using the cognitive orientation to daily occupational performance
TRANSCRIPT
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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
2.5.3 Single case experimental design findings: P2 ........................................................48
2.5.4 Single case experimental design findings: P3 ........................................................49
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
2.2 P2 PQRS scores with mean and upper 2 SD limits 51
2.3 P3 PQRS scores with mean and upper 2 SD limits 52
3.1 Study design, instruments, and timing 65
3.2 P5 PQRS charts with baseline mean and upper and lower control
limits
72
3.3 P7 PQRS charts with baseline mean and upper and lower control
limits
73
3.4 P8 PQRS charts with baseline mean and upper and lower control
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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First Author Year Design Population Intervention 1 Intervention 2 Outcomes Findings
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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First Author Year Design Population Intervention 1 Intervention 2 Outcomes Findings
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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First Author Year Design Population Intervention 1 Intervention 2 Outcomes Findings
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.
25
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First Author Year Design Population Intervention 1 Intervention 2 Outcomes Findings
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.
26
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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
27
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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
28
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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.
29
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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
`
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
31
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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).
33
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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
34
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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
35
`
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.
36
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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.
37
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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
38
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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.
2.5.3 Single case experimental design findings: P2
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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2.5.4 Single case experimental design findings: P3
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
Intervention Phase 2
Baseline 3
Intervention Phase 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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Figure 3.3 P7 PQRS charts with baseline means and upper and lower control limits
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Figure 3.4 P8 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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References
Achtziger, A., and Gollwitzer, P. (2008). Motivation and volition in the course of action. In
Heckhausen J., Heckhausen H. (Eds.), Motivation and Action (2nd ed.). New York:
Cambridge University Press.
Ahmed, S., Mayo, N. E., Corbiere, M., Wood-Dauphinee, S., Hanley, J., & Cohen, R. (2005).
Change in quality of life of people with stroke over time: True change or response shift?
Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment,
Care and Rehabilitation, 14(3), 611-627.
Aho, K., Harmsen, P., Hatano, S., Marquardsen, J., Smirnov, V. E., & Strasser, T. (1980).
Cerebrovascular disease in the community: Results of a WHO collaborative study. Bulletin
of the World Health Organization, 58(1), 113-130.
Ames, C. (1992). Classrooms: Goals, structures, and student motivation. Journal of Educational
Psychology, 84, 261-271.
Anderson, A. (1999). The case for learning strategies in physical education. Journal of Physical
Education, Recreation and Dance, 70, 45-49.
Appelros, P., Samuelsson, M., Karlsson-Tivenius, S., Lokander, M., & Terent, A. (2007). A
national stroke quality register: 12 years experience from a participating hospital. European
Journal of Neurology: The Official Journal of the European Federation of Neurological
Societies, 14(8), 890-894.
Bach-y-Rita, P. (1990). Brain plasticity as a basis for recovery of function in humans.
Neuropsychologia, 28(6), 547-554.
Badley, E. M. (2008). Enhancing the conceptual clarity of the activity and participation
components of the international classification of functioning, disability, and health. Social
Science & Medicine (1982), 66(11), 2335-2345.
Barlow, D. H. & Hersen M. (Eds) (1984). Single case experimental designs: Strategies for
studying behavior change. New York: Pergamon Press.
123
`
Battaglia, F., Quartarone, A., Ghilardi, M. F., Dattola, R., Bagnato, S., Rizzo, V., et al. (2006).
Unilateral cerebellar stroke disrupts movement preparation and motor imagery. Clinical
Neurophysiology : Official Journal of the International Federation of Clinical
Neurophysiology, 117(5), 1009-1016.
Becker, G., & Kaufman, S. R. (1995). Managing an uncertain illness trajectory in old age:
Patients' and physicians' views of stroke. Medical Anthropology Quarterly, 9(2), 165-187.
Bendz, M. (2000). Rules of relevance after a stroke. Social Science & Medicine (1982), 51(5),
713-723.
Bereby-Meyer, Y., & Kaplan, A. (2005). The effect of motivational goals and age on the ability
to transfer knowledge. Journal of Contemporary Education, 30, 1-22.
Berg, K. O., Wood-Dauphinee, S. L., Williams, J. I., & Maki, B. (1992). Measuring balance in
the elderly: Validation of an instrument. Canadian Journal of Public Health. Revue
Canadienne De Sante Publique, 83 Suppl 2, S7-11.
Berlowitz, D. R., Hoenig, H., Cowper, D. C., Duncan, P. W., & Vogel, W. B. (2008). Impact of
comorbidities on stroke rehabilitation outcomes: Does the method matter? Archives of
Physical Medicine and Rehabilitation, 89(10), 1903-1906.
Bobrovitz, C. D., & Ottenbacher, K. J. (1998). Comparison of visual inspection and statistical
analysis of single-subject data in rehabilitation research. American Journal of Physical
Medicine & Rehabilitation / Association of Academic Physiatrists, 77(2), 94-102.
Boyd, L. A., & Winstein, C. J. (2003). Impact of explicit information on implicit motor-sequence
learning following middle cerebral artery stroke. Physical Therapy, 83(11), 976-989.
Boyd, L. A., & Winstein, C. J. (2004a). Cerebellar stroke impairs temporal but not spatial
accuracy during implicit motor learning. Neurorehabilitation and Neural Repair, 18(3), 134-
143.
Boyd, L. A., & Winstein, C. J. (2004b). Providing explicit information disrupts implicit motor
learning after basal ganglia stroke. Learning & Memory, 11(4), 388-396.
124
`
Brock, K., Black, S., Cotton, S., Kennedy, G., Wilson, S., & Sutton, E. (2008). Goal
achievement in the six months after inpatient rehabilitation for stroke. Disability and
Rehabilitation, Nov. 26, 1-7.
Brunnstrom, S. (1966). Motor testing procedures in hemiplegia: Based on sequential recovery
stages. Physical Therapy, 46(4), 357-375.
Burton, C. R. (2000). Living with stroke: A phenomenological study. Journal of Advanced
Nursing, 32(2), 301-309.
Callahan, C. D., & Barisa, M. T. (2005). Statistical process control and rehabilitation outcome:
The single subject design reconsidered. Rehabilitation Psychology, 50(1), 24-33.
Cameron, D., Polatajko, H. J., Missiuna, C., & Schwellnus, H. (2009). Investigating best
practices for children with cerebral palsy: A pilot study of two approaches. Canadian
Journal of Occupational Therapy, 76(online supplement).
Camp, B., Blom, G., Herbert, F., & VanDoorwick, W. (1976). Think aloud: A program for
developing self-control in young aggressive boys. Unpublished manuscript.
Cardol, M., De Jong, B. A., & Ward, C. D. (2002). On autonomy and participation in
rehabilitation. Disability and Rehabilitation, 24(18), 970-4.
Carr, J., & Shepherd, R. (1987). A motor relearning programme for stroke (2nd ed.). Oxford:
Butterworth-Heineman.
Catalano, J. F., & Kleiner, B. M. (1984). Distant transfer in coincident timing as a function of
variability of practice. Perceptual and Motor Skills, 58(3), 851-851.
Chen, R., Cohen, L. G., & Hallett, M. (2002). Nervous system reorganization following injury.
Neuroscience, 111(4), 761-773.
Cicerone, K. D., Dahlberg, C., Malec, J. F., Langenbahn, D. M., Felicetti, T., Kneipp, S., et al.
(2005). Evidence-based cognitive rehabilitation: Updated review of the literature from 1998
through 2002. Archives of Physical Medicine and Rehabilitation, 86(8), 1681-1692.
125
`
Cirstea, C. M., Ptito, A., & Levin, M. F. (2006). Feedback and cognition in arm motor skill
reacquisition after stroke. Stroke; a Journal of Cerebral Circulation, 37(5), 1237-1242.
Collen, F. M., Wade, D. T., Robb, G. F., & Bradshaw, C. M. (1991). The Rivermead Mobility
Index: A further development of the Rivermead Motor Assessment. International Disability
Studies, 13(2), 50-54.
Cup, E. H., Scholte op Reimer, W. J., Thijssen, M. C., & van Kuyk-Minis, M. A. (2003).
Reliability and validity of the Canadian Occupational Performance Measure in stroke
patients. Clinical Rehabilitation, 17(4), 402-409.
Cutcliffe, J. R. (2003). Reconsidering reflexivity: Introducing the case for intellectual
entrepreneurship. Qualitative Health Research, 13(1), 136-148.
Dahl, A. E., Askim, T., Stock, R., Langorgen, E., Lydersen, S., & Indredavik, B. (2008). Short-
and long-term outcome of constraint-induced movement therapy after stroke: A randomized
controlled feasibility trial. Clinical Rehabilitation, 22(5), 436-447.
Dancause, N., Ptito, A., & Levin, M. F. (2002). Error correction strategies for motor behavior
after unilateral brain damage: Short-term motor learning processes. Neuropsychologia,
40(8), 1313-1323.
Dawson, D. R., Gaya, A., Hunt, A., Lemsky, C., Levine, B., Lo, A., et al. (in press). Using the
cognitive orientation to daily occupational performance approach with adults with traumatic
brain injury. Canadian Journal of Occupational Therapy,
Debaere, F., Wenderoth, N., Sunaert, S., Van Hecke, P., & Swinnen, S. P. (2004). Changes in
brain activation during the acquisition of a new bimanual coodination task.
Neuropsychologia, 42(7), 855-867.
Deci, E. L. (1985). In Ryan R. M. (Ed.), Intrinsic motivation and self-determination in human
behavior. New York: Plenum.
D'Elia, L. F., Satz, P., Uchiyama, C. L., & White, T. (1989). Professional manual for Color
Trails Test. Odessa, FL: Psychological Assessment Resources.
126
`
Desrosiers, J., Noreau, L., Rochette, A., Bourbonnais, D., Bravo, G., & Bourget, A. (2006).
Predictors of long-term participation after stroke. Disability and Rehabilitation, 28(4), 221-
230.
Doidge, N. (2007). The brain that changes itself. New York: Penguin.
Donkervoort, M., Dekker, J., Stehmann-Saris, F. C., & Deelman, B. G. (2001). Efficacy of
strategy training in left hemisphere stroke patients with apraxia: A randomised clinical trial.
Neuropsychological Rehabilitation, 11(5), 549-566.
Dove, H. G., Schneider, K. C., & Wallace, J. D. (1984). Evaluating and predicting outcome of
acute cerebral vascular accident. Stroke; a Journal of Cerebral Circulation, 15(5), 858-864.
Doyon, J., Penhune, V., & Ungerleider, L. G. (2003). Distinct contribution of the cortico-striatal
and cortico-cerebellar systems to motor skill learning. Neuropsychologia, 41(3), 252-262.
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.
Edgington, E. S. (1992). Nonparametric tests for single-case experiments. In T. R. Kratochwill,
& J. R. Levin (Eds.), Single-case research design and analysis: New directions for
psychology and education. (1st ed.). Hillsdale, N.J.: Lawrence Erlbaum Associates.
Egan, M., Kessler, D., Laporte, L., Metcalfe, V., & Carter, M. (2007). A pilot randomized
controlled trial of community-based occupational therapy in late stroke rehabilitation. Topics
in Stroke Rehabilitation, 14(5), 37-45.
Ezekiel, H. J., Lehto, N. K., Marley, T. L., Wishart, L. R., & Lee, T. D. (2001). Application of
motor learning principles: The physiotherapy client as a problem-solver. III. augmented
feedback. Physiotherapy Canada, 53, 33-40.
Feinstein, A. (1999). Mood and motivation in rehabilitation. In D. T. Stuss, G. Winocur & I. H.
Robertson (Eds.), Cognitive Neurorehabilitation . Cambridge: Cambridge University Press.
127
`
Fereday, J., Muir-Cochrane, E. (2006). Demonstrating rigor using thematic analysis: A hybrid
approach of inductive and deductive coding and theme development. International Journal
of Qualitative Methods, 5(1), 80-92.
Finlay, L. (2002). "Outing" the researcher: The provenance, process, and practice of reflexivity.
Qualitative Health Research, 12(4), 531-545.
Flansbjer, U. B., Miller, M., Downham, D., & Lexell, J. (2008). Progressive resistance training
after stroke: Effects on muscle strength, muscle tone, gait performance and perceived
participation. Journal of Rehabilitation Medicine : Official Journal of the UEMS European
Board of Physical and Rehabilitation Medicine, 40(1), 42-48.
Folden, S. (1994). Managing the effects of a stroke: The first months. Rehabilitation Nursing
Research, 3, 79-85.
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). "Mini-mental state". A practical
method for grading the cognitive state of patients for the clinician. Journal of Psychiatric
Research, 12(3), 189-198.
Franzen, M. D., & Harris, C. V. (1993). Neuropsychological rehabilitation: Application of a
modified multiple baseline design. Brain Injury, 7(6), 525-534.
Fugl-Meyer, A. R., Jaasko, L., Leyman, I., Olsson, S., & Steglind, S. (1975). The post-stroke
hemiplegic patient. 1. A method for evaluation of physical performance. Scandinavian
Journal of Rehabilitation Medicine, 7(1), 13-31.
Fuster, J. M. (2006). The cognit: A network model of cortical representation. International
Journal of Psychophysiology : Official Journal of the International Organization of
Psychophysiology, 60(2), 125-132.
Gabr, U., Levine, P., & Page, S. J. (2005). Home-based electromyography-triggered stimulation
in chronic stroke. Clinical Rehabilitation, 19(7), 737-745.
Gage, M., & Polatajko, H. (May 1994). Enhancing occupational performance through an
understanding of perceived self-efficacy. The American Journal of Occupational Therapy,
48(5), 452-461.
128
`
Gharbawie, O. A., & Whishaw, I. Q. (2006). Parallel stages of learning and recovery of skilled
reaching after motor cortex stroke: "oppositions" organize normal and compensatory
movements. Behavioural Brain Research, 175(2), 249-262.
Geusgens, C. A., van Heugten, C. M., Cooijmans, J. P., Jolles, J., & van den Heuvel, W. J.
(2007). Transfer effects of a cognitive strategy training for stroke patients with apraxia.
Journal of Clinical and Experimental Neuropsychology, 29(8), 831-841.
Geusgens, C. A., Winkens, I., van Heugten, C. M., Jolles, J., & van den Heuvel, W. J. (2007).
Occurrence and measurement of transfer in cognitive rehabilitation: A critical review.
Journal of Rehabilitation Medicine: Official Journal of the UEMS European Board of
Physical and Rehabilitation Medicine, 39(6), 425-439.
Geusgens, C., van Heugten, C., Donkervoort, M., van den Ende, E., Jolles, J., & van den Heuvel,
W. (2006). Transfer of training effects in stroke patients with apraxia: An exploratory study.
Neuropsychological Rehabilitation, 16(2), 213-229.
Gilmore, P. E., & Spaulding, S. J. (2007). Motor learning and the use of videotape feedback after
stroke. Topics in Stroke Rehabilitation, 14(5), 28-36.
Gowland, C. (1982). Recovery of motor function following stroke: Profile and predictors.
Physiotherapy Canada, 34, 77-84.
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.
Guadagnoli, M. A., & Lee, T. D. (2004). Challenge point: A framework for conceptualizing the
effects of various practice conditions in motor learning. Journal of Motor Behavior, 36(2),
212-224.
Gustafsson, L., & McKenna, K. (2006). A programme of static positional stretches does not
reduce hemiplegic shoulder pain or maintain shoulder range of motion--a randomized
controlled trial. Clinical Rehabilitation, 20(4), 277-286.
129
`
Hadidi, N., Treat-Jacobson, D. J., & Lindquist, R. (2009). Poststroke depression and functional
outcome: A critical review of literature. Heart & Lung : The Journal of Critical Care, 38(2),
151-162.
Hallett, M. (2001). Plasticity of the human motor cortex and recovery from stroke. Brain
Research. Brain Research Reviews, 36(2-3), 169-174.
Hanlon, R. E. (1996). Motor learning following unilateral stroke. Archives of Physical Medicine
and Rehabilitation, 77(8), 811-815.
Harbst, K. B., Ottenbacher, K. J., & Harris, S. R. (1991). Interrater reliability of therapists'
judgements of graphed data. Physical Therapy, 71(2), 107-115.
Heckhausen, H., & Gollwitzer, P. M. (1987). Thought contents and cognitive functioning in
motivational versus volitional states of mind. Motivation and Emotion, 11(2), 101-120.
Heckhausen, J., & Heckhausen, H. (2008) (Eds.). Motivation and Action. New York: Cambridge
University Press.
Henshaw, E., Polatajko, H. J., McEwen, S. E., Ryan, J. D., & Baum, C. (submitted). Using a
cognitive approach to enable participation after stroke: Two case studies. American Journal
of Occupational Therapy,
Hesse-Biber, S., N., & Leavy, P. (2005). The Practice of Qualitative Research. Thousand Oaks,
CA: Sage.
Holliday, R. C., Ballinger, C., & Playford, E. D. (2007). Goal setting in neurological
rehabilitation: Patients' perspectives. Disability and Rehabilitation, 29(5), 389-394.
Hornby, T. G., Campbell, D. D., Kahn, J. H., Demott, T., Moore, J. L., & Roth, H. R. (2008).
Enhanced gait-related improvements after therapist- versus robotic-assisted locomotor
training in subjects with chronic stroke: A randomized controlled study. Stroke; a Journal of
Cerebral Circulation, 39(6), 1786-1792.
Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis.
Qualitative Health Research, 15(9), 1277-1288.
130
`
Huijbregts, M. P., Myers, A. M., Streiner, D., & Teasell, R. (2008). Implementation, process, and
preliminary outcome evaluation of two community programs for persons with stroke and
their care partners. Topics in Stroke Rehabilitation, 15(5), 503-520.
Hull, C. L. (1943). Principles of Behavior. New York: Appleton-Century-Crofts.
Inatomi, Y., Yonehara, T., Omiya, S., Hashimoto, Y., Hirano, T., & Uchino, M. (2008). Aphasia
during the acute phase in ischemic stroke. Cerebrovascular Diseases (Basel, Switzerland),
25(4), 316-323.
Jackson, R. C., Ashford, K. J., & Norsworthy, G. (2006). Attentional focus, dispositional
reinvestment, and skilled motor performance under pressure. Journal of Sport & Exercise
Psychology, 28(1)
Jaeggi, S. M., Buschkuehl, M., Jonides, J., & Perrig, W. J. (2008). Improving fluid intelligence
with training on working memory. Proceedings of the National Academy of Sciences of the
United States of America, 105(19), 6829-6833.
Jantzen, K. J., Oullier, O., Marshall, M., Steinberg, F. L., & Kelso, J. A. (2007). A parametric
fMRI investigation of context effects in sensorimotor timing and coordination.
Neuropsychologia, 45(4), 673-684.
Jette, A. M. (2005). The changing language of disablement. Physical Therapy, 85(2), 118-119.
Jones, F., Mandy, A., & Partridge, C. (2008). Reasons for recovery after stroke: A perspective
based on personal experience. Disability and Rehabilitation, 30(7), 507-516.
Jordan, L. C., & Hillis, A. E. (2005). Aphasia and right hemisphere syndromes in stroke. Current
Neurology and Neuroscience Reports, 5(6), 458-464.
Jorgensen, H. S., Nakayama, H., Raaschou, H. O., Vive-Larsen, J., Stoier, M., & Olsen, T. S.
(1995). Outcome and time course of recovery in stroke. Part I: Outcome. The Copenhagen
stroke study. Archives of Physical Medicine and Rehabilitation, 76(5), 399-405.
131
`
Jueptner, M., Stephan, K. M., Frith, C. D., Brooks, D. J., Frackowiak, R. S., & Passingham, R. E.
(1997). Anatomy of motor learning. I. frontal cortex and attention to action. Journal of
Neurophysiology, 77(3), 1313-1324.
Kaneko, N., & Sawamoto, K. (2009). Adult neurogenesis and its alteration under pathological
conditions. Neuroscience Research, 63(3), 155-164.
Katz, D. I., Ashley, M., O'Shanick, G. J., & Connors, S. H. (2006). Cognitive rehabilitation: The
evidence, funding and case for advocacy in brain injury. McLean, VA: Brain Injury
Association of America.
Kaufman, S., & Becker, G. (1986). Stroke: Health care on the periphery. Social Science &
Medicine (1982), 22(9), 983-989.
Kazdin, A. E. (1984). Statistical analyses for single-case experimental designs. In D. H. Barlow,
& M. Hersen (Eds.), Single case experimental designs: Strategies for studying behavior
change (2nd ed., pp. 285-324). Elmsford, NY: Pergamon Press.
Keith, R. A., Granger, C. V., Hamilton, B. B., & Sherwin, F. S. (1987). The functional
independence measure: A new tool for rehabilitation. Advances in Clinical Rehabilitation, 1,
6-18.
Kinslikh, D., McEwen, S. E., Schneiderman, A., & Polatajko, H. J. (2008). Cognitive
Orientation to daily Occupational Performance and stroke treatment. Canadian Association
of Occupational Therapists Conference, Whitehorse, YK, Canada. F37.
Komrad, M. S. (1983). A defence of medical paternalism: Maximising patients' autonomy.
Journal of Medical Ethics, 9(1), 38-44.
Krakauer, J. W. (2006). Motor learning: Its relevance to stroke recovery and neurorehabilitation.
Current Opinion in Neurology, 19(1), 84-90.
Langhammer, B., Stanghelle, J. K., & Lindmark, B. (2008). Exercise and health-related quality
of life during the first year following acute stroke. A randomized controlled trial. Brain
Injury, 22(2), 135-145.
132
`
Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatajko, H., & Pollock, N. (2005).
Canadian Occupational Performance Measure (4th
ed.). Ottawa, ON: CAOT Publications
ACE.
Law, M., Polatajko, H., Pollock, N., McColl, M. A., Carswell, A., & Baptiste, S. (Oct 1994).
Pilot testing of the Canadian Occupational Performance Measure: Clinical and measurement
issues. Canadian Journal of Occupational Therapy, 61(4), 191-197.
Lee, T. D., Swinnen, S. P., & Serrien, D. J. (1994). Cognitive effort and motor learning. Quest,
46, 328-344.
Lee, T. D., & Wishart, L. (2005). Motor learning conundrums (and possible solutions). Quest,
57, 67-78.
Lee, M. J., Kilbreath, S. L., Singh, M. F., Zeman, B., Lord, S. R., Raymond, J., et al. (2008).
Comparison of effect of aerobic cycle training and progressive resistance training on
walking ability after stroke: A randomized sham exercise-controlled study. Journal of the
American Geriatrics Society, 56(6), 976-985.
Lesniak, M., Bak, T., Czepiel, W., Seniow, J., & Czlonkowska, A. (2008). Frequency and
prognostic value of cognitive disorders in stroke patients. Dementia and Geriatric Cognitive
Disorders, 26(4), 356-363.
Levack, W. M., Taylor, K., Siegert, R. J., Dean, S. G., McPherson, K. M., & Weatherall, M.
(2006). Is goal planning in rehabilitation effective? A systematic review. Clinical
Rehabilitation, 20(9), 739-755.
Levin, M. F., Kleim, J. A., & Wolf, S. L. (2008). What do motor "recovery" and "compensation"
mean in patients following stroke? Neurorehabilitation and Neural Repair,23(4), 313-319.
Lidor, R. (1997). Effectiveness of A structured learning strategy on acquisition of game related
gross motor tasks in school settings. Perceptual and Motor Skills, 84, 67-80.
Lidor, R. (2004). Developing metacognitive behaviour in physical education classes: The use of
task-pertinent learning strategies. Physical Education and Sport Pedagogy, 9(1), 55-71.
133
`
Lidor, R., Tennant, K. L., & Singer, R. N. (1996). The generalizability effect of three learning
strategies across motor task performances. International Journal of Sport Psychology, 27(1),
23-36.
Liepert, J. (2006). Motor cortex excitability in stroke before and after constraint-induced
movement therapy. Cognitive and Behavioral Neurology : Official Journal of the Society for
Behavioral and Cognitive Neurology, 19(1), 41-47.
Lin, K. C., Wu, C. Y., & Liu, J. S. (2008). A randomized controlled trial of constraint-induced
movement therapy after stroke. Acta Neurochirurgica.Supplement, 101, 61-64.
Lin, K. C., Wu, C. Y., Wei, T. H., Lee, C. Y., & Liu, J. S. (2007). Effects of modified constraint-
induced movement therapy on reach-to-grasp movements and functional performance after
chronic stroke: A randomized controlled study. Clinical Rehabilitation, 21(12), 1075-1086.
Liu, K. P., Chan, C. C., Lee, T. M., & Hui-Chan, C. W. (2004). Mental imagery for promoting
relearning for people after stroke: A randomized controlled trial. Archives of Physical
Medicine and Rehabilitation, 85(9), 1403-1408.
Livingston, J. (1997). Metacognition: An overview. Retrieved 04/12, 2007, from
http://www.gse.buffalo.edu/fas/shuell/cep564/Metacog.htm
Lopez, A. D., Mathers, C. D., Ezzati, M., Jamison, D. T., & Murray, C. J. (2006). Global and
regional burden of disease and risk factors, 2001: Systematic analysis of population health
data. Lancet, 367(9524), 1747-1757.
Lord, S., McPherson, K. M., McNaughton, H. K., Rochester, L., & Weatherall, M. (2008). How
feasible is the attainment of community ambulation after stroke? A pilot randomized
controlled trial to evaluate community-based physiotherapy in subacute stroke. Clinical
Rehabilitation, 22(3), 215-225.
Lorig, K. R., Sobel, D. S., Ritter, P. L., Laurent, D., & Hobbs, M. (2001). Effect of a self-
management program on patients with chronic disease. Effective Clinical Practice: ECP,
4(6), 256-262.
134
`
Mahoney, F.I., & Barthel, D. W. (1965). Functional evaluation: The Barthel index. Maryland
State Medical Journal, 14, 61-65.
Mandich, A. D., Polatajko, H. J., & Rodger, S. (2003). Rites of passage: Understanding
participation of children with developmental coordination disorder. Human Movement
Science, 22(4-5), 583-595.
Mangset, M., Tor Erling, D., Forde, R., & Wyller, T. B. (2008). 'We're just sick people, nothing
else': ... factors contributing to elderly stroke patients' satisfaction with rehabilitation.
Clinical Rehabilitation, 22(9), 825-835.
Mann, D. D., & Eland, D. C. (2005). Self-efficacy in mastery learning to apply a therapeutic
psychomotor skill. Perceptual and Motor Skills, 100(1), 77-84.
Matlin, M. W. (2005). Cognition (6th ed.). [New York]: J. Wiley & Sons.
Maxwell, J. P., Masters, R. S. W., & Poolton, J. M. (2006). Performance breakdown in sport:
The roles of reinvestment and verbal knowledge. Research Quarterly for Exercise and
Sport, 77(2), 271-276.
Mayer, R. E. (2004). Should there be a three-strikes rule against pure discovery learning? the
case for guided methods of instruction. The American Psychologist, 59(1), 14-19.
Mayo, N. E., Korner-Bitensky, N. A., & Becker, R. (1991). Recovery time of independent
function post-stroke. American Journal of Physical Medicine & Rehabilitation / Association
of Academic Physiatrists, 70(1), 5-12.
Mayo, N. E., Wood-Dauphinee, S., Ahmed, S., Gordon, C., Higgins, J., McEwen, S., et al.
(1999). Disablement following stroke. Disability and Rehabilitation, 21(5-6), 258-268.
Mayo, N. E., Wood-Dauphinee, S., Cote, R., Durcan, L., & Carlton, J. (2002). Activity,
participation, and quality of life 6 months poststroke. Archives of Physical Medicine and
Rehabilitation, 83(8), 1035-1042.
135
`
McDonnell, M. N., Hillier, S. L., Miles, T. S., Thompson, P. D., & Ridding, M. C. (2007).
Influence of combined afferent stimulation and task-specific training following stroke: A
pilot randomized controlled trial. Neurorehabilitation and Neural Repair, 21(5), 435-443.
McEwen, S. E., Huijbregts, M. P. J., Ryan, J., & Polatajko, H. J. (2009). Cognitive strategy use
in motor skill acquisition post stroke: A critical review. Brain Injury, 23(4), 263-277.
McEwen, S. E., Polatajko, H. J., Davis, J. A., Huijbregts, M. P. J., & Ryan, J. D. (submitted).
“There’s a real plan here, and I am responsible for that plan”: Participant experiences with
a novel cognitive-based treatment approach for adults living with chronic stroke. Disability
and Rehabilitation.
McEwen, S. E., Polatajko, H. J., Huijbregts, M. P. J., & Ryan, J. D. (submitted). Exploring a
cognitive-based treatment approach to improve motor skill performance in chronic stroke:
Results of three single case experiments. Brain Injury.
McEwen, S., Mayo, N., & Wood-Dauphinee, S. (2000). Inferring quality of life from
performance-based assessments. Disability and Rehabilitation, 22(10), 456-463.
McKevitt, C., Redfern, J., Mold, F., & Wolfe, C. (2004). Qualitative studies of stroke: A
systematic review. Stroke; a Journal of Cerebral Circulation, 35(6), 1499-1505.
McNevin, N. H., Shea, C. H., & Wulf, G. (2003). Increasing the distance of an external focus of
attention enhances learning. Psychological Research, 67(1), 22-29.
Meichenbaum, D. H., & Goodman, J. (1971). Training impulsive children to talk to themselves:
A means of developing self-control. Journal of Abnormal Psychology, 77(2), 115-126.
Meister, I., Krings, T., Foltys, H., Boroojerdi, B., Muller, M., Topper, R., et al. (2005). Effects of
long-term practice and task complexity in musicians and nonmusicians performing simple
and complex motor tasks: Implications for cortical motor organization. Human Brain
Mapping, 25(3), 345-352.
Miller, L.T., Polatajko, H. J., Missiuna, C., Mandich, A. D., & Macnab, J. J. (2001). A pilot of a
cognitive treatment for children with developmental coordination disorder. Human
Movement Science, 20, 183-210.
136
`
Missiuna, C., Mandich, A. D., Polatajko, H. J., & Malloy-Miller, T. (2001). Cognitive
orientation to daily occupational performance (CO-OP): Part I--theoretical foundations.
Physical & Occupational Therapy in Pediatrics, 20(2-3), 69-81.
Morris, J. H., van Wijck, F., Joice, S., Ogston, S. A., Cole, I., & MacWalter, R. S. (2008). A
comparison of bilateral and unilateral upper-limb task training in early post-stroke
rehabilitation: A randomized controlled trial. Archives of Physical Medicine and
Rehabilitation, 89(7), 1237-1245.
Morrow, S. (2005). Quality and trustworthiness in qualitative research in counselling
psychology. Journal of Counselling Psychology, 52(2), 250-260.
Mount, J., Pierce, S. R., Parker, J., DiEgidio, R., Woessner, R., & Spiegel, L. (2007). Trial and
error versus errorless learning of functional skills in patients with acute stroke.
NeuroRehabilitation, 22(2), 123-132.
Mountz, J. M. (2007). Nuclear medicine in the rehabilitative treatment evaluation in stroke
recovery. role of diaschisis resolution and cerebral reorganization. Europa Medicophysica,
43(2), 221-239.
Murase, N., Duque, J., Mazzocchio, R., & Cohen, L. G. (2004). Influence of interhemispheric
interactions on motor function in chronic stroke. Annals of Neurology, 55(3), 400-409.
Murray, C. J., & Lopez, A. D. (1997). Global mortality, disability, and the contribution of risk
factors: Global burden of disease study. Lancet, 349(9063), 1436-1442.
Myers, A. M., Fletcher, P. C., Myers, A. H., & Sherk, W. (1998). Discriminative and evaluative
properties of the activities-specific balance confidence (ABC) scale. The Journals of
Gerontology.Series A, Biological Sciences and Medical Sciences, 53(4), M287-94.
Neisser, U. (1967). Cognitive Psychology. New York: Appleton-Century-Crofts.
Noonan, V. K., Miller, W. C., & Noreau, L. (2009). A review of instruments assessing
participation in persons with spinal cord injury. Spinal Cord: The Official Journal of the
International Medical Society of Paraplegia,
137
`
Nudo, R. J., Milliken, G. W., Jenkins, W. M., & Merzenich, M. M. (1996). Use-dependent
alterations of movement representations in primary motor cortex of adult squirrel monkeys.
The Journal of Neuroscience: The Official Journal of the Society for Neuroscience, 16(2),
785-807.
O'Callaghan, M. E., & Couvadelli, B. (1998). Use of self-instructional strategies with three
neurologically impaired adults. Cognitive Therapy and Research, 22(2), 91-107.
Orme, J. G., & Cox, M. E. (2001). Analyzing single-subject design data using statistical process
control charts. Social Work Research, 25(2), 115-126.
Orrell, A. J., Eves, F. F., & Masters, R. S. (2006). Motor learning of a dynamic balancing task
after stroke: Implicit implications for stroke rehabilitation. Physical Therapy, 86(3), 369-
380.
Orrell, A. J., Masters, R. S., & Eves, F. F. (2009). Reinvestment and movement disruption
following stroke. Neurorehabilitation and Neural Repair, 23(2), 177-183.
Osborne, R. H., Hawkins, M., & Sprangers, M. A. (2006). Change of perspective: A measurable
and desired outcome of chronic disease self-management intervention programs that violates
the premise of preintervention/postintervention assessment. Arthritis and Rheumatism,
55(3), 458-465.
Ottenbacher, K. J. (1986a). Evaluation of Clinical Change: Strategies for Occupational and
Physical Therapists (First ed.). Baltimore: Williams and Wilkins.
Ottenbacher, K. J. (1986b). Reliability and accuracy of visually analyzing graphed data from
single-subject designs. The American Journal of Occupational Therapy, 40(7), 464-469.
Ottenbacher, K. J. (1990). Visual inspection of single-subject data: An empirical analysis.
Mental Retardation, 28(5), 283-290.
Ottenbacher, K. J. (1993). Interrater agreement of visual analysis in single-subject decisions:
Quantitative review and analysis. American Journal of Mental Retardation: AJMR, 98(1),
135-142.
138
`
Ownsworth, T. L., Turpin, M., Andrew, B., & Fleming, J. (2007). Participant perspectives on an
individualised self-awareness intervention following stroke: A qualitative case study.
Neuropsychological Rehabilitation, 18(5-6), 692-712.
Page, S. J., Gater, D. R., & Bach-Y-Rita, P. (2004). Reconsidering the motor recovery plateau in
stroke rehabilitation. Archives of Physical Medicine and Rehabilitation, 85(8), 1377-1381.
Page, S. J., Levine, P., Sisto, S., Bond, Q., & Johnston, M. V. (2002). Stroke patients' and
therapists' opinions of constraint-induced movement therapy. Clinical Rehabilitation, 16(1),
55-60.
Pak, S., & Patten, C. (2008). Strengthening to promote functional recovery poststroke: An
evidence-based review. Topics in Stroke Rehabilitation, 15(3), 177-199.
Park, J.H., Shea, C. H., McNevin, N., & Wulf, G. (2000). Attentional focus and the control of
dynamic balance. Journal of Sport & Exercise Psychology .Vol.22, Suppl., 22(Suppl.).
Patton, M. Q. (1990). Qualitative Evaluation and Research Methods (2nd ed.). Newbury Park,
CA: SAGE.
Phipps, S., & Richardson, P. (2007). Occupational therapy outcomes for clients with traumatic
brain injury and stroke using the Canadian Occupational Performance Measure. The
American Journal of Occupational Therapy, 61(3), 328-334.
Plautz, E. J., Milliken, G. W., & Nudo, R. J. (2000). Effects of repetitive motor training on
movement representations in adult squirrel monkeys: Role of use versus learning.
Neurobiology of Learning and Memory, 74(1), 27-55.
Podsiadlo, D., & Richardson, S. (1991). The timed "up & go": A test of basic functional mobility
for frail elderly persons. Journal of the American Geriatrics Society, 39(2), 142-148.
Polatajko, H. J., & Mandich, A. (2004). Enabling Occupation in Children: The Cognitive
Orientation to daily Occupational Performance (CO-OP) Approach (First ed.). Ottawa,
Canada: CAOT Publications ACE.
139
`
Polatajko, H. J., Fox, A. M., & Missiuna, C. (1995). An international consensus on children with
developmental coordination disorder. Canadian Journal of Occupational Therapy, 62(1), 3-
6.
Polatajko, H. J., Mandich, A. D., Miller, L. T., & Macnab, J. J. (2001). Cognitive Orientation to
daily Occupational Performance (CO-OP): Part II - the evidence. Physical & Occupational
Therapy in Pediatrics, 20(2/3), 83-105.
Polatajko, H. J., Mandich, A. D., Missiuna, C., Miller, L. T., Macnab, J. J., Malloy-Miller, T., et
al. (2001). Cognitive Orientation to daily Occupational Performance (CO-OP): Part III - the
protocol in brief. Physical & Occupational Therapy in Pediatrics, 20(2/3), 107-123.
Proot, I. M., ter Meulen, R. H., Abu-Saad, H. H., & Crebolder, H. F. (2007). Supporting stroke
patients' autonomy during rehabilitation. Nursing Ethics, 14(2), 229-241.
Puttemans, V., Wenderoth, N., & Swinnen, S. P. (2005). Changes in brain activation during the
acquisition of a multifrequency bimanual coordination task: From the cognitive stage to
advanced levels of automaticity. The Journal of Neuroscience, 25(17), 4270-4278.
Randall, K. E., & McEwen, I. R. (2000). Writing patient-centered functional goals. Physical
Therapy, 80(12), 1197-1203.
Rennie, D. L. (2004). Reflexivity and person-centred counseling. Journal of Humanistic
Psychology, 44, 427-437.
Robertson, I. H., & Murre, J. M. (1999). Rehabilitation of brain damage: Brain plasticity and
principles of guided recovery. Psychological Bulletin, 125(5), 544-575.
Rodger, S., Springfield, E., & Polatajko, H. J. (2007). Cognitive Orientation for daily
Occupational Performance approach for children with Asperger's syndrome:A case report.
Physical & Occupational Therapy in Pediatrics, 27(4), 7-22.
Rosenbaum, D. A. (2005). The Cinderella of psychology: The neglect of motor control in the
science of mental life and behavior. The American Psychologist, 60(4), 308-317.
140
`
Rosenshine, B. (1997). Advances in research on instruction. In J. W. Lloyd, E. J. Kameenui & D.
Chard (Eds.), Issues in Educating Students with Disabilities (1st ed., pp. 197-221). Mahwah,
NJ: Lawrence Erlbaum.
Ryan, G.W., Bernard, H.R. (2003). Techniques to identify themes. Field Methods, 15(1), 85-109.
Salter, K., Hellings, C., Foley, N., & Teasell, R. (2008). The experience of living with stroke: A
qualitative meta-synthesis. Journal of Rehabilitation Medicine, 40(8), 595-602.
Samonte, S., Solish, L., Delaney, L., & Polatajko, H. (2004). Cognitive Orientation to daily
Occupational Performance: Beyond developmental coordination disorder. Canadian
Association of Occupational Therapists Conference, Charlottetown, Prince Edward Island,
Canada.
Sangster, C. A., Beninger, C., Polatajko, H. J., & Mandich, A. (2005). Cognitive strategy
generation in children with developmental coordination disorder. Canadian Journal of
Occupational Therapy, 72(2), 67-77.
Schmidt, R. A., & Lee, T. D. (2005). Motor Control and Learning: A Behavioural Emphasis
(4th ed.). Champaign, IL: Human Kinetics.
Schmidt, R. A., & Bjork, R. A. (1992). New conceptualizations of practice: Common principles
in three paradigms suggest new concepts for training. Psychological Science, 3(4), 207-217.
Schneiderman, A., McEwen, S. E., Kinslikh, D., & Polatajko, H. J. (2008). On route to novel
strategies for adult stroke rehabilitation. Canadian Association of Occupational Therapists
Conference, Whitehorse, YK, Canada. S64.
Schultheiss, O. C., & Wirth, M. M. (2008). Biopsychological aspects of motivation. In J.
Heckhausen, & H. Heckhausen (Eds.), Motivation and Action (2nd ed.). New York:
Cambridge University Press.
Schuntermann, M. F. (2005). The implementation of the international classification of
functioning, disability and health in Germany: Experiences and problems. International
Journal of Rehabilitation Research, 28(2), 93-102.
141
`
Serrien, D. J., Ivry, R. B., & Swinnen, S. P. (2007). The missing link between action and
cognition. Progress in Neurobiology, 82(2), 95-107.
Shea, C. H., & Wulf, G. (1999). Enhancing motor learning through external focus instructions
and feedback. Human Movement Science, 18, 553-571.
Shumway-Cook, A., & Woollacott, M. (2007). Motor Control: Translating Research into
Clinical Practice (3rd ed.). Philadelphia: Lippincott, Williams, and Wilkins.
Sideridis, G. D., & Greenwood, C. R. (1996). Evaluating treatment effects in single-subject
behavioral experiments using quality-control charts. Journal of Behavioral Education, 6(2),
203-211.
Singer, R. N. (1989). Effectiveness of A global learning strategy practiced in different contexts
on primary and transfer self paced motor tasks. Journal of Sport and Exercise Psychology,
11, 290-303.
Singer, R. N., & Chen, D. (1994). A classification scheme for cognitive strategies: Implications
for learning and teaching psychomotor skills. Research Quarterly for Exercise and Sport,
65(2), 143-151.
Singer, R. N., & Suwanthada, S. (1986). The generalizability effectiveness of a learning strategy
on achievement in related closed motor skills. Research Quarterly.American Alliance for
Health, Physical Education and Recreation, 57, 205-214.
Singer, R. N., Flora, L. A., & Abourezk, T. L. (1989). The effect of a five-step cognitive learning
strategy on the acquisition of a complex motor task. Journal of Applied Sport Psychology,
1(2), 98-108.
Sterr, A. (2004). Training-based interventions in motor rehabilitation after stroke: Theoretical
and clinical considerations. Behavioral Neurology, 15(3-4), 55-63.
Stokes, P. D., & Balsam, P. (2001). An optimal period for setting sustained variability levels.
Psychonomic Bulletin & Review, 8(1), 177-184.
142
`
Stokes, P. D., Lai, B., Holtz, D., Rigsbee, E., & Cherrick, D. (2008). Effects of practice on
variability, effects of variability on transfer. Journal of Experimental Psychology: Human
Perception and Performance, 34(3), 640-640.
Swinnen, S. P., Schmidt, R. A., Nicholson, D. E., & Shapiro, D.C. (1990). Information feedback
for skill acquisition: Instantaneous knowledge of results degrades learning. Journal of
Experimental Psychology: Learning, 16(4), 706-716.
Taub, E., Crago, J. E., Burgio, L. D., Groomes, T. E., Cook, E. W.,3rd, DeLuca, S. C., et al.
(1994). An operant approach to rehabilitation medicine: Overcoming learned nonuse by
shaping. Journal of the Experimental Analysis of Behavior, 61(2), 281-293.
Teasdale, T. W., & Engberg, A. W. (2005). Psychosocial consequences of stroke: A long-term
population-based follow-up. Brain Injury, 19(12), 1049-1058.
Tennant, L. K., Murray, N. P., & Tennant, L. M. (2004). Effects of strategy use on acquisition of
a motor task during various stages of learning. Perceptual and Motor Skills, 98(3), 1337-
1344.
Tombaugh, T. N., & McIntyre, N. J. (1992). The Mini-Mental State Examination: A
comprehensive review. Journal of the American Geriatrics Society, 40(9), 922-935.
Ullen, F., Forssberg, H., & Ehrsson, H. H. (2003). Neural networks for the coordination of the
hands in time. Journal of Neurophysiology, 89(2), 1126-1135.
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.
Van der Lee, J. H., De Groot, V., Beckerman, H., Wagenaar, R. C., Lankhorst, G. J., & Bouter,
L. M. (2001). The intra- and interrater reliability of the action research arm test: A practical
test of upper extremity function in patients with stroke. Archives of Physical Medicine and
Rehabilitation, 82(1), 14-19.
143
`
Van Peppen, R. P., Kwakkel, G., Wood-Dauphinee, S., Hendriks, H. J., Van der Wees, P. J., &
Dekker, J. (2004). The impact of physical therapy on functional outcomes after stroke:
What's the evidence? Clinical Rehabilitation, 18(8), 833-862.
van Vliet, P. M., & Wulf, G. (2006). Extrinsic feedback for motor learning after stroke: What is
the evidence? Disability and Rehabilitation, 28(13-14), 831-840.
Wade, D. T., Wood, V. A., Heller, A., Maggs, J., & Langton Hewer, R. (1987). Walking after
stroke. measurement and recovery over the first 3 months. Scandinavian Journal of
Rehabilitation Medicine, 19(1), 25-30.
Wang, T., Wang, X., Wang, H., He, X., Su, J., Zhu, Y., et al. (2007). Effects of ULEM apparatus
on motor function of patients with stroke. Brain Injury, 21(11), 1203-1208.
Ward, A., & Rodger, S. (2004). The application of Cognitive Orientation to daily Occupational
Performance (CO-OP) with children 5-7 years with developmental coordination disorder.
British Journal of Occupational Therapy, 67(6), 256-264.
Ware, J. E.,Jr, & Sherbourne, C. D. (1992). The MOS 36-item short-form health survey (SF-36).
I. Conceptual framework and item selection. Medical Care, 30(6), 473-483.
Webster's College Dictionary (1991). New York: Random House.
Winzer, M. (1999). Children with Exceptionalities in Canadian Classrooms (5th
ed.).
Scarborough, ON, Canada: Prentice Hall.
Wohlin Wottrich, A., Stenstrom, C. H., Engardt, M., Tham, K., & von Koch, L. (2004).
Characteristics of physiotherapy sessions from the patient's and therapist's perspective.
Disability and Rehabilitation, 26(20), 1198-1205.
Wolf, S. L., Catlin, P. A., Ellis, M., Archer, A. L., Morgan, B., & Piacentino, A. (2001).
Assessing Wolf Motor Function Test as outcome measure for research in patients after
stroke. Stroke, 32(7), 1635-1639.
Wolf, S. L., Winstein, C. J., Miller, J. P., Taub, E., Uswatte, G., Morris, D., et al. (2006). Effect
of constraint-induced movement therapy on upper extremity function 3 to 9 months after
144
`
stroke: The EXCITE randomized clinical trial. JAMA : The Journal of the American
Medical Association, 296(17), 2095-2104.
Wolf, S. L., Winstein, C. J., Miller, J. P., Thompson, P. A., Taub, E., Uswatte, G., et al. (2008).
Retention of upper limb function in stroke survivors who have received constraint-induced
movement therapy: The EXCITE randomised trial. Lancet Neurology, 7(1), 33-40.
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.
World Health Organization. (2001). International Classification of Functioning, Disability and
Health (ICF). Geneva, Switzerland: World Health Organization.
World Health Organization. (2002). Towards a Common Language for Functioning, Disability,
and Health. ICF (Beginner’s Guide). Geneva, Switzerland: World Health Organization.
Retrieved from http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf
Wu, T., & Hallett, M. (2005). A functional MRI study of automatic movements in patients with
parkinson's disease. Brain : A Journal of Neurology, 128(Pt 10), 2250-2259.
Wulf, G., Shea, C., & Park, J. H. (2001). Attention and motor performance: Preferences for and
advantages of an external focus. Research Quarterly for Exercise and Sport, 72(4), 335-344.
Zhan, S., & Ottenbacher, K. J. (2001). Single subject research designs for disability research.
Disability and Rehabilitation, 23(1), 1-8.
Zimmerman, B. (2002). Becoming a self-regulated learner: An overview. Theory into Practice,
41(2), 64-70.
Zinn, S., Bosworth, H. B., Hoenig, H. M., & Swartzwelder, H. S. (2007). Executive function
deficits in acute stroke. Archives of Physical Medicine and Rehabilitation, 88(2), 173-180.
145
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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
Graduate Department of Rehabilitation Science
University of Toronto
416-946-7130
Email: [email protected]
Helene Polatajko, PhD, OT (Reg. Ont.)
Professor and Chair
Department of Occupational Science and Occupational Therapy
Graduate Department of Rehabilitation Science
University of Toronto
416-978-5936
Email: [email protected]
Maria Huijbregts, PhD, PT
Coordinator Evaluation and Outcome
Physiotherapy Department
Baycrest
Tel: 416 785 2500 ext.2677
Email: [email protected]
Jennifer Ryan, PhD
Rotman Research Institute
Baycrest
Tel: 416-785-2500 ext. 3550
Email: [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
Graduate Department of Rehabilitation Science
University of Toronto
416-946-7130
Email: [email protected]
Helene Polatajko, PhD, OT (Reg. Ont.)
Professor and Chair
Department of Occupational Science and Occupational Therapy
Graduate Department of Rehabilitation Science
University of Toronto
416-978-5936
Email: [email protected]
Maria Huijbregts, PhD, PT
Coordinator Evaluation and Outcome
Physiotherapy Department
Baycrest
Tel: 416 785 2500 ext.2677
Email: [email protected]
Jennifer Ryan, PhD
Rotman Research Institute
Baycrest
Tel: 416-785-2500 ext. 3550
Email: [email protected]
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 3, approximately one hour long.
tbd Treatment session 4, approximately one hour long.
tbd Treatment session 5, approximately one hour long.
tbd Treatment session 6, approximately one hour long.
tbd Treatment session 7, approximately one hour long.
tbd Treatment session 8, approximately one hour long.
tbd Treatment session 9, 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.
Combination of questionnaires and physical tasks.
tbd One month follow-up (2) , approximately one and a half hours long.
Combination of questionnaires and physical tasks.
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)
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 deviations
from proper formation.
P2 Operational Definitions for PQRS Ratings
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
4 Open book sits on top of right hand (right
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.
8 Right hand grasps and stabilizes open book
while left hand is turning pages.
10 Right hand grasps and stabilizes open book
while left hand is turning pages. Right hand
closes the book.
P3 Operational Definitions for PQRS Ratings
Participant Goal PQRS
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
4 Holds the clippers in the right
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
6 Holds the clippers in the right
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.
P5 Operational Definitions for PQRS Ratings
Participant Goal PQRS
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
deviations from proper formation.
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
deviations from proper formation.
Participant Goal PQRS Score Description
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.
6 Buttoned in 15s-30s.
8 Buttoned in 5s-15s.
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.
Participant Goal PQRS Score Description
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
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
4 Open book sits on top of right hand (right
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.
8 Right hand grasps and stabilizes open book
while left hand is turning pages.
10 Right hand grasps and stabilizes open book
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.
6. 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. 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.
7. In the past 2 weeks, how difficult
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.
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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.
175
`
176
`
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).
SID_______ Name __________________ Date _________ Visit _______ Examiner _________
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:
1. “I used the unaffected arm entirely.” (assign “0”).
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).
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SID_______ Name __________________ Date _________ Visit _______ Examiner _________
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:
1. “I used the unaffected arm entirely.” (assign “0”).
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).
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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
Lag Autocorrelation Std. Errora
Box-Ljung Statistic
Value df Sig.b
1 -.167 .365 .208 1 .648
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
P1 bike autocorrelations could not be calculated, value was constant (3)
Autocorrelations
Series: P2 Mouse
Lag Autocorrelation Std. Errora
Box-Ljung Statistic
Value df Sig.b
1 -.667 .365 3.333 1 .068
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
Autocorrelations
Series:P2 Read
Lag Autocorrelation Std. Errora
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
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
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Autocorrelations
Series:P2 Stairs
Lag Autocorrelation Std. Errora
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
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
Autocorrelations
Series:P3 Nails
Lag Autocorrelation Std. Errora
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
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
Autocorrelations
Series:P3 Yoga
Lag Autocorrelation Std. Errora
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
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
Autocorrelations
Series:P3 Walk
Lag Autocorrelation Std. Errora
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
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
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Autocorrelations
Series:Photo_Baseline1
Lag Autocorrelation Std. Errora
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
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
Autocorrelations
Series:Sewing_TotalBaseline
Lag Autocorrelation Std. Errora
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
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
Autocorrelations
Series:Cutting_TotalBaseline
Lag Autocorrelation Std. Errora
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
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
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Autocorrelations
Series:Writing_TotalBaseline
Lag Autocorrelation Std. Errora
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
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
Autocorrelations
Series:GardenBaseline1
Lag Autocorrelation Std. Errora
Box-Ljung Statistic
Value df Sig.b
1 -.417 .354 1.389 1 .239
2 -.167 .289 1.722 2 .423
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
Autocorrelations
Series:Button_B
Lag Autocorrelation Std. Errora
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
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
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Autocorrelations
Series:Carry_TotalBaseline
Lag Autocorrelation Std. Errora
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
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
Autocorrelations
Series:Tie_TotalBaseline
Lag Autocorrelation Std. Errora
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
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
Autocorrelations
Series:Walk_Baseline1
Lag Autocorrelation Std. Errora
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
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
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Autocorrelations
Series:Jacket_TotalBaseline
Lag Autocorrelation Std. Errora
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
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
Autocorrelations
Series:Transfer_TotalBaseline
Lag Autocorrelation Std. Errora
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
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
Autocorrelations
Series:Book_TotalBaseline
Lag Autocorrelation Std. Errora
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
a. The underlying process assumed is independence (white noise).
b. Based on the asymptotic chi-square approximation.
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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)