SIGNIFICANCE: Individuals with cognitive impairments after stroke make fewer gains in occupational therapy and display poorer performance in activities of daily living over time. One contributing factor may be the methods used to train individuals with cognitive impairments after stroke. Specifically, therapeutic cues have been shown to influence occupational therapy outcomes. Guided training is composed of cueing that is used to enable a client to discover a strategy or plan to solve a problem. Directed training is a method in which the therapist identifies and solves the problem and instructs the client on how to improve performance. Evidence suggests that guided cues may be more optimal than directed cues for individuals with cognitive impairments after stroke. However, additional study of therapeutic cues is needed in clinical practice.

INNOVATION: Heretofore, the study of the impact of therapeutic cues on occupational therapy outcomes has only been completed in controlled experimental conditions. We set out to study the impact of therapeutic cues in usual occupational therapy sessions. We used a newly validated standardized coding scheme to document the number and types of cues used in inpatient rehabilitation after stroke.

APPROACH: Using a sampling of inpatient rehabilitation sessions, what is the frequency of therapeutic cues applied, and what proportion of applied cues is guided cues? By exploring the type and number of cues used in typical occupational therapy practice, we can begin to examine the impact of systematically altering therapeutic cues in a real-world setting.

METHOD: In this exploratory study, we used a standardized coding scheme to code video-recordings of therapy sessions for 10 participants with cognitive impairments after stroke. The setting occurred in two inpatient rehabilitation facilities. Individuals diagnosed with acute stroke who were admitted to inpatient rehabilitation were recruited for participation. All participants demonstrated cognitive impairments, but they did not demonstrate dementia, severe aphasia, mood disorders, or substance abuse.

The types and number of cues were tallied, and the amount of time for training activities in each session was recorded. We examined the type and number of cues using descriptive statistics. We computed intraclass correlation coefficients (ICCs) to examine interrater reliability.

RESULTS: Ninety-eight percent of cues in inpatient occupational therapy sessions were directed cues. Interrater reliability for the coding scheme was excellent (ICC = .950 for guided cues, and ICC = .995 for directed cues).

CONCLUSION: It is feasible to reliably assess training in inpatient rehabilitation with a standardized coding scheme. Guided cues were applied less frequently than directed cues across participants and activities.