Maria Huijbregts

Counting what counts: A framework for capturing real‐life outcomes of aphasia intervention

Background: The initial motivation was our inability to capture the important but often elusive outcomes of interventions that focus on making a difference to the everyday experience of individuals with aphasia and their families. In addition, a review of the literature and input from stakeholder focus groups revealed the lack of an integrated approach to outcome evaluation across diverse approaches to aphasia intervention. Input from focus groups also indicated that existing classifications and models offering potential solutions are not always easily accessible and user friendly. This research has been generously funded by a grant from the Ontario Ministry of Health and Long Term Care. The views expressed here do not necessarily reflect those of the Ministry. The authors thank staff at the Aphasia Institute and members of the Ontario Aphasia Centres Interest Group for their participation in the project, Drs Audrey Holland and Roberta Elman for useful feedback on earlier drafts of this article, Laura Dickey for administrative support, and Carmela Simone and Meghan Roberts for development of pictographs. Aims: We aimed to create a user‐friendly conceptual framework for outcome measurement in aphasia that included a focus on real‐life outcomes of intervention and could be easily accessed by clinicians, researchers, policy makers, funders, and those living with aphasia. We wanted to build on existing work, e.g., that of the World Health Organisation, simplify presentation for accessibility, and make specific adaptations relevant to aphasia. By providing a common context for a broad range of outcome tools or measures, we hoped to enable more efficient and effective communication between and among all stakeholders. Main contribution: Living with Aphasia: Framework for Outcome Measurement (A‐FROM) is a conceptual guide to outcome assessment in aphasia that is situated within current thinking about health and disability. This simple platform can be used to frame and broaden thinking concerning outcome measurement for aphasia clinicians and researchers while enhancing the potential for meaningful communication between the clinical community, policy makers, and funders. By integrating Quality of Life and including domains related to environment, participation, and personal identity in the same framework as impairment, the importance of outcomes in all these areas is acknowledged for aphasia in particular and disability in general. A‐FROM has the potential to be used as an advocacy tool. Conclusions: This article is the first presentation of A‐FROM as an alternate guide to outcome measurement in aphasia. Initial ideas regarding applications are discussed. Further development and applications await input from our community of practice.

Development of the Chedoke Arm and Hand Activity Inventory: Theoretical Constructs, Item Generation, and Selection

Abstract The Chedoke Arm and Hand Activity Inventory (CAHAI) was developed to address the need for a valid, clinically relevant, responsive functional assessment of the recovering paretic upper limb. The purpose of this article is to describe the development of the measure including its theoretical constructs, item generation, and item selection. From the literature, survivors of stroke, and their caregivers, 751 items were generated. Using factor analyses stem leaf plots, clinical judgment, and pilot testing on individuals with stroke, the list was reduced to 13 bilateral, real-life items. Research continues to provide evidence of the CAHAI’s test-retest and interrater reliability as well as construct, concurrent, and longitudinal validity.

Progressive Resistance Strengthening Exercises After Stroke: A Single-Blind Randomized Controlled Trial

OBJECTIVE To determine the effectiveness of progressive resistance strengthening exercises to improve gross motor function and walking in patients receiving intensive rehabilitation after stroke. DESIGN Randomized controlled trial. SETTING Five inpatient rehabilitation programs affiliated with teaching hospitals. PARTICIPANTS Inclusion criteria included less than 6 months poststroke and recovery of the leg stages 3 to 5 on the Chedoke-McMaster Stroke Assessment (CMSA). INTERVENTIONS Both groups received conventional physical therapy programs. In addition, the experimental group performed 9 lower-extremity progressive resistance exercises 3 times a week for the duration of their stay, whereas the control group did the same exercises and for the same duration but without resistance. MAIN OUTCOME MEASURES The Disability Inventory of the CMSA and the 2-minute walk test (2MWT) at baseline, 4 weeks, discharge, and 6 months after discharge. RESULTS Over the length of stay, the rate of change in the Disability Inventory was.27 points per day in the experimental group and.29 points per day in the control group; the between-group difference was -.02 points per day (95% confidence interval [CI], -.10 to.06; P=.62). At discharge, the rate of change in the 2MWT was -.01 m in the experimental group and.15m in the control group; the between-group difference was -.16 m (95% CI, -.37 to.05; P=.14). CONCLUSIONS Progressive resistance strengthening exercises as applied in our study were not effective when compared with the same exercises given without resistance.

Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis.

OBJECTIVE To update the Evidence-Based Clinical Practice Guidelines (EBCPGs) on aerobic walking programs for the management of osteoarthritis (OA) of the knee. DATA SOURCES A literature search was conducted using the electronic databases MEDLINE, PubMed, and the Cochrane Library for all studies related to aerobic walking programs for OA from 1966 until February 2011. STUDY SELECTION The literature search found 719 potential records, and 10 full-text articles were included according to the selection criteria. The Ottawa Methods Group established the inclusion and exclusion criteria regarding the characteristics of the population, by selecting adults of 40 years old and older who were diagnosed with OA of the knee. DATA EXTRACTION Two reviewers independently extracted important information from each selected study using standardized data extraction forms, such as the interventions, comparisons, outcomes, time period of the effect measured, and study design. The statistical analysis was reported using the Cochrane collaboration methods. An improvement of 15% or more relative to a control group contributes to the achievement of a statistically significant and clinically relevant progress. A specific grading system for recommendations, created by the Ottawa Panel, used a level system (level I for randomized controlled studies and level II for nonrandomized articles). The strength of the evidence of the recommendations was graded using a system with letters: A, B, C+, C, D, D+, or D-. DATA SYNTHESIS Evidence from 7 high-quality studies demonstrated that facility, hospital, and home-based aerobic walking programs with other therapies are effective interventions in the shorter term for the management of patients with OA to improve stiffness, strength, mobility, and endurance. CONCLUSIONS The greatest improvements were found in pain, quality of life, and functional status (grades A, B, or C+). A common limitation inherent to the EBCPGs is the heterogeneity of studies included with regards to the characteristics of the population, the interventions, the comparators, the outcomes, the period of time, and the study design. It is strongly recommended to use the Cochrane Risk of Bias Summary assessment to evaluate the methodologic quality of the studies and to consider avenues for future research on how aerobic walking programs would be beneficial in the management of OA of the hip.

Implementation, Process, and Preliminary Outcome Evaluation of Two Community Programs for Persons with Stroke and Their Care Partners

Abstract Purpose: This evaluation compared a new self-management program with land and water exercise (Moving On after STroke or MOST) to a standard education program (Living with Stroke or LWS). Participants: Of 30 persons with stroke (average age 68 and 2 years post stroke), 18 selected MOST and 12 chose LWS. Sixteen care partners participated. Method: Assessments at baseline, program completion, and 3-month follow-up included the Reintegration to Normal Living (RNL) Index, Activity-specific Balance Confidence (ABC) scale, exercise participation, and goal attainment (for the MOST group). Program delivery costs were calculated and focus groups conducted to examine participant expectations and experiences. Results: Social support was an important benefit of both programs, but only MOST participants improved significantly on the RNL (p < .05) and ABC (p < .001). Seventy-eight percent of all short-term personal goals in MOST were achieved, and overall goal attainment was above the expected level. At follow-up, a higher percentage of MOST participants were enrolled in exercise programs (p < .05). Conclusion: Although self-management programs with exercise are more costly to deliver than standard educational programs, these preliminary results indicate that such programs may be more effective in helping persons with stroke and care partners deal with the challenges of living with stroke.

Cognitive strategy use to enhance motor skill acquisition post-stroke: A critical review

Objective: The objective of this critical review was to examine the literature regarding the use of cognitive strategies to acquire motor skills in people who have had a stroke, to determine which strategies are in use and to compile evidence of their effectiveness. Search terms: A computerized search of a range of databases was conducted using the following search terms: stroke, cerebrovascular accident; combined with strategy training, learning strateg*, cognitive strateg*, metacognitive strateg*, goal setting, goal planning, goal attainment, goal direct*, goal orient*, self talk, imagery, mental practice, self evaluat*, ready*, attentional focus*, problem solv*, goal management; combined with motor, mobility, activit*, skill, task, function, ADL. Results: Twenty-six articles were reviewed. Seven studies investigated general cognitive strategies and 19 investigated task-specific strategies. The most commonly studied task-specific strategy was motor imagery. Findings suggest that general strategy training improves performance in both trained and untrained activities compared to traditional therapy; and that a specific motor imagery protocol can improve mobility and recovery in the affected upper extremity in people living with the chronic effects of stroke. Conclusion: This foundational evidence supports the further development of novel cognitive strategy-based interventions with the intention of improving long-term stroke outcomes.

The implementation of a community-based aerobic walking program for mild to moderate knee osteoarthritis: A knowledge translation randomized controlled trial: Part II: Clinical outcomes

BackgroundOsteoarthritis (OA) is the most common joint disorder in the world, as it is appears to be prevalent among 80% of individuals over the age of 75. Although physical activities such as walking have been scientifically proven to improve physical function and arthritic symptoms, individuals with OA tend to adopt a sedentary lifestyle. There is therefore a need to improve knowledge translation in order to influence individuals to adopt effective self-management interventions, such as an adapted walking program.MethodsA single-blind, randomized control trial was conducted. Subjects (n = 222) were randomized to one of three knowledge translation groups: 1) Walking and Behavioural intervention (WB) (18 males, 57 females) which included the supervised community-based aerobic walking program combined with a behavioural intervention and an educational pamphlet on the benefits of walking; 2) Walking intervention (W) (24 males, 57 females) wherein participants only received the supervised community-based aerobic walking program intervention and the educational pamphlet; 3) Self-directed control (C) (32 males, 52 females) wherein participants only received the educational pamphlet. One-way analyses of variance were used to test for differences in quality of life, adherence, confidence, and clinical outcomes among the study groups at each 3 month assessment during the 12-month intervention period and 6-month follow-up period.ResultsThe clinical and quality of life outcomes improved among participants in each of the three comparative groups. However, there were few statistically significant differences observed for quality of life and clinical outcomes at long-term measurements at 12-months end of intervention and at 6- months post intervention (18-month follow-up). Outcome results varied among the three groups.ConclusionThe three groups were equivalent when determining the effectiveness of knowledge uptake and improvements in quality of life and other clinical outcomes. OA can be managed through the implementation of a proven effective walking program in existing community-based walking clubs.Trial registrationCurrent Controlled Trials IRSCTNO9193542

Exploring a cognitive-based treatment approach to improve motor-based skill performance in chronic stroke: Results of three single case experiments

Primary objective: Early evidence suggests the use of cognitive strategies has potential to improve 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 the Cognitive Orientation to daily Occupational Performance (CO-OP) protocol to improve the 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 for the focus of the CO-OP intervention. Multiple video recorded data points were collected at baseline, during intervention, post-intervention and at 1-month follow-up. Results: The nine goals selected varied widely, e.g. using a computer mouse, bicycling and yoga. An independent observer used the observational Performance Quality Rating Scale (PQRS) to rate performances throughout. Using the 2 SD band method to analyse the data, each participant showed significant performance improvements in at least two goals during the course of the intervention and at follow-up. 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.

Inter-task transfer of meaningful, functional skills following a cognitive-based treatment: Results of three multiple baseline design experiments in adults with chronic stroke

The transfer of skills learned in rehabilitation to new skills in the home has hitherto been notoriously difficult to achieve. The Cognitive Orientation to daily Occupational Performance (CO-OP) treatment approach has been associated with improved performance in people living with stroke, but the specific impact on transfer to untrained skills has not been investigated. The objective of the study was to investigate the capacity of CO-OP treatment to improve performance in both trained and untrained self-selected skills in adults living with stroke. A single case experiment with multiple baselines across skills was conducted, with two replications. The participants self-selected four skills; three were trained using CO-OP; the fourth was not. Using video recording, data points were collected at multiple baselines, during intervention, post-intervention, and at follow-up. 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. At follow-up, significant performance improvements were seen in all three single case experiments in all trained and untrained skills. A cognitive-based approach was associated with improved performance in trained and untrained skills in three adults with chronic stroke; further controlled research is warranted.

The implementation of a community-based aerobic walking program for mild to moderate knee osteoarthritis (OA): a knowledge translation (KT) randomized controlled trial (RCT): Part I: The Uptake of the Ottawa Panel clinical practice guidelines (CPGs)

BackgroundThe implementation of evidence based clinical practice guidelines on self-management interventions to patients with chronic diseases is a complex process. A multifaceted strategy may offer an effective knowledge translation (KT) intervention to promote knowledge uptake and improve adherence in an effective walking program based on the Ottawa Panel Evidence Based Clinical Practice Guidelines among individuals with moderate osteoarthritis (OA).MethodsA single-blind, randomized control trial was conducted. Patients with mild to moderate (OA) of the knee (n=222) were randomized to one of three KT groups: 1) Walking and Behavioural intervention (WB) (18 males, 57 females) which included the supervised community-based aerobic walking program combined with a behavioural intervention and an educational pamphlet on the benefits of walking for OA; 2) Walking intervention (W) (24 males, 57 females) wherein participants only received the supervised community-based aerobic walking program intervention and the educational pamphlet; 3) Self-directed control (C) (32 males, 52 females) wherein participants only received the educational pamphlet. One-way analyses of variance were used to test for differences in quality of life, adherence, confidence, and clinical outcomes among the study groups at each 3 month assessment during the 12-month intervention period and 6-month follow-up period.ResultsShort-term program adherence was greater in WB compared to C (p<0.012) after 3 months. No statistical significance (p> 0.05) was observed for long-term adherence (6 to 12 months), and total adherence between the three groups. The three knowledge translation strategies demonstrated equivalent long-term results for the implementation of a walking program for older individuals with moderate OA. Lower dropout rates as well as higher retention rates were observed for WB at 12 and 18 months.ConclusionThe additional knowledge translation behavioural component facilitated the implementation of clinical practice guidelines on walking over a short-term period. More studies are needed to improve the long-term walking adherence or longer guidelines uptake on walking among participants with OA. Particular attention should be taken into account related to patient’s characteristic and preference. OA can be managed through the implementation of a walking program based on clinical practice guidelines in existing community-based walking clubs as well as at home with the minimal support of an exercise therapist or a trained volunteer.Trial RegistrationCurrent Controlled Trials IRSCTNO9193542