Cognitive Approach to Improving Participation After Stroke: Two Case Studies

Erin Henshaw; Helen Polatajko; Sara McEwen; Jennifer D. Ryan; Carolyn M. Baum

doi:10.5014/ajot.2011.09010

Abstract

Despite the need for occupational therapy to emphasize client-specific occupational performance, primary emphasis in stroke rehabilitation continues to be on the remediation of client factors and self-care. Such practice leaves many survivors of stroke with continuing performance deficits. Two case studies demonstrate a novel, alternative approach. The Cognitive Orientation to Daily Occupational Performance (CO–OP) treatment is a performance-based, problem-solving approach to developing functional skills that are client centered. CO–OP was used to guide treatment with 2 older women. The findings suggest that the approach has the potential to successfully help clients with stroke achieve their everyday occupational goals and support continued research in this area. This work will lead to a pilot randomized controlled trial.

Stroke is a debilitating cardiovascular disease and a leading cause of long-term disability in industrialized society. Nearly 800,000 people in the United States suffer a stroke each year (American Stroke Association, 2007). Stroke has a major impact on functional recovery: A large percentage of stroke survivors have significant disabilities and limited participation 6 mo after stroke (Kelly-Hayes et al., 2003).

Evidence-based guidelines for current best practice in stroke intervention are limited. Latham and colleagues (2006) suggested that U.S. guidelines for poststroke rehabilitation are outdated compared with those of other countries, pointing to the most recent update of the National Clinical Guidelines for Stroke published in the United Kingdom (Royal College of Physicians, 2004), which advocates the use of task-specific training over remedial, impairment-driven approaches. A recent meta-analysis of stroke intervention (Trombly & Ma, 2002) supported this direction.

The purpose of the study reported in this article was to investigate the use of a task-specific training program, Cognitive Orientation to Daily Occupational Performance (CO–OP), with adults after stroke. CO–OP is an individualized “client-centered, performance-based, problem-solving approach that enables skill acquisition through a process of guided discovery and strategy use” (Polatajko & Mandich, 2004, p. 2). CO–OP focuses on the strategy use to support the acquisition, generalization, and transfer of three client-chosen skills (Polatajko & Mandich, 2004). Applied over 12 one-hour, one-to-one sessions, CO–OP starts with the client being taught a global problem-solving strategy, “Goal–Plan–Do–Check,” which is used throughout the intervention as a framework to support the acquisition of the chosen skills. In addition, the therapist guides the discovery of domain-specific strategies (e.g., altering body position and modifying the task) necessary to support performance. Underpinning the identification of strategies is a process referred to as dynamic performance analysis (DPA), which is used iteratively to identify the specific performance problems requiring strategies.

CO–OP is based on contemporary theories of learning, including cognitive, behavioral, and cognitive–behavioral paradigms (Polatajko & Mandich, 2004). Originally developed for children with developmental coordination disorder (DCD), the effectiveness of CO–OP has been demonstrated with children with DCD in a series of studies (Polatajko, Mandich, Miller, & Macnab, 2001). More recently, support has been found for its use with other populations, including children and adults with acquired brain injury (Dawson et al., 2009; Missiuna, Mandich, Dematteo, Law, & Hanna, 2006). These findings provide support for CO–OP’s potential utility in treating disorders with more diverse performance deficits, such as stroke. Accordingly, we determined to undertake an investigation of CO–OP as a potential treatment protocol for adults with stroke. A multiphase approach was adopted, starting with two exploratory case studies (reported here), two series of single-case experimental designs (McEwen, Polatajko, Huijbregts, & Ryan, 2009, 2010), and the groundwork for a pilot, two-group randomized controlled trial (RCT) to investigate its potential merit relative to the contemporary approach (Polatajko, McEwen, Ryan, & Baum, 2010). The two case studies presented here provide an in-depth description of the use of CO–OP with older adults with stroke. The specific aim was to inform future research by providing a rich description of the process and outcomes, including participant perspectives on the experience.

Method

Study Design

As part of the initial investigations of the usefulness of CO–OP in stroke rehabilitation, two in-depth case studies were undertaken to describe the process and outcome of CO–OP and to determine whether replication is possible. In both case studies, preliminary measures were administered in three initial encounters, followed by 10 CO–OP sessions and immediate follow-up testing. The data from the case studies were supplemented by field notes and a posttest interview to capture participants’ perspectives.

Participants

Participants were recruited through the Cognitive Rehabilitation Research Group at Washington University in St. Louis from the Stroke Management and Rehabilitation Team service at Barnes–Jewish Hospital in St. Louis, MO. Informed, written consent was obtained from all participants. Data collected during the hospital stay included demographics, comorbidities, stroke severity, and neuropsychological data.

Inclusion criteria were as follows: (1) mild to moderate stroke (≤13 on the acute National Institutes of Health Stroke Scale [NIHSS; Brott et al., 1989 ]); (2) ≥40 years old; (3) 6–18 mo poststroke; (4) English speaking; (5) informed consent; and (6) three client-identified, functional goals to address in treatment.

Exclusion criteria were as follows: (1) severe mental illness with the exception of depression, (2) global aphasia in the acute setting, (3) severe language impairment, (4) evidence of dementia at study intake (Short Blessed Test >10 [Katzman et al., 1983 ] or an established diagnosis in the medical record), (5) evidence of visual or tactile neglect at study intake, (6) severe impairment in general intellectual functioning (Wechsler Adult Intelligence Scale Full Scale IQ ≤ 70 [Wechsler, 1997a ]), (7) concurrent neurological diagnoses, (8) current drug or alcohol abuse, and (9) currently receiving rehabilitation or participating in other studies.

Measures

Measures were chosen to serve several purposes: sample description, evaluation before and after intervention, and response tracking. (A table summarizing the measures used in the study is available online at www.ajot.ajotpress.net; navigate to this article, and click on “supplemental materials.”) Descriptive measures were administered at the outset only; the response tracking measure and the preintervention–postintervention measures were administered as the names imply—throughout intervention and before and after intervention, respectively. Descriptive and pre–post measures were administered by an independent tester. In addition, the first author (Erin Henshaw) kept field notes and conducted postintervention interviews to record participant experiences.

Procedure

Initial Sessions.

Each participant participated in three sessions before the first treatment. The first two sessions, lasting 2 hr each and conducted by a third-party tester, were used to obtain informed consent and administer the descriptive and pretest measures. The third session, conducted by the treating therapist (Henshaw), consisted of functional goal setting using the Canadian Occupational Performance Measure (COPM; Law et al., 1998). In this interview, participants identified performance problems in the areas of self-care, productivity, and leisure and ranked their importance.

Treatment Sessions.

All treatment sessions were conducted by Erin Henshaw, who was supervised by a licensed occupational therapist. Sessions were conducted at the Washington University School of Medicine in sites chosen to fit specific activity needs, as modeled after the methods of Polatajko and Mandich (2004) . Treatment sessions were videotaped for review for compliance by an originator of CO–OP (Polatajko). The first session began with a baseline assessment of the participant’s chosen goals using the Performance Quality Rating Scale (PQRS; Martini, 1994; Miller, Polatajko, Missiuna, Mandich, & Macnab, 2001). The participant was introduced to the CO–OP approach and the global problem-solving strategy Goal–Plan–Do–Check. The subsequent treatment sessions used the global strategy to enable the participant to achieve the three chosen goals, usually addressing two goals per session. During these sessions, the therapist conducted a DPA to determine points of performance breakdown and guided the discovery of domain-specific strategies to support skill acquisition. PQRS scores were recorded at each session to track the participant’s goal performance throughout. Detailed field notes documented the intervention proceedings.

Posttesting.

After treatment, the pretest measures were readministered by a third-party rater. The COPM, PQRS, and a postintervention interview were administered by the treating therapist (Henshaw).

Therapist Training.

The treating therapist (Henshaw) was trained to administer CO-OP by Polatajko, an originator of the approach. After attending a CO–OP workshop given by Polatajko, Henshaw practiced the approach with volunteer participants to gain experience. These practice sessions were supervised by Polatajko, and once she deemed that Henshaw was competent with the approach, the first case study was initiated.

Data Analysis

The exploratory nature of this study warranted the use of only descriptive and qualitative analyses. Pre- and postintervention scores were examined to describe the impact of CO–OP intervention. Change in pre- and postintervention scores and participant-reported improvements were considered in exploring clinical significance. PQRS scores were graphed for each participant to examine observed changes in performance. Field notes, along with the semistructured interviews and videotaped data, served as resources to provide direct and detailed information about participant behaviors, environmental contexts, and perspectives (Bogdan & Biklen, 1998; Llewellyn, 1996). A content analysis was conducted to determine themes regarding the participant’s experience and strategy use across treatment.

Findings

The two cases, although quite different in specifics, proved to be similar in process and outcomes: Both participants were able to identify goals, learn the global strategy, and develop domain-specific strategies with guidance, and both showed improvement in their chosen skills and some outcome measures. Because of the similarities, and in the interest of space constraints, only the first case is discussed in full here; for the second case, only differences are highlighted.

Case 1: Ms. A

Ms. A, a 75-yr-old African-American woman, lived alone in a senior housing complex.

History.

In April 2006, she was hospitalized with symptoms of left hemiparesis and left facial droop. She was diagnosed as having a right middle cerebral artery ischemic stroke of moderate severity (rating on the NIHSS = 10). She had no functional limitations before her stroke, and although she had retired from being a seamstress, she was working part time as a cashier. She had 11 yr of schooling. At the time of the study, Ms. A was 10 mo poststroke and had completed all of her rehabilitation. She presented with upper-limb ataxia, mild dysarthria, mild language difficulty, executive function problems, and decreased mobility (using a cane for ambulation). Performance on the neuropsychological tests is reported in Table 1. Issues considered in planning treatment were her IQ, deficits in attention, executive ability, and memory.

Table 1.

Neuropsychological Profiles for Case A and Case B

		Ms. A	Ms. B
Test and Construct	Measure	Standard Score	Standard Score
Wechsler Abbreviated Scale of Intelligence
General intellectual ability	Full-Scale IQ	86	82
Language	Vocabulary	82	88
Executive ability	Matrix Reasoning	92	76
Wechsler Memory Scales–III
Working memory	Digit Span	80	80
Working memory	Spatial Span	85	80
Delis–Kaplan Executive Function System Trailmaking Test
Attention	Visual Scanning	95	55^a
Executive ability	Number Sequencing	55^a	55^a
Executive ability	Letter Sequencing	85	55^a
Executive ability	Number–Letter Switching	80	55^a
Motor	Motor Speed	115	55^a
Color–Word Interference
Language	Color Naming	105	55^a
Language	Word Reading	85	55^a
Executive ability	Inhibition	90	60^a
Executive ability	Inhibition-Switching	65^a	75
Verbal Fluency
Executive ability	Letter Fluency	65^a	85
Executive ability	Category Fluency	60^a	55^a
Sorting
Executive ability	Free Sorting	70^a	70^a
Executive ability	Correct Sorts	65^a	65^a
California Verbal Learning Test (2nd ed.)
Immediate recall	Immediate Recall	45^a	58^a
Short-term recall	Short-Delay Free Recall	77	55^a
Short-term recall	Short-Delay Cued Recall	62^a	62^a
Long-term recall	Long-Delay Free Recall	70^a	47^a
Long-term recall	Long-Delay Cued Recall	62^a	55^a
Long-term recall	Long-Delay Yes/No Recognition	70^a	47^a

aTwo standard deviations below the mean.

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Table 1.

Neuropsychological Profiles for Case A and Case B

		Ms. A	Ms. B
Test and Construct	Measure	Standard Score	Standard Score
Wechsler Abbreviated Scale of Intelligence
General intellectual ability	Full-Scale IQ	86	82
Language	Vocabulary	82	88
Executive ability	Matrix Reasoning	92	76
Wechsler Memory Scales–III
Working memory	Digit Span	80	80
Working memory	Spatial Span	85	80
Delis–Kaplan Executive Function System Trailmaking Test
Attention	Visual Scanning	95	55^a
Executive ability	Number Sequencing	55^a	55^a
Executive ability	Letter Sequencing	85	55^a
Executive ability	Number–Letter Switching	80	55^a
Motor	Motor Speed	115	55^a
Color–Word Interference
Language	Color Naming	105	55^a
Language	Word Reading	85	55^a
Executive ability	Inhibition	90	60^a
Executive ability	Inhibition-Switching	65^a	75
Verbal Fluency
Executive ability	Letter Fluency	65^a	85
Executive ability	Category Fluency	60^a	55^a
Sorting
Executive ability	Free Sorting	70^a	70^a
Executive ability	Correct Sorts	65^a	65^a
California Verbal Learning Test (2nd ed.)
Immediate recall	Immediate Recall	45^a	58^a
Short-term recall	Short-Delay Free Recall	77	55^a
Short-term recall	Short-Delay Cued Recall	62^a	62^a
Long-term recall	Long-Delay Free Recall	70^a	47^a
Long-term recall	Long-Delay Cued Recall	62^a	55^a
Long-term recall	Long-Delay Yes/No Recognition	70^a	47^a

aTwo standard deviations below the mean.

Goal Acquisition.

The COPM enabled Ms. A to establish three goals for intervention: (1) alter pants with a sewing machine, (2) put on earrings, and (3) put on a bracelet. She strongly identified with sewing because she had been a seamstress for 38 yr and had sewn for her family and friends her entire life. To address this goal, Ms. A brought in her sewing machine, sewing supplies, and several pairs of pants that required alteration. The DPA revealed difficulty setting up the spool of thread, threading the needle, ripping out previous seams, and sewing a straight hem. Examples of domain-specific strategies identified by Ms. A during the treatment of this and the other two goals she selected are presented in Table 2, which also provides examples of the guided discovery process that supported strategy identification.

Table 2.

Examples of Goals, Strategies, Guided Discovery, and Outcomes

Case	Goal	Self-Generated Strategies Supported by Guided Discovery
Ms. A.	Altering pants with sewing machine	Use lamp to increase task lighting. Place lamp in front of sewing machine. Check to see that glasses are on. Sit on pillow to increase height in chair. Use needle-threading device. Start from the front side when ripping out the seam. Use sharp scissors as backup plan to seam ripper. Clear off the table to provide more space to work. Place pants on table instead of lap.
	Putting on earrings	Feel the tension of the fabric. Feel for the hole. Apply pressure to front of earring to prevent slippage. Use mirror to check performance.
	Putting on a bracelet	Take a break when frustrated. Wear bracelet on left hand instead of right hand as backup plan. Use magnetic clasp.
Goal and Strategy	Example of Guided Discovery
Ms. A: Altering pants with sewing machine—use lamp to increase task lighting	Client: “I really can’t see this needle that I’m trying to thread—it’s just too small, and there’s not enough light.” Therapist: “What might be a way to increase the amount of light that you have?” Client: “Well my sewing machine used to have a light bulb at the top that I could just turn on and off, but I don’t know what happened to it.” Therapist: “Well if you used to use a light bulb to give you light, what might you do now, since you no longer have a light bulb?” Client: “Well I guess I’ll need a lamp to put right next to the machine.”
		Canadian Occupational Performance Measure Score
		Performance		Satisfaction
Case	Goal	Pre	Post	Pre	Post
Ms. A	Altering pants	6	8	4	7
	Putting on earrings	3	7	3	8
	Putting on bracelet	3	7	2	7
Ms. B	Making earrings	6	9	5	8
	Improving signature	6	8	6	8
	Remembering during cooking	7	8	6	8

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Table 2.

Examples of Goals, Strategies, Guided Discovery, and Outcomes

Case	Goal	Self-Generated Strategies Supported by Guided Discovery
Ms. A.	Altering pants with sewing machine	Use lamp to increase task lighting. Place lamp in front of sewing machine. Check to see that glasses are on. Sit on pillow to increase height in chair. Use needle-threading device. Start from the front side when ripping out the seam. Use sharp scissors as backup plan to seam ripper. Clear off the table to provide more space to work. Place pants on table instead of lap.
	Putting on earrings	Feel the tension of the fabric. Feel for the hole. Apply pressure to front of earring to prevent slippage. Use mirror to check performance.
	Putting on a bracelet	Take a break when frustrated. Wear bracelet on left hand instead of right hand as backup plan. Use magnetic clasp.
Goal and Strategy	Example of Guided Discovery
Ms. A: Altering pants with sewing machine—use lamp to increase task lighting	Client: “I really can’t see this needle that I’m trying to thread—it’s just too small, and there’s not enough light.” Therapist: “What might be a way to increase the amount of light that you have?” Client: “Well my sewing machine used to have a light bulb at the top that I could just turn on and off, but I don’t know what happened to it.” Therapist: “Well if you used to use a light bulb to give you light, what might you do now, since you no longer have a light bulb?” Client: “Well I guess I’ll need a lamp to put right next to the machine.”
		Canadian Occupational Performance Measure Score
		Performance		Satisfaction
Case	Goal	Pre	Post	Pre	Post
Ms. A	Altering pants	6	8	4	7
	Putting on earrings	3	7	3	8
	Putting on bracelet	3	7	2	7
Ms. B	Making earrings	6	9	5	8
	Improving signature	6	8	6	8
	Remembering during cooking	7	8	6	8

Ms. A’s second goal was being able to put on earrings. To address this goal, she brought a pair of earrings to the treatment sessions. DPA revealed subtle performance; breakdowns, including excess time to complete the task, difficulty finding the hole, fingers slipping off the earrings, and uncertainty as to whether earrings were fully in place.

Ms. A’s third goal was to be able to put on her bracelet. To address this goal, she brought in a bracelet from home that had been particularly difficult to wear. The DPA revealed performance breakdowns in pushing back the lever and holding it open, positioning the bracelet around her wrist while keeping the lever open, and excess time.

PQRS scores for Ms. A’s three goals are presented in Figure 1A. As can be seen, for the first goal, during the course of the intervention the PQRS scores went from 4 (because she was capable of doing part of the task) to 9 (because she demonstrated the ability to transfer strategies from lightweight to heavy denim). Identification of strategies led to observable improvements in setting up the spool of thread, threading the needle, ripping the seam, and sewing a straight hem. Performance did not reach a 10 because the line was not consistently straight across the entire hem.

Figure 1.

Performance Quality Rating Scale (PQRS) performance across sessions. (A) Ms. A. (B) Ms. B.

Note. 1 = unable to perform; 10 = optimal performance.

Full Size | Slide (.ppt)

The PQRS scores for her second goal were 7 at the outset, and by the fourth session, she had improved to achieve a 10, being able to perform the activity without therapist feedback. She also transferred strategies to other earrings.

The PQRS scores for the third goal progressed from an initial score of 2 to 10. She eventually demonstrated the ability to attach the magnetic clasp to the bracelet, clasp the two halves together, and then slide it over her right hand. She also was able to transfer this strategy to different bracelets by taking the magnetic clasp on and off.

Pre–Postintervention Performance.

COPM, the primary outcome relating to skill acquisition, showed performance and satisfaction score increases for all three goals (Table 2).

Pre–postintervention findings for all the remaining measures appear in Table 3. A small increase occurred on multiple components of the Activity Card Sort (ACS; Baum & Edwards, 2001). An increase was also noted on the Reintegration to Normal Living index (RNL; Wood-Dauphinee, Opzoomer, Williams, Marchand, & Spitzer 1988) and the FIM™ (Deutsch, Braun, & Granger, 1996), suggesting improvement in participation and self-care. Results for the Stroke Impact Scale (SIS; Duncan, Bode, Min Lai, & Johnson, 2003) were varied; a relatively large improvement was noted for perceived strength, and scores were lower for hand function, emotion, and communication.

Table 3.

Findings Before and After Intervention

	Ms. A		Ms. B
Measure	Pretest	Posttest	Pretest	Posttest
ACS
Total Current Activity	29	30.5	16	16
Current Social	8	6	6.5	6.5
Current Instrumental	8	10.5	3	4.5
Current LD Leisure	12.5	11.5	5	5
Current HD Leisure	0.5	2.5	1.5	0
RNL	41	44	37	37
FIM	122	125	113	122
SIS
Recovery	75	80	50	75
Strength	43.75	62.50	50	56.25
Hand Function	90	75	75	65
Emotion	97.22	91.67	66.67	83.33
Communication	92.86	64.28	71.43	71.42
Activities of daily living	67.50	70	85	82.50
Mobility	75	77.78	63.89	61.11
Social participation	78.13	81.25	56.25	59.38
Memory	75	82.14	67.86	57.14
CES–D	11	11	13	13

Note. ACS = Activity Card Sort; CES–D = Center for Epidemiological Studies Depression Scale; LD = Low Physical Demand; HD = High Physical Demand; RNL = Reintegration to Normal Living, SIS = Stroke Impact Scale.

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Table 3.

Findings Before and After Intervention

	Ms. A		Ms. B
Measure	Pretest	Posttest	Pretest	Posttest
ACS
Total Current Activity	29	30.5	16	16
Current Social	8	6	6.5	6.5
Current Instrumental	8	10.5	3	4.5
Current LD Leisure	12.5	11.5	5	5
Current HD Leisure	0.5	2.5	1.5	0
RNL	41	44	37	37
FIM	122	125	113	122
SIS
Recovery	75	80	50	75
Strength	43.75	62.50	50	56.25
Hand Function	90	75	75	65
Emotion	97.22	91.67	66.67	83.33
Communication	92.86	64.28	71.43	71.42
Activities of daily living	67.50	70	85	82.50
Mobility	75	77.78	63.89	61.11
Social participation	78.13	81.25	56.25	59.38
Memory	75	82.14	67.86	57.14
CES–D	11	11	13	13

Note. ACS = Activity Card Sort; CES–D = Center for Epidemiological Studies Depression Scale; LD = Low Physical Demand; HD = High Physical Demand; RNL = Reintegration to Normal Living, SIS = Stroke Impact Scale.

Case 2: Ms. B

Ms. B, a 65-yr-old African-American woman, lived with her husband in a suburban neighborhood.

History.

In February 2006, she arrived at the hospital with symptoms of disorientation, generalized weakness, and indicators for aphasia. Ms. B was diagnosed as having a left ischemic stroke of moderate severity (NIHSS score = 9) and was discharged to an inpatient rehabilitation facility. She later received and completed outpatient therapy. Before the stroke, Ms. B was independent. She had 12 yr of education and was retired. At the start of the study, she was 13 mo poststroke and presented with a right visual field cut and abnormal gaze, moderate cognitive impairment, self-reported executive symptoms, and intermittent numbness and tingling (Table 2 includes her neuropsychological test results). She walked without the use of an assistive device.

Goal Acquisition.

Ms. B identified three goals: (1) making earrings, (2) improving her signature, and (3) remembering what she is doing when cooking. DPA revealed initial performance breakdowns in task initiation, problems with sequencing, difficulty locating particular materials in the containers, perseveration when choosing materials, difficulty picking up small items because of abnormal sensation, problems matching the earrings, and excess time to complete the task. As with Ms. A, Ms. B was able to develop domain-specific strategies and use them to support skill acquisition across the sessions (see Figure 1B for PQRS scores).

Preintervention–Postintervention Performance.

Preintervention–postintervention findings for the COPM are presented in Table 2. Performance and satisfaction scores increased from pre- to postintervention for each goal, although the third goal yielded a posttest score that was lower than the others.

Findings for the other measures are presented in Table 3. Where improvements were noted, they tended to be of varying amounts with clinical significance debatable. Scores that showed decreases at posttest included current high-demand leisure activity on the ACS Form C (Baum, 1995; Baum & Edwards, 2001) and four domains of the SIS (hand function, mobility, activities of daily living, and memory).

Perspectives on CO–OP.

The analysis of the semistructured interviews, together with field notes and videotaped data, revealed several considerations in implementing the CO–OP approach.

1.Impact of a motivating goal: Ms. A’s statements demonstrated that with increased motivation, she was more willing to problem solve, more persistent in the face of challenges, and less frustrated with performance.
2.Customized guidance, structure, and support: Both Ms. A and Ms. B required guidance and support for problem solving and self-identification of strategies. Discovery of strategies was more difficult when the therapist took a subtle approach with less direct questioning and less involvement. Ms. B needed structure and support from the therapist throughout the treatment to maximize success.
3.Resistance to a new approach: Ms. A suggested that CO–OP was very different from the traditional therapies she received after the stroke. She made frequent comments about wanting to be told how to fix the underlying deficits and performance problems she was experiencing.
4.Impact of rapport: Efforts aimed at building rapport had a positive impact on both women’s willingness to participate in a novel treatment.
5.Social support: Both women sought opportunities for social interaction during the course of treatment and responded positively to the interpersonal components of the approach.

Discussion

The case studies describe the application of CO–OP with two older adults with stroke who presented with cognitive impairments in addition to other conditions. Both women improved in their self-selected goals, as rated by themselves and the treating therapist. Their changes in pre- and postintervention measures included both increases and decreases. Semistructured interview findings revealed attitudes that should be considered when implementing the CO–OP treatment approach in adults with stroke. In the following paragraphs, we elaborate on these findings in the context of the people studied.

A change of two points or more on the COPM is considered clinically meaningful (Law et al., 1998). Ms. A reported clinically meaningful improvements for all goals on both performance and performance satisfaction; Ms. B reported clinically meaningful improvements on performance of all goals except for memory during cooking and performance satisfaction with all three goals. Changes in PQRS scores similarly revealed improvements in goal performance from the therapist’s viewpoint. These findings lend support to earlier research with other populations suggesting that CO–OP may improve performance on client-chosen goals (Dawson et al., 2009; Missiuna et al., 2006; Polatajko et al., 2001).

Both participants reported some improvements on the SIS. Duncan and colleagues (1999) wrote that changes of 10–15 points in an SIS domain are clinically meaningful. Using that criterion, Ms. A reported meaningful improvements in strength, and Ms. B reported meaningful improvements in recovery and emotion. Regarding strength, involvement in functional treatment activities enabled participants to engage in new body movements and positions and may have resulted in the perception of being stronger or more conditioned. Considering the emotion domain, changes may be related to the highly interpersonal nature of the CO–OP approach. Further research is needed to confirm these observations.

For both participants, some measures did not improve after CO–OP. One explanation for this lack of increase is the amount of time between pre- and posttesting. Intervention lasted 4–5 wk for each participant, and posttesting occurred immediately after intervention. Participants may not have had sufficient time to fully process their learning. Further research is needed to explore why some of the scores decreased at posttest, particularly any activity and participation scores, because such decreases are inconsistent with expectations. It is possible that participants were more aware of their deficits at posttest, resulting in lower scores on certain domains of self-report measures (e.g., Ms. B reported decreased memory on the SIS).

Ms. B’s goal of remembering during cooking improved less markedly than the other five goals. It differed from the other goals in that it was open-ended: Each cooking task could be approached in multiple ways, and the participant cooked different items at each session. It may have been difficult to practice this goal in a novel kitchen with distractions. Given the participant’s cognitive limitations—specifically, deficits in attention, executive ability, and memory—the combination of factors may have made this goal more challenging. Alternatively, because Ms. B was never seen to spontaneously implement the strategy of writing things down, it may be that this strategy was not the correct one for her and a substitute should have been sought. This difficulty with using her chosen strategy may be an additional factor affecting the outcome of the cooking goal. When the participant was performing other goals, she referred to a list of plans to support her memory of strategies. Once the plans were written down, the list was always there to cue her strategy use. By contrast, the cooking goal required her to remember to write down different plans each time, because the meal items were different at each session.

The improvements in these two cases in just 10 treatment sessions is promising, because both participants demonstrated impaired attention, memory, and executive function at pretest and the cognitive strategies used in CO–OP rely on some or all of those cognitive processes at times. A review of cognitive rehabilitation after brain injury reported substantial evidence to support strategy training in mild memory impairment and attention deficits. The same review, however, stated that most interventions directed treatment and evaluated outcomes at the impairment level and that there is a “persistent need” to evaluate the effects of interventions on “relevant, functional, outcomes” (Cicerone et al., 2005, p. 1689). The CO–OP approach is directed specifically at relevant, functional outcomes, and the intervention was associated with performance improvements in functional outcomes in the two cases presented here. The improvements in the two cases encourage us to move forward to a larger pilot study to determine feasibility for an RCT.

Limitations

Limitations of the current research include the case study design, because it does not allow for the determination of causality or the generalization of results to a wider population. During the time of preparation of this article, a pilot RCT was underway at the Washington University School of Medicine to address those issues. Another limitation was the use of PQRS scores rated by the treating therapist rather than by an objective third party. Finally, the maintenance of treatment effects is unknown, because of the lack of long-term follow-up testing, which was beyond the scope of this project, part of a student’s clinical doctoral work.

Future Directions

Future research should examine the impact of caregiver and family involvement on the CO–OP process, specifically the long-term generalization and transfer of skills to the home environment. Ms. A lived alone and did not have a significant other or close friend to participate. Ms. B lived with her husband, but he was not willing to be involved. Significant other participation may be especially important for people with cognitive impairment who, like Ms. B, require extra structure and support to succeed. Future studies may also explore the use of CO–OP with broader patterns of stroke deficits and syndromes. The patients in our study had mild to moderate strokes, leaving us with little information on the ability of more severely impaired patients to learn and retain strategies, problem solve, and participate in a highly verbal approach.

Instrumentation for future studies should continue to include measures of occupational performance and participation to further explore the impact of CO–OP intervention. In addition, it may be interesting to explore the impact of CO–OP on measures of executive functioning, given the emphasis in CO–OP on training of a higher-order, executive strategy for organizing behavior and solving performance issues. Although CO–OP is not designed to remediate component skills, it may be useful to consider whether an interaction effect takes place at the same time skills are being learned.

In conclusion, several implications might be drawn from this study to inform occupational therapy practice. CO–OP is potentially an effective approach to skill development in adults after stroke; in other words, it is a possible alternative for shifting the focus of rehabilitation from addressing impairments to improving the skills of everyday life. Motivating goals, customized guided discovery, and structure and support may be important for adapting the CO–OP approach for use with the stroke population. Our next step is to apply for funding to test CO–OP in a larger sample of people with stroke.

Acknowledgments

This work was partially funded by the James S. McDonnell Foundation, the Canada Social Sciences and Research Council and the Canada Research Chairs Program. It was conducted with the support of a research team including Rebecca Birkenmeier, Kathleen Rummel, Tim Wolf, and Alexis Young.

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Table 1.

Neuropsychological Profiles for Case A and Case B

		Ms. A	Ms. B
Test and Construct	Measure	Standard Score	Standard Score
Wechsler Abbreviated Scale of Intelligence
General intellectual ability	Full-Scale IQ	86	82
Language	Vocabulary	82	88
Executive ability	Matrix Reasoning	92	76
Wechsler Memory Scales–III
Working memory	Digit Span	80	80
Working memory	Spatial Span	85	80
Delis–Kaplan Executive Function System Trailmaking Test
Attention	Visual Scanning	95	55^a
Executive ability	Number Sequencing	55^a	55^a
Executive ability	Letter Sequencing	85	55^a
Executive ability	Number–Letter Switching	80	55^a
Motor	Motor Speed	115	55^a
Color–Word Interference
Language	Color Naming	105	55^a
Language	Word Reading	85	55^a
Executive ability	Inhibition	90	60^a
Executive ability	Inhibition-Switching	65^a	75
Verbal Fluency
Executive ability	Letter Fluency	65^a	85
Executive ability	Category Fluency	60^a	55^a
Sorting
Executive ability	Free Sorting	70^a	70^a
Executive ability	Correct Sorts	65^a	65^a
California Verbal Learning Test (2nd ed.)
Immediate recall	Immediate Recall	45^a	58^a
Short-term recall	Short-Delay Free Recall	77	55^a
Short-term recall	Short-Delay Cued Recall	62^a	62^a
Long-term recall	Long-Delay Free Recall	70^a	47^a
Long-term recall	Long-Delay Cued Recall	62^a	55^a
Long-term recall	Long-Delay Yes/No Recognition	70^a	47^a

aTwo standard deviations below the mean.

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Table 1.

Neuropsychological Profiles for Case A and Case B

		Ms. A	Ms. B
Test and Construct	Measure	Standard Score	Standard Score
Wechsler Abbreviated Scale of Intelligence
General intellectual ability	Full-Scale IQ	86	82
Language	Vocabulary	82	88
Executive ability	Matrix Reasoning	92	76
Wechsler Memory Scales–III
Working memory	Digit Span	80	80
Working memory	Spatial Span	85	80
Delis–Kaplan Executive Function System Trailmaking Test
Attention	Visual Scanning	95	55^a
Executive ability	Number Sequencing	55^a	55^a
Executive ability	Letter Sequencing	85	55^a
Executive ability	Number–Letter Switching	80	55^a
Motor	Motor Speed	115	55^a
Color–Word Interference
Language	Color Naming	105	55^a
Language	Word Reading	85	55^a
Executive ability	Inhibition	90	60^a
Executive ability	Inhibition-Switching	65^a	75
Verbal Fluency
Executive ability	Letter Fluency	65^a	85
Executive ability	Category Fluency	60^a	55^a
Sorting
Executive ability	Free Sorting	70^a	70^a
Executive ability	Correct Sorts	65^a	65^a
California Verbal Learning Test (2nd ed.)
Immediate recall	Immediate Recall	45^a	58^a
Short-term recall	Short-Delay Free Recall	77	55^a
Short-term recall	Short-Delay Cued Recall	62^a	62^a
Long-term recall	Long-Delay Free Recall	70^a	47^a
Long-term recall	Long-Delay Cued Recall	62^a	55^a
Long-term recall	Long-Delay Yes/No Recognition	70^a	47^a

aTwo standard deviations below the mean.

Table 2.

Examples of Goals, Strategies, Guided Discovery, and Outcomes

Case	Goal	Self-Generated Strategies Supported by Guided Discovery
Ms. A.	Altering pants with sewing machine	Use lamp to increase task lighting. Place lamp in front of sewing machine. Check to see that glasses are on. Sit on pillow to increase height in chair. Use needle-threading device. Start from the front side when ripping out the seam. Use sharp scissors as backup plan to seam ripper. Clear off the table to provide more space to work. Place pants on table instead of lap.
	Putting on earrings	Feel the tension of the fabric. Feel for the hole. Apply pressure to front of earring to prevent slippage. Use mirror to check performance.
	Putting on a bracelet	Take a break when frustrated. Wear bracelet on left hand instead of right hand as backup plan. Use magnetic clasp.
Goal and Strategy	Example of Guided Discovery
Ms. A: Altering pants with sewing machine—use lamp to increase task lighting	Client: “I really can’t see this needle that I’m trying to thread—it’s just too small, and there’s not enough light.” Therapist: “What might be a way to increase the amount of light that you have?” Client: “Well my sewing machine used to have a light bulb at the top that I could just turn on and off, but I don’t know what happened to it.” Therapist: “Well if you used to use a light bulb to give you light, what might you do now, since you no longer have a light bulb?” Client: “Well I guess I’ll need a lamp to put right next to the machine.”
		Canadian Occupational Performance Measure Score
		Performance		Satisfaction
Case	Goal	Pre	Post	Pre	Post
Ms. A	Altering pants	6	8	4	7
	Putting on earrings	3	7	3	8
	Putting on bracelet	3	7	2	7
Ms. B	Making earrings	6	9	5	8
	Improving signature	6	8	6	8
	Remembering during cooking	7	8	6	8

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Table 2.

Examples of Goals, Strategies, Guided Discovery, and Outcomes

Case	Goal	Self-Generated Strategies Supported by Guided Discovery
Ms. A.	Altering pants with sewing machine	Use lamp to increase task lighting. Place lamp in front of sewing machine. Check to see that glasses are on. Sit on pillow to increase height in chair. Use needle-threading device. Start from the front side when ripping out the seam. Use sharp scissors as backup plan to seam ripper. Clear off the table to provide more space to work. Place pants on table instead of lap.
	Putting on earrings	Feel the tension of the fabric. Feel for the hole. Apply pressure to front of earring to prevent slippage. Use mirror to check performance.
	Putting on a bracelet	Take a break when frustrated. Wear bracelet on left hand instead of right hand as backup plan. Use magnetic clasp.
Goal and Strategy	Example of Guided Discovery
Ms. A: Altering pants with sewing machine—use lamp to increase task lighting	Client: “I really can’t see this needle that I’m trying to thread—it’s just too small, and there’s not enough light.” Therapist: “What might be a way to increase the amount of light that you have?” Client: “Well my sewing machine used to have a light bulb at the top that I could just turn on and off, but I don’t know what happened to it.” Therapist: “Well if you used to use a light bulb to give you light, what might you do now, since you no longer have a light bulb?” Client: “Well I guess I’ll need a lamp to put right next to the machine.”
		Canadian Occupational Performance Measure Score
		Performance		Satisfaction
Case	Goal	Pre	Post	Pre	Post
Ms. A	Altering pants	6	8	4	7
	Putting on earrings	3	7	3	8
	Putting on bracelet	3	7	2	7
Ms. B	Making earrings	6	9	5	8
	Improving signature	6	8	6	8
	Remembering during cooking	7	8	6	8

Table 3.

Findings Before and After Intervention

	Ms. A		Ms. B
Measure	Pretest	Posttest	Pretest	Posttest
ACS
Total Current Activity	29	30.5	16	16
Current Social	8	6	6.5	6.5
Current Instrumental	8	10.5	3	4.5
Current LD Leisure	12.5	11.5	5	5
Current HD Leisure	0.5	2.5	1.5	0
RNL	41	44	37	37
FIM	122	125	113	122
SIS
Recovery	75	80	50	75
Strength	43.75	62.50	50	56.25
Hand Function	90	75	75	65
Emotion	97.22	91.67	66.67	83.33
Communication	92.86	64.28	71.43	71.42
Activities of daily living	67.50	70	85	82.50
Mobility	75	77.78	63.89	61.11
Social participation	78.13	81.25	56.25	59.38
Memory	75	82.14	67.86	57.14
CES–D	11	11	13	13

Note. ACS = Activity Card Sort; CES–D = Center for Epidemiological Studies Depression Scale; LD = Low Physical Demand; HD = High Physical Demand; RNL = Reintegration to Normal Living, SIS = Stroke Impact Scale.

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Table 3.

Findings Before and After Intervention

	Ms. A		Ms. B
Measure	Pretest	Posttest	Pretest	Posttest
ACS
Total Current Activity	29	30.5	16	16
Current Social	8	6	6.5	6.5
Current Instrumental	8	10.5	3	4.5
Current LD Leisure	12.5	11.5	5	5
Current HD Leisure	0.5	2.5	1.5	0
RNL	41	44	37	37
FIM	122	125	113	122
SIS
Recovery	75	80	50	75
Strength	43.75	62.50	50	56.25
Hand Function	90	75	75	65
Emotion	97.22	91.67	66.67	83.33
Communication	92.86	64.28	71.43	71.42
Activities of daily living	67.50	70	85	82.50
Mobility	75	77.78	63.89	61.11
Social participation	78.13	81.25	56.25	59.38
Memory	75	82.14	67.86	57.14
CES–D	11	11	13	13

Note. ACS = Activity Card Sort; CES–D = Center for Epidemiological Studies Depression Scale; LD = Low Physical Demand; HD = High Physical Demand; RNL = Reintegration to Normal Living, SIS = Stroke Impact Scale.