Strategy Training for Adults With Chronic Stroke and Brain Injury in Taiwan: Perspectives of Clients and Therapists

PURPOSE: Strategy training has shown promise for improving independent living in adults with cognitive impairments following stroke and brain injury (Dawson, A. Binns, Hunt, Lemsky, & Polatajko, 2013; McEwen et al., 2015). However, this training approach has limited adoption in clinical settings in Asian countries; it is unclear how strategy training works in chronic stroke and brain injury in Taiwan and how clients and therapists perceived the intervention. This study explored the experiences of clients and their therapists using strategy training in outpatient settings in Taiwan to understand the benefits and challenges that they perceived during the intervention.

DESIGN: Semi-structured interviews were conducted with a convenience sample of 20 adults with stroke or brain injury (85% males, mean age: 55.9 years) who received strategy training intervention in a feasibility study. Clients were recruited from the rehabilitation outpatient units of four hospitals in Taipei. Inclusion criteria included: (1) age ≥ 20 years; (2) diagnosis of stroke or brain injury; (3) understanding Mandarin; (4) presence of cognitive impairment (indicated by a score of 25 or less on the Montreal Cognitive Assessment); and (5) providing an informed consent. Participants were excluded if they had: (1) severe aphasia; (2) diagnosis of dementia; or (3) psychiatric disorders that may impede their participation in the study. All clients received 8 to 17 sessions of strategy training, delivered by three trained occupational therapists (all female, mean age: 35 years), in addition to their regular outpatient occupational therapy.

METHOD: Clients and their therapists were interviewed about their experiences regarding involvement in strategy training after the intervention. Semi-structured interviews were audiotaped, transcribed verbatim, and analyzed thematically by two independent coders. The coding results were compared and synthesized by the research group.

RESULTS: Clients and therapists reported an overall satisfactory experience during the strategy training intervention. Several benefits of strategy training were identified by both clients and therapists, indicating that the training helped participants (1) build confidence, (2) develop a sense of reality, (3) be more independent, (4) set goals in life; and (5) obtain problem-solving strategies. Nevertheless, some challenges were identified by clients and therapists. For example, some clients mentioned that failing to achieve the goals that they set often frustrated them and reduced their desire to continue the training. The therapists reported that concerns about clients’ poor self-awareness and low motivation were sometimes significant challenges in goal-setting and plan-making. Moreover, some clients and therapists had difficulty accepting/delivering the strategy training intervention since it deviated from widely held perspectives on impairment remediation. Many clients and therapists mentioned that support from significant others and encouragement from the therapists were the keys for success of this intervention.

CONCLUSION: The potential benefits of strategy training identified by clients and therapists support the use of strategy training in community-dwelling individuals with cognitive impairments following stroke and brain injury. Findings of this study also contribute to practice through identifying potential challenges that occupational therapists may encounter as delivering strategy training to clients in outpatient settings in Taiwan. Further discussion of strategies to address these challenges is warranted, including ways to better leverage encouragement from therapists and involvement of significant others in the training process.

References

Dawson, D. R., A. Binns, M., Hunt, A., Lemsky, C., & Polatajko, H. J. (2013). Occupation-based strategy training for adults with traumatic brain injury: a pilot study. Archives of Physical Medicine and Rehabilitation, 94(10), 1959-1963. doi:10.1016/j.apmr.2013.05.021

McEwen, S., Polatajko, H., Baum, C., Rios, J., Cirone, D., Doherty, M., & Wolf, T. (2015). Combined cognitive-strategy and task-specific training improve transfer to untrained activities in subacute stroke: an exploratory randomized controlled trial. Neurorehabilitation and Neural Repair, 29(6), 526-536. doi:10.1177/1545968314558602