Cognitive orientation to daily occupation group in the adult day rehabilitation setting: A feasibility study

Introduction

Engagement in one’s tasks of everyday life or occupations as a basic human need is a foundational tenet of occupational therapy (Townsend and Polatajko 2013). Occupation in this context has been defined as self-care, productivity, and leisure. Many of those who have sustained acquired brain injuries (ABIs) experience long-term disabilities (Andelic, 2012; DeSilva, 2009). A brain injury that has occurred after birth such as a stroke or traumatic brain injury (TBI) is referred to as an ABI (Hofgren et al., 2010). More than one-third of people following stroke report unsuccessful return to participation in meaningful occupations (Eriksson et al., 2013). Additionally, TBI is the principal cause of disability in people under 35 years of age in the United States (US) (Raymont et al., 2011) resulting in unemployment rates six times higher for those 2 years post-TBI than those without a TBI diagnosis (Cuthbert et al., 2015). Metacognitive strategy training (MST) has emerged as an effective approach to increase participation in clients affected by ABI (Dawson et al., 2017a, 2017b; McEwen et al., 2017).

MST techniques are effective tools for increasing the independence of patients with occupational performance deficits. These approaches have been delivered effectively to adults in a one-on-one structure and in a group structure for pediatric populations. However, day rehabilitation for adults is typically delivered using a group model. While this group model has many advantages, its use also creates unique challenges for occupational therapists attempting to implement MST techniques. The leading MST approach in the occupational therapy field is the Cognitive Orientation to daily Occupational Performance (CO-OP) Approach^TM (Polatajko and Mandich, 2004). The CO-OP Approach^TM is a “client-centered, performance-based, problem-solving approach that enables skill acquisition through a process of strategy use and guided discovery” (Polatajko and Mandich, 2004: p. 17). The goal of the CO-OP Approach^TM is to generalize and transfer skills and problem-solving strategies learned in therapy into everyday life. The CO-OP Approach^TM is effective with adults in inpatient and outpatient settings in a one-to-one structure with clients affected by ABI and in a group format with children (Dawson et al., 2017a, 2017b).

The purpose of this study was to assess the feasibility of a CO-OP group for adults with occupational performance deficits in the day rehabilitation setting. Feasibility studies are distinct from pilot studies in that they build the foundations for intervention trials, assessing whether a given intervention is practical to implement rather than focusing on the intervention outcome (Tickle-Degnen, 2013). To explore the feasibility of implementing the CO-OP group, the following questions were addressed:

Will a minimum of three participants complete four of six group sessions?

Method

Participants

A convenience sample of day rehabilitation patients was recruited from a day rehabilitation center located within a large Midwestern city. Inclusion criteria included being a participant within the day rehabilitation program, experiencing occupational performance deficits as determined by the occupational therapist, and able to identify goals on the Canadian Occupational Performance Measure (COPM). Patients in day rehabilitation must meet the criteria of being able to participate in 3 hours of therapy a day and need at least two of the three therapies offered (occupational therapy, physical therapy, and speech therapy). Because of the intensive nature of day rehabilitation, many patients in this setting are receiving rehabilitation after an ABI. Patients with any diagnosis were considered, as long as they met the previously stated inclusion criteria because day rehabilitation groups often include patients with a wide variety of diagnoses.

Exclusion criteria included inability to identify goals on the COPM and insufficient language skills to identify goals on the COPM. Using the inclusion and exclusion criteria, day rehabilitation occupational therapists identified patients for the adult CO-OP group. While neurological diagnoses were not specifically targeted for this group, it is possible that occupational therapists who recommended participants may have identified this population as most appropriate for the CO-OP Approach^TM. Table 1 provides details regarding the four participants that completed the group.

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Table 1.

Participant characteristics.

Variable	Participant 1	Participant 2	Participant 3	Participant 4
Age (years)	19	76	27	60
Gender	Male	Male	Male	Male
Diagnosis	Medulloblastoma	Normal pressure hydrocephalus	Anoxic brain injury	Right-side stroke
Pre-injury employment	Park District instructor	Commodities and securities trader	Computer software sales	Journalist and instructor
Living situation at the time of the study	With parents and siblings	With spouse	With mother	Alone, part-time caregiver

The occupational therapists at the day rehabilitation site identified nine participants who would be appropriate to participate in the study. Two patients declined to participate, one consented but was unable to adjust her schedule to accommodate the time the group was offered, and one attended the first three sessions but chose to discontinue the group at that time because he preferred to participate in traditional day rehabilitation occupational therapy. Caregivers of the participants were invited but not required to attend the group.

Intervention

The CO-OP Approach^TM has been described in the literature (Dawson et al., 2017b; Polatajko and Mandich, 2004). The adult CO-OP group was developed according to the needs of the individual participants, the constraints of the day rehabilitation, and the need to accommodate the group approach. Essential elements of the original approach were maintained (Skidmore et al., 2017). Table 2 lists the essential elements of the CO-OP Approach^TM and provides an explanation of how these key features were incorporated into the curriculum. The approach was modified into a group curriculum that included one individual session and six group sessions. Six sessions were selected based on the work of Lee et al. (2017) who successfully implemented a six-session group intervention in day rehabilitation. The curriculum was tailored throughout the implementation phase to best address the participants’ goals within the group approach. Each group session was 55 min in length and two times a week for 3 weeks. The adult CO-OP group facilitator was a day rehabilitation occupational therapist and was assisted by an occupational therapy student. Appendix 1 provides a summary of the final curriculum.

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Table 2.

Incorporation of CO-OP essential elements in the curriculum.

Essential elements of the CO-OP ApproachTM	Example of how feature is incorporated	Example from the group
Client-centered, occupation-focused goals	Use of the COPM	Participant’s goal of going to breakfast
Dynamic performance analysis	Practice of goals and plans during the group	As a group, members created a plan for putting a golf ball. Group members modified the plan together while observing one member practicing putting
Cognitive strategy use	Use of global problem-solving strategy and domain-specific strategies	Goal-Plan-Do-Check was reviewed at the beginning of each session
		Homework assigned each session
Guided discovery	Practice during the group	Participants shared their homework each week. The occupational therapist used guided discovery to highlight to participants which domain-specific strategies were working for them
		Guided discovery was used to assist participants in writing plans and checks
Enabling principles	Creating fun group learning environment	Within introductions, participants were encouraged to share something about themselves
Make it fun	Homework assigned each session	Activities were planned to address participants’ interests (planning and going on an outing to the museum and golfing)
Promote learning	Educating families/homework
Work toward independence	Sharing of homework with group members
Promote generalization and transfer

COPM: Canadian Occupational Performance Measure; CO-OP: Cognitive Orientation to daily Occupational Performance.

Results

Quantitative

Due to the small size of the group and lack of the control group, change was examined within each participant and not within the group. Of the four participants that completed the CO-OP group, all participants improved in both trained and untrained goals on the COPM. The optimal decision threshold of the COPM for evaluating improvement in outpatients has been found to be 0.90 for performance and 1.45 for satisfaction (Eyssen et al., 2011). Three of four participants met this threshold for change in performance and all participants met it for change in satisfaction in overall change scores. The participant who did not meet the threshold for performance only attended four sessions and did not have a caregiver present at any sessions. See Table 3 for details of all participant’s goals and COPM scores.

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Table 3.

COPM goals, participant ratings, and scores.

Participant	COPM	Performance			Satisfaction
	Goals	Pre	Post	Change	Pre	Post	Change
1	Taking a shower	6	7	1	4	5	1
	Walking	7	7	0	6	6	0
	Video games	1	6	5	1	5	4
	Talking	6	9	3	6	8	2
	*Taking care of dogs	1	8	7	1	7	6
	Total score	4.2	7.4	3.2	3.6	6.2	2.6
2	Counseling traders	5	7	2	5	7	2
	Reading	3	8	5	3	7	4
	Grandchildren (active)	4	7	3	6	6	0
	*Breakfast—pancake house	9	9	0	8	9	1
	Golf	2	5	3	1	2	1
	Total score	4.6	7	2.4	4.6	6.2	1.6
3	*Getting from here to there without getting lost	6	7	1	4	7	3
	Playing hockey	2	4	2	1	2	1
	Reading	8	8	0	6	8	2
	Laundry	6	7	1	6	8	2
	Work	4	6	2	6	4	2
	Total score	5.2	5.8	0.6	4.2	5.8	1.6
4	Showering	8	9	1	8	9	3
	Dress pants	1	9	8	1	9	1
	*Walking outside by yourself	7	8	1	8	10	2
	Church	1	9	8	1	9	2
	Restaurants	1	10	9	1	10	2
	Total score	3.6	9	5.4	3.8	9.4	5.8

*Goal selected in partnership with the occupational therapist or group facilitator to focus on. COPM: Canadian Occupational Performance Measure.

The AMPS pre- and posttest measures were analyzed using the OTAP software by which ordinal ratings were converted to ability measures using Rasch analysis. This analysis converts each participants’ ordinal data into ADL motor and ADL process ability measures, referred to as logits, or logarithmic units of measurement, that are adjusted to account for the relative challenge of the tasks the participant performed as well as the severity of the rater who observed and scored the participant. The sum of the standard errors of measurement for each participant’s AMPS measures is used to determine significance of change. To be considered statistically significant, the ADL motor ability must differ by at least 0.5 logits, and the ADL process ability must differ by at least 0.4 logits to indicate a high likelihood of significant change (p ≤ 0.15). A gain of 0.3 logits from pre- to posttest may be considered to reflect an observable, or clinical, change (Fisher and Jones, 2011).

All four participants completed pre- and post-AMPS assessments. Two participants demonstrated improvements in their motor performance: one demonstrated observable change and one a significant change (Fisher and Jones, 2011). One participant demonstrated a significant change in process performance and one participant was trending toward improvement. Participant 1 exhibited a decline in his process score and yet his motor score improved. Participant 4 also had a decline in his AMPS motor score. See Table 4 for AMPS results.

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Table 4.

Assessment of Motor and Process Skills outcomes (logits).

Participant	Pretest motor	Posttest motor	Gain scores motor	Pretest process	Posttest process	Gain scores process
1	−0.6	−0.2	0.4*	0.8	0.6	−0.2
2	0.8	1.5	0.7*	0.6	0.6	0
3	1	1	0	−1.4	0.1	1.5**
4	1.4	1.2	−0.2	0.7	0.9	0.2

*Indicates significant change (Fisher and Jones, 2011).

**Indicates observable change (Fisher and Jones, 2011).

Feasibility

This project explored the feasibility of implementing a CO-OP group within the day rehabilitation setting. Four questions were formed to explore the feasibility of implementing the CO-OP group. The first question asked, would a minimum of three participants complete four of six group sessions? This question was formed because group interventions require a sufficient number of participants to provide peer interaction and feedback (Bandura, 1994; Baranowski et al., 2002). One participant who consented was unable to participate because she was not available at the time the group was scheduled. Participants 1 and 3 were both absent the first week of the group, missing sessions one and two. A makeup session was held to provide them with the introductory content from session one immediately before session three. All four participants attended at least four of six sessions.

The second feasibility question asked if it would be possible to complete pre- and posttests with all participants who completed four of six group sessions? Implementing occupation-based outcome measures is often challenging in clinical settings such as day rehabilitation. However, occupation-based outcome measures are valued in day rehabilitation as an important part of applying evidence-based practice (Silverman, 2014). One obstacle of the COPM is the time required to administer the outcome measure. McColl et al. (2000) found the COPM took an average of 46 min to administer. To address this concern, the COPM was completed either with the primary occupational therapist or the group facilitator. The post-COPM assessment was completed within session six by the group facilitator and a student occupational therapist who was also present.

Anecdotally, therapists calibrated in the AMPS report the greatest challenges are time constraints and the controlled environment required, as supported by the literature (Chard, 2006). To address the time required, four AMPS-trained occupational therapists within the organization were identified to administer the AMPS, decreasing the time burden on the study assessors. Additionally, the group facilitator initiated a conversation with the group participants prior to administration of the AMPS to identify the activities that would be completed during the AMPS assessment. By identifying the activities and procuring the supplies and space, prior to the administration of the AMPS, the likelihood of completing the measure within one 55-min treatment session was increased.

The third question regarding the feasibility of the CO-OP group was if the original curriculum which was developed consistent with a children’s CO-OP group protocol as found in the literature (Green and Martini, 2017; Green et al., 2008) would be practical for the day rehabilitation population. The original curriculum included a participant acting as a model to actively work on their plan each day while the group assisted with developing strategies. The individualized and dynamic goals identified by the adult participants in this group did not lend themselves to this approach. The participants’ COPM goals were reflected upon, and the curriculum was modified to a tailored approach for adults. Examples included creating plans on the white board for different activities such as going to a sporting event, creating a plan for an outing and doing the outing, and actively creating a plan for putting a golf ball and doing the putting in a group session. These modifications resulted in a more dynamic curriculum that the participants reported enjoying.

The final question regarding the feasibility of the CO-OP group was if day rehabilitation participants would identify appropriate goals to be addressed within a group setting. This was addressed during the initial one-on-one session. An example of how goals were negotiated with participants was when participant 1 selected “talking” as his goal to work on in the group. While talking could be addressed as an occupation-based intervention through tasks such as ordering from a menu or making an informational phone call, goals focused on articulation and voicing are typically addressed in speech therapy. The participant was encouraged to continue to work on this goal with his speech language pathologist. The group facilitator suggested two occupation-based goals from his COPM, playing computer games and taking care of his dogs. Participant 1 was motivated to take care of his dogs and agreed to work on this goal during the group. Anecdotally, the group facilitator noted this participant was speaking more often and louder by the final session. Participant 1’s performance and satisfaction COPM scores did improve for talking (performance from 6 to 9 and satisfaction from 6 to 8). See Table 3 for the goals selected by the participants.

Discussion

To our knowledge, this is the first adult CO-OP group in a clinical setting. We found the adult CO-OP group is feasible in day rehabilitation. Performing this study allowed multiple aspects of the group to be evaluated and provided the opportunity to resolve unanticipated challenges before the implementation of a pilot study.

It is likely that group dynamics were highly influential in the participants’ motivations, learning, and ultimately results. Bandura’s concepts of social models and reciprocal determinism were demonstrated throughout group sessions as group members learned from each other how to make plans and checks (Bandura, 1994). Working with clients in a one-to-one atmosphere precludes opportunities for social models. While clinicians can provide learning opportunities by modeling example plans and checks, they likely do not hold the same weight to a participant as a peer’s work. The success of this group appears to lie in the group format itself.

The initial curriculum developed for the adult CO-OP group which included one participant acting as a model to actively work on their plan each day while the group assisted with developing strategies was not appropriate for the dynamic goals identified by the participants and was adjusted accordingly. Participants worked together within the group sessions to learn the global problem-solving approach by creating plans on the white board, planning an outing, and creating a plan to putt a golf ball. Participants created a plan for homework, shared their homework, and worked on their homework outside of the group. Participants provided positive feedback on the group learning atmosphere.

Scheduling and attendance is a challenge in the busy and dynamic day rehabilitation setting. Because the day rehabilitation model includes both individual and group treatment, it can be difficult to schedule all the individual sessions occupational therapists may prefer to plan with clients. In this study, three of four participants met with the group facilitator in a one-on-one format prior to the group sessions to set their goal and discuss the group. The participant that did not meet with the group facilitator set his goal with his primary occupational therapist. This flexibility in scheduling is one example of the requirements necessary to make group interventions successful in busy clinical environments.

Flexibility with participant scheduling was also essential for the group’s success. Due to a hospitalization and a vacation, participants 1 and 3 missed sessions one and two. Both participants received the introductory content in a makeup session immediately before session three. While both participants received the content, they did not have the opportunity to complete their homework prior to session three, an important component of the CO-OP Approach^TM. This likely had an impact on their generalization and transfer of the approach and may be reflected in participant 3’s COPM scores. It should be noted that participant 1 made significant improvements on his COPM. Participant 1’s caregiver attended all of his sessions, while participant 3’s caregiver did not. This likely impacted the difference in their results.

Participants were invited but not required to bring their caregivers or loved ones to the group sessions. Participant 1’s mother came to all sessions and his whole family came to the group outing. Participant 4’s friend attended one session. Participants 2 and 3 had no caregivers present and the group facilitator educated their caregivers on homework at the end of the day. It does appear that caregiver participation was key in overall progress because as noted above participants 1 and 3 had the same level of attendance; however, participant 1 scored a full point higher than participant 2 in overall change on the COPM.

When evaluating AMPS scores, multiple factors must be taken into consideration. Participant 1 exhibited a decline in his process score and yet his motor score improved. This participant was in chemo therapy during the group which may have affected his process score, yet his COPM demonstrated a significant improvement. Participant 4 also had a decline in his AMPS motor score. He elected to participate in AMPS tasks that required more standing for his second assessment which may have affected his score. This participant demonstrated the greatest change on the COPM within the group.

Implementing occupation-based outcome measures is often challenging. Obstacles include time requirements and environmental barriers (Chard, 2006; McColl et al., 2000). Bridges were created to navigate these barriers such as identifying multiple assessors for both the COPM and the AMPS. Additionally, the group facilitator interviewed participants to identify the activities to complete during the AMPS, procured the supplies required, and reserved the space in advance. This process increased the likelihood of completing the measure within one treatment session. It is recommended that future studies use both objective assessments of occupational performance such as the AMPS and the self-reported measure of the COPM. Measures of self-report and measures of observed quality of performance demonstrate little relationship and should both be used to assess participant outcomes (Nielsen and Waehrens, 2015).

This feasibility study was designed to contribute to the development of a future pilot study. Future studies should further examine the subjective findings. The dose of the treatment warrants deeper investigation. Six group sessions were selected based on previous group interventions; however, participants reported they would have preferred more sessions. That said, all participants expressed increased performance and satisfaction on their self-selected goals. While participants may have enjoyed the group and wanted to continue to participate, the question of if more group sessions lead to greater gains in occupational performance requires further study. Participants also reported appreciating the global problem-solving strategy and increased motivation to participate in occupations outside of scheduled therapy. These themes should be further examined through a more rigorous study with long-term follow-up.

Conclusion

Results of this study suggest the CO-OP Approach^TM-informed group intervention is a feasible method of delivering occupational therapy in day rehabilitation. This feasibility warrants a pilot study with a control group to further examine the effectiveness of this approach.

Key findings

1. CO-OP Approach^TM-informed group interventions are feasible to implement with adults in day rehabilitation.

What this study has added

Findings from this study indicate that it is feasible to deliver CO-OP-informed group interventions in adult day rehabilitation settings.