is to evaluate how

stroke has impacted your health and life. We want to

know from YOUR POINT OF VIEW how stroke has

affected you. We will ask you questions about

impairments and disabilities caused by your stroke, as

well as how stroke has affected your quality of life.

Finally, we will ask you to rate how much you think you

have recovered from your stroke.

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Stroke Impact Scale These questions are about the physical problems which may have occurred as a result of your

stroke.

1. In the past week, how would

you rate the strength of your....

A lot of

strength

Quite a

bit of

strength

Some

strength

A little

strength

No

strength

at all

a. Arm that was most affected by

your stroke?

5 4 3 2 1

b. Grip of your hand that was

most affected by your stroke?

5 4 3 2 1

c. Leg that was most affected by

your stroke?

5 4 3 2 1

d. Foot/ankle that was most

affected by your stroke?

5 4 3 2 1

These questions are about your memory and thinking.

2. In the past week, how difficult

was it for you to...

Not

difficult at

all

A little

difficult Somewhat

difficult Very

difficult Extremely

difficult

a. Remember things that people just

told you?

5 4 3 2 1

b. Remember things that happened the

day before?

5 4 3 2 1

c. Remember to do things (e.g. keep

scheduled appointments or take

medication)?

5 4 3 2 1

d. Remember the day of the week? 5 4 3 2 1

e. Concentrate? 5 4 3 2 1

f. Think quickly? 5 4 3 2 1

g. Solve everyday problems? 5 4 3 2 1

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These questions are about how you feel, about changes in your mood and about your ability to

control your emotions since your stroke.

3. In the past week, how often did

you...

None of

the time

A little

of the

time

Some of

the time

Most of

the time

All of

the time

a. Feel sad? 5 4 3 2 1

b. Feel that there is nobody you are

close to?

5 4 3 2 1

c. Feel that you are a burden to others? 5 4 3 2 1

d. Feel that you have nothing to look

forward to?

5 4 3 2 1

e. Blame yourself for mistakes that

you made?

5 4 3 2 1

f. Enjoy things as much as ever? 5 4 3 2 1

g. Feel quite nervous? 5 4 3 2 1

h. Feel that life is worth living? 5 4 3 2 1

i. Smile and laugh at least once a day? 5 4 3 2 1

The following questions are about your ability to communicate with other people, as well as your

ability to understand what you read

and what you hear in a conversation.

4. In the past week, how difficult

was it to...

Not

difficult at

all

A little

difficult Somewhat

difficult Very

difficult Extremely

difficult

a. Say the name of someone who was

in front of you?

5 4 3 2 1

b. Understand what was being said to

you in a conversation?

5 4 3 2 1

c. Reply to questions? 5 4 3 2 1

d. Correctly name objects? 5 4 3 2 1

e. Participate in a conversation with a

group of people?

5 4 3 2 1

f. Have a conversation on the

telephone?

5 4 3 2 1

g. Call another person on the

telephone, including selecting the

correct phone number and dialing?

5 4 3 2 1

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The following questions ask about activities you might do during a typical day.

5. In the past 2 weeks, how difficult

was it to...

Not difficult

at all A little

difficult Somewhat

difficult Very

difficult Could not

do at all

a. Cut your food with a knife and fork? 5 4 3 2 1

b. Dress the top part of your body? 5 4 3 2 1

c. Bathe yourself? 5 4 3 2 1

d. Clip your toenails? 5 4 3 2 1

e. Get to the toilet on time? 5 4 3 2 1

f. Control your bladder (not have an

accident)?

5 4 3 2 1

g. Control your bowels (not have an

accident)?

5 4 3 2 1

h. Do light household tasks/chores

(e.g. dust, make a bed, take out

garbage, do the dishes)?

5 4 3 2 1

i. Go shopping? 5 4 3 2 1

j. Do heavy household chores (e.g.

vacuum, laundry or yard work)?

5 4 3 2 1

The following questions are about your ability to be mobile, at home and in the community.


was it to... Not

difficult

at all

A little

difficult

Somewhat

difficult Very

difficult

Could

not do at

all

a. Stay sitting without losing your

balance?

5 4 3 2 1

b. Stay standing without losing your

balance?

5 4 3 2 1

c. Walk without losing your balance? 5 4 3 2 1

d. Move from a bed to a chair? 5 4 3 2 1

e. Walk one block? 5 4 3 2 1

f. Walk fast? 5 4 3 2 1

g. Climb one flight of stairs? 5 4 3 2 1

h. Climb several flights of stairs? 5 4 3 2 1

i. Get in and out of a car? 5 4 3 2 1

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The following questions are about your ability to use your hand that was MOST AFFECTED by

your stroke.


was it to use your hand that was most

affected by your stroke to...

Not

difficult

at all

A little

difficult

Somewhat

difficult Very

difficult

Could

not do

at all

a. Carry heavy objects (e.g. bag of

groceries)?

5 4 3 2 1

b. Turn a doorknob? 5 4 3 2 1

c. Open a can or jar? 5 4 3 2 1

d. Tie a shoe lace? 5 4 3 2 1

e. Pick up a dime? 5 4 3 2 1

The following questions are about how stroke has affected your ability to participate in the

activities that you usually do, things that are meaningful to you and help you to find purpose in

life.

8. During the past 4 weeks, how

much of the time have you been

limited in...

None of

the time

A little

of the

time

Some of

the time

Most of

the time

All of

the time

a. Your work (paid, voluntary or other) 5 4 3 2 1

b. Your social activities? 5 4 3 2 1

c. Quiet recreation (crafts, reading)? 5 4 3 2 1

d. Active recreation (sports, outings,

travel)?

5 4 3 2 1

e. Your role as a family member

and/or friend?

5 4 3 2 1

f. Your participation in spiritual or

religious activities?

5 4 3 2 1

g. Your ability to control your life as

you wish?

5 4 3 2 1

h. Your ability to help others? 5 4 3 2 1

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9. Stroke Recovery

On a scale of 0 to 100, with 100 representing full recovery and 0 representing

no recovery, how much have you recovered from your stroke?

100 Full Recovery

__

90 __

80

__

70

__

60

__

50

__

40

__

30

__

20

__

10

________ 0 No Recovery

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Appendix G: Stanford Self-Efficacy for Managing Chronic Disease 6-Item Scale

Any of the Stanford Self-Management Evaluation tools may be used without permission

(http://patienteducation.stanford.edu/research/ ).

Available from http://patienteducation.stanford.edu/research/secd6.html

We would like to know how confident you are in doing certain activities. For each of the

following questions, please choose the number that corresponds to your confidence that you can

do the tasks regularly at the present time.

1. How confident are you that you can keep the fatigue caused by

your disease from interfering with the things you want to do?

Not at all

confident 1 2 3 4 5 6 7 8 9 10

Totally

confident

Items (using the same format as above):

1. How confident are you that you can keep the fatigue caused by your disease from interfering with

the things you want to do? 2. How confident are you that you can keep the physical discomfort or pain of your disease from

interfering with the things you want to do? 3. How confident are you that you can keep the emotional distress caused by your disease from

interfering with the things you want to do? 4. How confident are you that you can keep any other symptoms or health problems you have from

interfering with the things you want to do? 5. How confident are you that you can do the different tasks and activities needed to manage your

health condition so as to reduce you need to see a doctor? 6. How confident are you that you can do things other than just taking medication to reduce how much

you illness affects your everyday life?

Scoring

The score for each item is the number circled. If two consecutive numbers are circled, code the

lower number (less self-efficacy). If the numbers are not consecutive, do not score the item. The

score for the scale is the mean of the six items. If more than two items are missing, do not score

the scale. Higher number indicates higher self-efficacy.

http://patienteducation.stanford.edu/research/

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Appendix H: Activity-specific Balance Confidence Scale (ABC)

Name:_________________ Date:______________ Study ID: _________________

For each of the following activities, please indicate your level of self-confidence by choosing a

corresponding number from the following rating scale:

0% 10 20 30 40 50 60 70 80 90 100%

No Completely

Confidence Confident

"How confident are you that you can maintain your balance and remain steady when you....

1. walk around the house? _____%

2. walk up or down stairs?_____%

3. bend over and pick up a slipper from the front of a closet floor? _____%

4. reach for a small can off a shelf at eye level? _____%

5. stand on your tip toes and reach for something above your head? _____%

6. stand on a chair and reach for something?_____%

7. sweep the floor?_____%

8. walk outside the house to a car parked in the driveway?_____%

9. get into or out of a car?_____%

10. walk across a parking lot to the mall?_____%

11. walk up or down a ramp?_____%

12. walk in a crowded mall where people rapidly walk past you?_____%

13. are bumped into by people as you walk through the mall?_____%

14. step onto or off of an escalator while holding onto a railing?_____%

15. step onto or off an escalator while holding onto parcels such that you cannot hold onto the

railing?_____%

16. walk outside on icy sidewalks?_____%

©Anita M. Myers. Dept of Health Studies & Gerontology. University of Waterloo. Waterloo, Ontario,

Canada N2L 3G1.

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Appendix I: Chedoke-McMaster Stroke Assessment Scale Impairment Inventory

Gowland, C., VanHullenaar, S., Torresin, W., Moreland, J., Vanspall, B., Barreca, S., et al. (1995).

Chedoke-McMaster Stroke Assessment. Development, validation, and administration manual.

Hamilton, ON: Chedoke-McMaster Hospitals and McMaster University.

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Appendix J: Reintegration to Normal Living Index (RNL)

Wood-Dauphinee, S. L., Williams, J.I. (1987). Reintegration to Normal Living as a proxy to

quality of life. Journal of Chronic Diseases, 40 (6), 491-502.

Name: __________________________ Date:______________ Study ID: ____________

The next set of questions will be a set of statements and you will have three choices.

The choices are: yes, partially or no.

Y P N

1. Do you move around your living quarters as you feel is necessary? 0 1 2

2. Do you move around your community as you feel is necessary?

0 1 2

(shopping, banking, etc.)

3. Are you able to take trips out of town as you feel necessary? 0 1 2

4. Are you comfortable with how you feel your self–care needs are met? 0 1 2

5. Do you spend most of your days occupied in activity that is necessary

or important to you?

0 1 2

6. Are you able to participate in recreational activities as you want to?

(hobbies, sports, cards, etc.)

0 1 2

7. Are you participating in social activities with family, friends, and/or

business acquaintances as is necessary or desirable to you?

0 1 2

8. Are you assuming a role in your family which meets your needs

and those of other family members? (family means people with

whom you live and/or relatives who you see on a regular basis)

0 1 2

9. In general, are you comfortable with your personal relationships?

0 1 2

10. In general, are you comfortable with yourself when you are in the

company of others? 0 1 2

11. Do you feel that you can deal with life events when they happen?

0 1 2

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Appendix K: Motor Activity Log (MAL)

Uswatte, G., Taub, E., Morris, D., Light, K., & Thompson, P. A. (2006). The Motor Activity

Log-28: Assessing daily use of the hemiparetic arm after stroke. Neurology, 67(7), 1189-

1194.

Upper Extremity Motor Activity Log (UE MAL)

Constraint-Induced Movement Therapy Research Group

University of Alabama at Birmingham and Birmingham VA Medical Center

SID_______ Name __________________ Date _________ Visit _______ Examiner _________

Motor Activity Log (UE MAL) Score Sheet

Amount Scale How Well Scale

1. Turn on a light with ____ ____ if no, why? (use code) _________________________

a light switch Comments ________________________________

2. Open drawer ____ ____ if no, why? (use code) ______________________

Comments _______________________________

3. Remove an item ____ ____ if no, why? (use code) _______________________

of clothing from a drawer Comments ________________________________

4. Pick up phone ____ ____ if no, why? (use code) _______________________

Comments ________________________________

5. Wipe off a kitchen ____ ____ if no, why? (use code) _______________________

counter or other surface Comments ________________________________

6. Get out of a car ____ ____ if no, why? (use code) _______________________

(includes only the movement needed to get Comments __________________________

body from sitting to standing outside of the car,

once the door is open).

7. Open refrigerator ____ ____ if no, why? (use code) _______________________

Comments ________________________________

8. Open a door by ____ ____ if no, why? (use code) _______________________

turning a door knob/ Comments ________________________________

handle

9. Use a TV remote ____ ____ if no, why? (use code) _______________________

control Comments ________________________________

10. Wash your hands ____ ____ if no, why? (use code) _______________________

( includes lathering and rinsing hands; does Comments ________________________________

not include turning water on and off with a faucet handle).

Codes for recording “no” responses:

1. “I used the unaffected arm entirely.” (assign “0”).

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2. “Someone else did it for me.” (assign “0”).

3. “I never do that activity, with or without help from someone else because it is impossible.” For example, combing hair for

people who are bald. (assign “N/A” and drop from list of items).

4. “I sometimes do that activity, but did not have the opportunity since the last time I answered these questions.” (carry-over last

assigned number for that activity).

5. Non-dominant hand hemiparesis. (only applicable to #24; assign “N/A” and drop from list of items).


Amount Scale How Well Scale 11. Turning water on/off ____ ____ if no, why? (use code) _______________________

with knob/lever on faucet Comments ________________________________

12. Dry your hands ____ ____ if no, why? (use code) _______________________

Comments ________________________________

13. Put on your socks ____ ____ if no, why? (use code) _______________________

Comments ________________________________

14. Take off your socks ____ ____ if no, why? (use code) _______________________

Comments ________________________________

15. Put on your shoes ____ ____ if no, why? (use code) _______________________

(includes tying shoestrings and fastening straps) Comments ________________________________

16. Take off your shoes ____ ____ if no, why? (use code) _______________________

(includes untying shoestrings and unfastening straps) Comments ________________________________

17. Get up from a chair ____ ____ if no, why? (use code) _______________________

with armrests Comments ________________________________

18. Pull chair away from ____ ____ if no, why? (use code) _______________________

table before sitting down Comments ________________________________

19. Pull chair toward table ____ ____ if no, why? (use code) _______________________

after sitting down Comments ________________________________

20. Pick up a glass, bottle, ____ ____ if no, why? (use code) _______________________

drinking cup, or can (does not need Comments ________________________________

to include drinking)

Codes for recording “no” responses:








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Amount Scale How Well Scale

21. Brush your teeth ____ ____ if no, why? (use code) _______________________

(does not include preparation of toothbrush Comments ________________________________

or brushing dentures unless the dentures are brushed

while left in the mouth)

22. Put on makeup base, ____ ____ if no, why? (use code) _______________________

lotion, or shaving cream on face Comments ________________________________

23. Use a key to ____ ____ if no, why? (use code) _______________________

unlock a door Comments ________________________________

24. Write on paper ____ ____ if no, why? (use code) _______________________

(If hand used to write pre-stroke is more affected, Comments

________________________________

score item; if non-writing hand pre-stroke is more affected,

drop item and assign N/A)

25. Carry an object in ____ ____ if no, why? (use code) _______________________

your hand (draping an item over the arm Comments ________________________________

is not acceptable)

26. Use a fork or ____ ____ if no, why? (use code) _______________________

spoon for eating (refers to the action Comments ________________________________

of bringing food to the mouth with fork

or spoon)

27. Comb your hair ____ ____ if no, why? (use code) _______________________

Comments ________________________________

28. Pick up a cup ____ ____ if no, why? (use code) _______________________

by a handle Comments ________________________________

29. Button a shirt ____ ____ if no, why? (use code) _______________________

Comments ________________________________

30. Eat half a sandwich ____ ____ if no, why? (use code) _______________________

or finger foods Comments ________________________________ Codes for recording “no” responses:








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Amount Scale (AS)

0 - Did not use my weaker arm (not used).

.5

1 - Occasionally used my weaker arm, but only

very rarely (very rarely).

1.5

2 - Sometimes used my weaker arm but did the

activity most of the time with my stronger arm

(rarely).

2.5

3 - Used my weaker arm about half as much as

before the stroke (half pre-stroke).

3.5

4 - Used my weaker arm almost as much as before

the stroke (3/4 pre-stroke).

4.5

5 - Used my weaker arm as often as before the

stroke (same as pre-stroke).

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How Well Scale (HW)

0 - The weaker arm was not used at all for that

activity (never).

.5

1 - The weaker arm was moved during that activity

but was not helpful (very poor).

1.5

2 - The weaker arm was of some use during that

activity but needed some help from the stronger

arm or moved very slowly or with difficulty

(poor).

2.5

3 - The weaker arm was used for the purpose

indicated but movements were slow or were

made with only some effort (fair).

3.5

4 - The movements made by the weaker arm were

almost normal, but were not quite as fast or

accurate as normal (almost normal).

4.5

5 - The ability to use the weaker arm for that

activity was as good as before the stroke

(normal).

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Possible Reasons for Not Using the Weaker Arm

for the Activity:

Reason A. “I used the unaffected arm entirely.”

Reason B. “Someone else did it for me.”.

Reason C. “I never do that activity, with or without help

from someone else because it is impossible.” For

example, combing hair for people who are bald.

Reason D. “I sometimes do that activity, but did not have

the opportunity since the last time I answered these

questions.”

Reason E. "That is an activity that I normally did only

with my dominant hand before the stroke, and continue to

do with my dominant hand now."

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Appendix L: SPSS output for baseline autocorrelations

Autocorrelations

Series:P1 Write

Lag Autocorrelation Std. Errora

Box-Ljung Statistic

Value df Sig.b

1 -.500 .365 1.875 1 .171

a. The underlying process assumed is independence (white noise).

b. Based on the asymptotic chi-square approximation.

Autocorrelations

Series: P1 Swim


Box-Ljung Statistic

Value df Sig.b

1 -.167 .365 .208 1 .648



P1 bike autocorrelations could not be calculated, value was constant (3)

Autocorrelations

Series: P2 Mouse


Box-Ljung Statistic

Value df Sig.b

1 -.667 .365 3.333 1 .068



Autocorrelations

Series:P2 Read


Box-Ljung Statistic

Value df Sig.b

1 -.221 .338 .428 1 .513

2 -.307 .293 1.529 2 .466

3 .008 .239 1.530 3 .675



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Autocorrelations

Series:P2 Stairs


Box-Ljung Statistic

Value df Sig.b

1 -.600 .309 3.780 1 .052

2 .100 .282 3.906 2 .142

3 .000 .252 3.906 3 .272

4 -.100 .218 4.116 4 .391

5 .200 .178 5.376 5 .372



Autocorrelations

Series:P3 Nails


Box-Ljung Statistic

Value df Sig.b

1 .582 .309 3.553 1 .059

2 -.025 .282 3.562 2 .169

3 -.288 .252 4.869 3 .182

4 -.384 .218 7.967 4 .093

5 -.297 .178 10.743 5 .057



Autocorrelations

Series:P3 Yoga


Box-Ljung Statistic

Value df Sig.b

1 -.069 .323 .046 1 .830

2 -.228 .289 .672 2 .714

3 -.073 .250 .758 3 .860

4 -.120 .204 1.103 4 .894



Autocorrelations

Series:P3 Walk


Box-Ljung Statistic

Value df Sig.b

1 -.500 .338 2.188 1 .139

2 .000 .293 2.188 2 .335

3 .000 .239 2.188 3 .534



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Autocorrelations

Series:Photo_Baseline1


Box-Ljung Statistic

Value df Sig.b

1 .016 .296 .003 1 .956

2 -.359 .274 1.719 2 .423

3 .136 .250 2.014 3 .570

4 -.022 .224 2.023 4 .731

5 -.266 .194 3.915 5 .562

6 -.033 .158 3.957 6 .682



Autocorrelations

Series:Sewing_TotalBaseline


Box-Ljung Statistic

Value df Sig.b

1 -.167 .274 .370 1 .543

2 -.152 .258 .715 2 .700

3 -.136 .242 1.033 3 .793

4 .242 .224 2.209 4 .697

5 -.076 .204 2.347 5 .799

6 -.030 .183 2.374 6 .882

7 -.136 .158 3.118 7 .874

8 .182 .129 5.101 8 .747



Autocorrelations

Series:Cutting_TotalBaseline


Box-Ljung Statistic

Value df Sig.b

1 .207 .264 .613 1 .434

2 -.318 .251 2.221 2 .329

3 -.468 .237 6.142 3 .105

4 -.252 .221 7.444 4 .114

5 .160 .205 8.053 5 .153

6 .349 .187 11.537 6 .073

7 -.024 .167 11.558 7 .116

8 -.005 .145 11.560 8 .172

9 -.057 .118 11.790 9 .225



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Autocorrelations

Series:Writing_TotalBaseline


Box-Ljung Statistic

Value df Sig.b

1 .518 .264 3.835 1 .050

2 .373 .251 6.044 2 .049

3 .076 .237 6.147 3 .105

4 -.052 .221 6.203 4 .185

5 -.102 .205 6.449 5 .265

6 -.196 .187 7.549 6 .273

7 -.307 .167 10.928 7 .142

8 -.374 .145 17.590 8 .025

9 -.300 .118 24.017 9 .004



Autocorrelations

Series:GardenBaseline1


Box-Ljung Statistic

Value df Sig.b

1 -.417 .354 1.389 1 .239

2 -.167 .289 1.722 2 .423



Autocorrelations

Series:Button_B


Box-Ljung Statistic

Value df Sig.b

1 .443 .256 3.003 1 .083

2 .230 .244 3.891 2 .143

3 .002 .231 3.891 3 .273

4 -.277 .218 5.507 4 .239

5 -.505 .204 11.639 5 .040

6 -.361 .189 15.294 6 .018

7 -.159 .173 16.141 7 .024

8 -.153 .154 17.128 8 .029

9 .064 .134 17.357 9 .043

10 .128 .109 18.727 10 .044



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Autocorrelations

Series:Carry_TotalBaseline


Box-Ljung Statistic

Value df Sig.b

1 .453 .284 2.542 1 .111

2 -.094 .266 2.666 2 .264

3 -.509 .246 6.937 3 .074

4 -.556 .225 13.048 4 .011

5 -.102 .201 13.307 5 .021

6 .088 .174 13.561 6 .035

7 .146 .142 14.619 7 .041



Autocorrelations

Series:Tie_TotalBaseline


Box-Ljung Statistic

Value df Sig.b

1 -.004 .284 .000 1 .988

2 .203 .266 .583 2 .747

3 -.099 .246 .746 3 .862

4 -.084 .225 .887 4 .926

5 -.214 .201 2.017 5 .847

6 -.199 .174 3.320 6 .768

7 -.068 .142 3.552 7 .830



Autocorrelations

Series:Walk_Baseline1


Box-Ljung Statistic

Value df Sig.b

1 -.033 .323 .011 1 .918

2 -.067 .289 .064 2 .969

3 -.100 .250 .224 3 .974

4 -.133 .204 .651 4 .957



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Autocorrelations

Series:Jacket_TotalBaseline


Box-Ljung Statistic

Value df Sig.b

1 .409 .323 1.607 1 .205

2 .000 .289 1.607 2 .448

3 -.318 .250 3.226 3 .358

4 -.455 .204 8.185 4 .085



Autocorrelations

Series:Transfer_TotalBaseline


Box-Ljung Statistic

Value df Sig.b

1 .466 .264 3.104 1 .078

2 .094 .251 3.245 2 .197

3 .091 .237 3.395 3 .335

4 -.080 .221 3.526 4 .474

5 -.320 .205 5.974 5 .309

6 -.192 .187 7.028 6 .318

7 -.089 .167 7.309 7 .397

8 -.123 .145 8.027 8 .431

9 -.194 .118 10.727 9 .295



Autocorrelations

Series:Book_TotalBaseline


Box-Ljung Statistic

Value df Sig.b

1 .061 .274 .050 1 .823

2 -.312 .258 1.507 2 .471

3 .168 .242 1.992 3 .574

4 -.081 .224 2.122 4 .713

5 -.081 .204 2.281 5 .809

6 .073 .183 2.440 6 .875

7 -.176 .158 3.679 7 .816

8 -.161 .129 5.239 8 .732



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Appendix M: SPSS output: Normal P-P plots for PQRS scores for all participants

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Appendix N: PQRS inter-rater agreement P1-P3, treating therapist SM compared to

research assistant TC.

Statistic

Goal Spearman’s rho ICC Raw agreement

Bike 0.89 0.78 76.92%

Swim 0.66 0.58 75.00%

Mouse 0.95 0.84 65.00%

Read 0.73 0.64 55.00%

Stairs 0.69 0.57 77.78%

Walk 0.76 0.88 94.74%

Clip 0.81 0.78 69.57%

Yoga 0.82 0.66 54.55%

ICC=Interclass correlation coefficient (absolute agreement, single measure)

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