Annals of International Occupational Therapy

Case Study 

Task-Oriented Training and Evaluation at Home (TOTE Home)

Veronica T. Rowe, PhD, OTR/L; Marsha Neville, PhD, OT

Abstract

Objective:

Evidence and theory support the idea that a task-oriented training and evaluation at home (TOTE Home) intervention would benefit motor recovery and function after stroke. This study preliminarily examined whether TOTE Home would improve function of the hemiparetic upper extremity and promote continued use of this approach after the intervention ceased.

Methods:

This case study described changes in four participants who received TOTE Home. The TOTE Home intervention included repetitive and intense practice of meaningful, goal-oriented activities, with participants engaging in problem-solving to achieve desired skills. Participant outcomes were measured with the Functional Test for the Hemiparetic Upper Extremity, the Fugl-Meyer Assessment for the Upper Extremity, the Canadian Occupational Performance Measure, the Motor Activity Log, and the recovery question of the Stroke Impact Scale. Assessment was performed at preintervention, postintervention (10 weeks), and follow-up (4 weeks).

Results:

Improvements were noted from preintervention to immediately postintervention. The improvements were generally maintained or continued to improve at 1-month follow-up for all measures except the Functional Test for the Hemiparetic Upper Extremity.

Conclusion:

This study provides preliminary support for the effectiveness of TOTE Home. The study results were promising but were limited by a small sample size. A larger study is recommended for better validation. [Annals of International Occupational Therapy. 2020; 3(1):45–52.]

Abstract

Objective:

Evidence and theory support the idea that a task-oriented training and evaluation at home (TOTE Home) intervention would benefit motor recovery and function after stroke. This study preliminarily examined whether TOTE Home would improve function of the hemiparetic upper extremity and promote continued use of this approach after the intervention ceased.

Methods:

This case study described changes in four participants who received TOTE Home. The TOTE Home intervention included repetitive and intense practice of meaningful, goal-oriented activities, with participants engaging in problem-solving to achieve desired skills. Participant outcomes were measured with the Functional Test for the Hemiparetic Upper Extremity, the Fugl-Meyer Assessment for the Upper Extremity, the Canadian Occupational Performance Measure, the Motor Activity Log, and the recovery question of the Stroke Impact Scale. Assessment was performed at preintervention, postintervention (10 weeks), and follow-up (4 weeks).

Results:

Improvements were noted from preintervention to immediately postintervention. The improvements were generally maintained or continued to improve at 1-month follow-up for all measures except the Functional Test for the Hemiparetic Upper Extremity.

Conclusion:

This study provides preliminary support for the effectiveness of TOTE Home. The study results were promising but were limited by a small sample size. A larger study is recommended for better validation. [Annals of International Occupational Therapy. 2020; 3(1):45–52.]

After a stroke, patients often experience arm and hand hemiparesis as well as learned nonuse of the involved upper extremity (Lang, Wagner, Edwards, & Dromerick, 2007). Learned nonuse is a common poststroke phenomenon that refers to the lack of use of a limb despite sufficient motor innervation (Taub, 1976). To reverse learned nonuse, task-oriented training (TOT) is a treatment intervention that has been found to be effective (Bass-Haugen & Mathiowetz, 2008). The TOT intervention incorporates principles of motor learning theory (Nudo, Wise, SiFuentes, & Milliken, 1996), which proposes that movement is facilitated through identification and performance of meaningful occupations and often requires adaptations within the intended movement and environment.

Motor learning theory encompasses components of neural science, cognitive and information processing, and psychological components of motivation and self-efficacy (Winstein, Lewthwaite, Blanton, Wolf, & Wishart, 2014). The translation of motor learning research into applied neurorehabilitation practice has most recently supported advances in sustainable and generalizable gains in motor skills and associated behaviors (Winstein et al., 2014). These advances include changes in physical activity, habits, and role-defining behaviors that contribute to recovery (Winstein et al., 2014).

Interventions that are used in TOT incorporate repetitive and intense practice of meaningful, goal-oriented activities (Lang & Birkenmeier, 2013). Components of experience-dependent neural plasticity, such as “use it and improve it, repetition, intensity, salience, and specificity,” also are used within TOT (Kleim & Jones, 2008, p. S228). The goal of TOT in recovery after stroke is skilled movement, which is defined as “the ability to achieve a goal (the task) with consistency, flexibility, and efficiency” (Winstein & Wolf, 2004, p. 267).

With TOT, the client engages in problem-solving to achieve the desired skills. This engagement changes the client's perspective of motor performance. Instead of grading tasks and giving instructions, the therapist encourages and guides the client in developing the skills needed to create ways to break down meaningful tasks, make activities easier or more difficult, and adjust the repetition and intensity of movements. The theory of occupational adaptation proposes that this change in the client can result from a “desire for mastery” (Schkade & Schultz, 1992; Schultz & Schkade, 1992). The desire to perform the activity successfully underlies the motivation for change. A person pursues change when it has meaning and persists when the goal is achievable. Therefore, the adaptive process occurs when the activities are meaningful, salient, and at the “just right” level of challenge to drive motor relearning.

During TOT, the occupational therapist acts as a facilitator, promoting problem-solving by the client. The client identifies meaningful activities and works with the occupational therapist to achieve the desired level of mastery. The occupational therapist progressively withdraws assistance to promote the client's adaptive problem-solving skills and ultimately encourage a sense of mastery.

Implementing TOT in the home setting offers opportunities for engaging in meaningful activities, role fulfilment, and practice, such as cooking, home management, and gardening. On returning home after a stroke, the client is faced with a new reality of changed participation in activities, roles, and routines. The client is likely to desire to return to familial and community roles, such as spouse, parent, worker, neighbor, and friend. Difficulty moving the involved upper extremity can limit the ability to complete desired tasks as a mother, husband, handyman, or caring companion. Although research has found TOT to be beneficial in a clinical setting (Almhdawi, Mathiowetz, White, & delMas, 2016; Marryam & Umar, 2017), the unique demand for real-world participation in the home may provide a richer environment and a greater press for mastery of old activities and roles as well as an exploration of new roles (Schultz & Schkade, 1994).

This case study assessed the preliminary effectiveness of TOT on motor recovery and function when implemented in the home environment. Task-oriented training and evaluation at home (TOTE Home) is a specific implementation of TOT in the home environment based on the premises of motor learning and occupational adaptation. Previous studies of TOTE Home with a single-subject design (Rowe & Neville, 2018b) and qualitative methods (Rowe & Neville, 2018a) have suggested promising results for the use of TOT in the home setting. Implementation of this intervention also has been found to be feasible (Rowe & Neville, 2019). Ideally, a randomized clinical trial would provide the most conclusive evidence for TOTE Home; however, a power analysis suggested that a minimum total sample size of 34 participants would be needed to identify differences between TOTE Home and the usual and customary care (Rowe & Neville, 2019). Before undertaking a large randomized clinical trial, which requires extensive funds and resources, we implemented a case study to investigate the preliminary results of a TOTE Home intervention on the effects of function in the hemiparetic upper extremity and continued changes in function after training ceased.

Methods

Participants

Participants were consecutively recruited and enrolled from a convenience sample of stroke survivors within central Arkansas and were recruited from local therapists. Inclusion criteria were diagnosis of a stroke; residence in the community; completion of prescribed therapies; active movement of the affected upper extremity of at least 10 degrees at the wrist, elbow, shoulder, thumb, and two other fingers; functional cognition and memory, as assessed by the occupational therapist's interpretation of the participant's performance of daily activities and a score of 24 or higher on the Mini-Mental Status Examination (Folstein, Folstein, & Fanjiang, 2002); and ability to identify at least five specific tasks that the participant wished to achieve with the affected upper extremity, assessed with the Canadian Occupational Performance Measure (Law et al., 2014). This study was approved by the university institutional review board, and all participants provided written informed consent.

Intervention and Procedures

The TOTE Home intervention was based on the principles of motor learning theory and guided by the theory of occupational adaptation (Schkade & Schultz, 1992; Schultz & Schkade, 1992). All assessments and interventions were administered in the participant's home. Preintervention data were collected during the initial contact at the home. Intervention times were scheduled based on each participant's schedule. All participants began the TOTE Home interventions within 10 days of preintervention data collection. The TOTE Home intervention was administered over 30 visits and 10 weeks. Participants were reassessed within 2 to 3 days of the last visit. One month after the last intervention, participants were reassessed in their homes. Participants received individualized TOTE Home training two to three times per week for up to 30 sessions, and each session lasted up to 1 hour. The individualized interventions during each session were modeled after the protocol outlined by Winstein et al. (2014). The participants identified meaningful activities to be performed within the natural environment. At the beginning of the process, the occupational therapist and the participant developed a “real-world” task list linked to the participant's roles. Examples included getting mail from the mailbox, opening it, and sorting it; pulling weeds in the yard; and retrieving items from the refrigerator and preparing lunch. As a guide for analyzing the chosen activities, the occupational therapist and the participant used a manual, Upper-Extremity Task-Specific Training after Stroke or Disability (Lang & Birkenmeier, 2013). For activities that were not included in the manual, the occupational therapist and the participant analyzed the activity with the format that was represented in the manual. The therapist incorporated techniques of verbal cueing, patterning, and shaping to facilitate movement if needed and then gradually withdrew assistance. Analysis of the activities allowed both the occupational therapist and the participant to grade the tasks according to the “just right” challenge that was appropriate for the participant.

During sessions, participants performed tasks inside and outside of the home. To reinforce learning and internalize feedback, participants were encouraged to reflect on performance efficiency, effectiveness, and satisfaction. Working to improve these aspects of performance increased participants' self-confidence in the adaptation process. Improved self-confidence enhances satisfaction in performance (Bandura, 1997; Hellström, Lindmark, Wahlberg, & Fugl-Meyer, 2003). Participants were encouraged to perform the activities between intervention sessions (Rowe, 2016).

Outcome Measures

Upper extremity function was assessed in the participants' homes before and after the intervention phase and 1 month later. The assessments included the Fugl-Meyer Assessment for the Upper Extremity (FMA-UE), Functional Test for the Hemiparetic Upper Extremity (FTHUE), the Canadian Occupational Performance Measure—Performance and Satisfaction Scales (COPM-P, COPM-S), the Motor Activity Log (MAL), and the recovery question on the Stroke Impact Scale (SIS).

Physical movement and function were measured with the FMA-UE (Fugl-Meyer & Jääskö, 1980) and FTHUE (Wilson, Baker, & Craddock, 1984). The FMA-UE showed good sensitivity to change (Rabadi & Rabadi, 2006), with an estimated minimally clinically important difference of 4.25 to 7.25 points (Page, Fulk, & Boyne, 2012). Both assessments had good reliability and validity. The FMA-UE and FTHUE are highly correlated (rho = .96, p < .01) (Filiatrault, Arsenault, Dutil, & Bourbonnais, 1991).

The participant's perception of upper extremity movement was measured with the COPM-P scale (Law et al., 2014) and the Amount and How Well scales of the MAL (van der Lee, Beckerman, Knol, de Vet, & Bouter, 2004). The participant's satisfaction with upper extremity movement was measured with the COPM-S scale (Law et al., 2014) and the recovery question on the SIS (Duncan et al., 1999). The COPM, MAL, and SIS all have strong psycho-metrics and are reliable and valid assessments. As evidence of the validity of the COPM, mean change scores in performance and satisfaction were responsive to changes in perception of occupational performance by clients (Law et al., 2014). The MAL is internally consistent and relatively stable, and it showed reasonable construct validity in patients with chronic stroke (van der Lee et al., 2004). For the SIS, there are a few instances of the analysis of the last question in stroke research (Fritz, George, Wolf, & Light, 2007); however, a participant-based questionnaire such as this has been assessed in other studies of physical rehabilitation (Liang, 2000; Osoba, Rodrigues, Myles, Zee, & Pater, 1998). Change scores were analyzed for differences preintervention, postintervention, and at 1-month follow-up.

Results

Participants

Four participants were eligible for the study and volunteered to participate. Demographic features, measures of general functioning, and characteristics of TOTE Home are shown in Table 1. These four participants had mild to moderate hemiparesis, showed equal distribution between hand dominance and gender, and represented four different home environments that could be considered somewhat representative of a typical sample of stroke survivors.

Participant Demographics, Initial Level of Function, and Characteristics of the TOTE Home Intervention

Table 1:

Participant Demographics, Initial Level of Function, and Characteristics of the TOTE Home Intervention

Participant Outcomes

For the COPM, all participants showed marked improvement in performance and satisfaction with activities at preintervention, postintervention, and 1-month follow-up. Most of the improvements continued at 1-month follow-up. Ratings tended to exceed the minimal detectable change of 1.7 points for performance and 2.7 points for satisfaction (Cup, Scholte op Reimer, Thijssen, & van Kuyk-Minis, 2003).

For the FMA-UE, participants did not show a minimal detectable change between preintervention and postintervention (Wagner, Rhodes, & Patten, 2008). At 1-month follow-up, all participants showed a significant change of at least 5.2 points, which indicated improvement.

For the MAL, all participants reported improvement in the amount and quality of movement from pretest to post-test. Changes from posttest to 1-month follow-up varied, but were mostly positive.

For the SIS, all participants showed improvement in recovery of the arm immediately after the intervention, and half of the participants reported continued perceived improvement in recovery 1 month later.

For the FTHUE, results were inconsistent and difficult to interpret. However, differences in the number of tasks that each participant was able to complete were nominal at each stage of evaluation.

Table 2 shows the results of all assessments for each participant as well as change score summaries.

Comparison of Standardized Assessments for Each Participant and Change Score Summaries

Table 2:

Comparison of Standardized Assessments for Each Participant and Change Score Summaries

Discussion

This case study contributes to the body of evidence for interventions for motor recovery after stroke (Bosch, O'Donnell, Barreca, Thabane, & Wishart, 2014; Han, Wang, Meng, & Qi, 2013; Wolf et al., 2008). All study participants showed improved motor function with the TOTE Home intervention. The results of testing 1 month after the intervention suggested the gains continued after treatment. Outcomes from these case studies showed mostly positive changes, and measures sensitive to capturing change were identified for future consideration. The FTHUE was the only assessment that did not show a change from baseline through follow-up. All other assessments showed changes in movement or participant satisfaction with movement and achievement of goals. Participants had increased functional use of the hemiparetic upper extremity that generally increased beyond discontinuation of the intervention. Although preliminary, the results of functional change from this study, which was conducted in the home environment, were comparable to and sometimes better than the findings of previous TOT research that was conducted in clinical settings (Almhdawi et al., 2016; Winstein et al., 2016).

This study supports previous work that showed that the theory of occupational adaptation is applicable to patients after cerebrovascular accident (Gibson & Schkade, 1997) and in the home health setting (Schultz & Schkade, 1994). The overall goal of TOTE Home is to increase function through the use of meaningful occupations within a person's environment, increasing movement and adaptive responses for use of the affected upper extremity. By engaging in activities that provide the “just right” challenge, clients can regain old skills or establish new routines, habits, and roles. Ultimately, relative mastery enables the person to continue to adapt to occupational challenges.

Procedures based on the principles of contemporary motor learning theory that stimulate neural plasticity provided the foundation for the rehabilitative intervention used in this study. Motor learning theory addressed motor recovery, and the theory of occupational adaptation addressed the person component. Functional recovery after a stroke is not defined as functioning without a disability but rather functioning with physical changes. According to the occupational adaptation perspective, the client must desire to change and engage in problem-solving through the change. The use of occupational adaptation with motor learning theory addressed both the desire for participation in meaningful occupations and science-based therapy for motor recovery. These outcomes are promising, and the four study participants showed improvement in motor function and satisfaction with performance. This study is supported by evidence and could be replicated in clinical practice.

Strengths and Weaknesses

Strengths of this study included the use of an intervention based on evidence in neuroscience, psychology, and physical rehabilitation. The intervention was delivered in the participant's environment, which was convenient for the client and provided a wealth of opportunities for real-life practice. The home environment allowed the participants and the researcher to work on the desired occupations in the desired context. Facilitating adaptation in the participant's home could allow long-term generalization beyond the structured therapy sessions.

Weaknesses of this study involved the inclusion of participants who were 2 to 8 months from the onset of a stroke, so natural recovery cannot be ruled out. In addition, the participants had mild to moderate hemiparesis, which does not represent the full range of impairment. The use of 30 treatment sessions may not be representative of the length of traditional occupational therapy in the home health setting; however, it allowed a preliminary look at the proof of concept. This small sample limits generalization of conclusions about TOTE Home. A larger study is needed to validate changes observed after TOTE Home beyond chance. This study could be enhanced with additional follow-up assessments 3 and 6 months after the intervention to evaluate the continued adaptive process. Further investigation is needed as to how other factors, such as motivation of the participant, reliability of the therapist, and sensitivity of the outcome measures, may affect outcomes.

Conclusion and Future Directions

This study provided a model of implementing evidence-based task-oriented training within a client's home. Future questions for study include comparing clinic-based TOT with home-based TOT and analyzing the differences in goals and practice schedules with larger sample sizes. Specifying how TOTE Home may be tailored to fit individual participants also would add to its effectiveness. For this study, participants had 30 treatment sessions. Additional studies could compare different lengths of treatment. In addition, with appropriate funding resources, future study of TOTE Home would benefit from a randomized clinical trial.

References

  • Almhdawi, K. A., Mathiowetz, V. G., White, M. & delMas, R. C. (2016). Efficacy of occupational therapy task-oriented approach in upper extremity post-stroke rehabilitation. Occupational Therapy International, 23(4), 444–456. doi:10.1002/oti.1447 [CrossRef]27761966
  • Bandura, A. (1997). The nature and structure of self-efficacy. In Self-efficacy: The exercise of control (pp. 36–78). New York, NY: W. H. Freeman.
  • Bass-Haugen, J. & Mathiowetz, V. (2008). Optimizing motor behavior using the occupational therapy task-oriented approach (6th ed.). Baltimore, MD: Lippincott Williams & Wilkins.
  • Bosch, J., O'Donnell, M. J., Barreca, S., Thabane, L. & Wishart, L. (2014). Does task-oriented practice improve upper extremity motor recovery after stroke? A systematic review. International Scholarly Research Notices Stroke, 2014, 1–10. doi:10.1155/2014/504910 [CrossRef]
  • Cup, E. H., Scholte op Reimer, W. J., Thijssen, M. C. & van Kuyk-Minis, M. A. (2003). Reliability and validity of the Canadian occupational performance measure in stroke patients. Clinical Rehabilitation, 17(4), 402–409. doi:10.1191/0269215503cr635oa [CrossRef]12785249
  • Duncan, P. W., Wallace, D., Lai, S. M., Johnson, D., Embretson, S. & Laster, L. J. (1999). The stroke impact scale version 2.0: Evaluation of reliability, validity, and sensitivity to change. Stroke, 30(10), 2131–2140. doi:10.1161/01.STR.30.10.2131 [CrossRef]10512918
  • Filiatrault, J., Arsenault, A. B., Dutil, E. & Bourbonnais, D. (1991). Motor function and activities of daily living assessments: A study of three tests for persons with hemiplegia. American Journal of Occupational Therapy, 45(9), 806–810. doi:10.5014/ajot.45.9.806 [CrossRef]1928288
  • Folstein, M. F., Folstein, S. E. & Fanjiang, G. (2002). Mini-mental state examination: Clinical guide. Lutz, FL: Psychological Assessment Resources.
  • Fritz, S. L., George, S. Z., Wolf, S. L. & Light, K. E. (2007). Participant perception of recovery as criterion to establish importance of improvement for constraint-induced movement therapy outcome measures: A preliminary study. Physical Therapy, 87(2), 170–178. doi:10.2522/ptj.20060101 [CrossRef]17244694
  • Fugl-Meyer, A. R. & Jääskö, L. (1980). Post-stroke hemiplegia and ADL-performance. Scandinavian Journal of Rehabilitation Medicine. Supplement, 7, 140–152.6932722
  • Gibson, J. W. & Schkade, J. K. (1997). Occupational adaptation intervention with patients with cerebrovascular accident: A clinical study. American Journal of Occupational Therapy, 51(7), 523–529. doi:10.5014/ajot.51.7.523 [CrossRef]9242858
  • Han, C., Wang, Q., Meng, P. P. & Qi, M. Z. (2013). Effects of intensity of arm training on hemiplegic upper extremity motor recovery in stroke patients: A randomized controlled trial. Clinical Rehabilitation, 27(1), 75–81. doi:10.1177/0269215512447223 [CrossRef]
  • Hellström, K., Lindmark, B., Wahlberg, B. & Fugl-Meyer, A. R. (2003). Self-efficacy in relation to impairments and activities of daily living disability in elderly patients with stroke: A prospective investigation. Journal of Rehabilitation Medicine, 35(5), 202–207. doi:10.1080/16501970310000836 [CrossRef]14582550
  • Kleim, J. A. & Jones, T. A. (2008). Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech, Language & Hearing Research, 51(1), S225–S239. doi:10.1044/1092-4388(2008/018) [CrossRef]
  • Lang, C. E. & Birkenmeier, R. L. (2013). Upper-extremity task-specific training after stroke or disability: A manual for occupational therapy and physical therapy. Bethesda, MD: AOTA Press.
  • Lang, C. E., Wagner, J. M., Edwards, D. F. & Dromerick, A. W. (2007). Upper extremity use in people with hemiparesis in the first few weeks after stroke. Journal of Neurologic Physical Therapy, 31(2), 56–63. doi:10.1097/NPT.0b013e31806748bd [CrossRef]17558358
  • Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatajko, H. & Pollock, N. (2014). Canadian occupational performance measure (5th ed.). Ottawa, Ontario, Canada: CAOT Publications.
  • Liang, M. H. (2000). Longitudinal construct validity: Establishment of clinical meaning in patient evaluative instruments. Medical Care, 38(9)(suppl 2), II84–II90. doi:10.1097/00005650-200009002-00013 [CrossRef]10982093
  • Marryam, M. & Umar, M. (2017). Effectiveness of task oriented training in improving upper limb function after stroke. Rawal Medical Journal, 42(3), 341–343.
  • Nudo, R. J., Wise, B. M., SiFuentes, F. & Milliken, G. W. (1996). Neural substrates for the effects of rehabilitative training on motor recovery after ischemic infarct. Science, 272(5269), 1791–1794. doi:10.1126/science.272.5269.1791 [CrossRef]8650578
  • Osoba, D., Rodrigues, G., Myles, J., Zee, B. & Pater, J. (1998). Interpreting the significance of changes in health-related quality-of-life scores. Journal of Clinical Oncology, 16(1), 139–144. doi:10.1200/JCO.1998.16.1.139 [CrossRef]9440735
  • Page, S. J., Fulk, G. D. & Boyne, P. (2012). Clinically important differences for the upper-extremity Fugl-Meyer scale in people with minimal to moderate impairment due to chronic stroke. Physical Therapy, 92(6), 791–798. doi:10.2522/ptj.20110009 [CrossRef]22282773
  • Rabadi, M. H. & Rabadi, F. M. (2006). Comparison of the action research arm test and the Fugl-Meyer assessment as measures of upper-extremity motor weakness after stroke. Archives of Physical Medicine & Rehabilitation, 87(7), 962–966. doi:10.1016/j.apmr.2006.02.036 [CrossRef]
  • Rowe, V. T. (2016). Task oriented training at home (TOTE home) (Doctoral dissertation). Available from Pioneer Open Access Repository. (2017-02-02T17:22:35Z)
  • Rowe, V. T. & Neville, M. (2018a). Client perceptions of task-oriented training at home: “I forgot I was sick.”Occupational Therapy Journal of Research: Occupation, Participation and Health, 38(3), 190–195. doi:10.1177/1539449218762729 [CrossRef]
  • Rowe, V. T. & Neville, M. (2018b). Task oriented training and evaluation at home. Occupational Therapy Journal of Research: Occupation, Participation and Health, 38(1), 46–55. doi:10.1177/1539449217727120 [CrossRef]
  • Rowe, V. T. & Neville, M. (2019). The feasibility of conducting task-oriented training at home for patients with stroke. Open Journal of Occupational Therapy, 7(1), 6. doi:10.15453/2168-6408.1514 [CrossRef]
  • Schkade, J. K. & Schultz, S. (1992). Occupational adaptation: Toward a holistic approach for contemporary practice, part 1. American Journal of Occupational Therapy, 46(9), 829–837. doi:10.5014/ajot.46.9.829 [CrossRef]1514569
  • Schultz, S. & Schkade, J. K. (1992). Occupational adaptation: Toward a holistic approach for contemporary practice, part 2. American Journal of Occupational Therapy, 46(10), 917–925. doi:10.5014/ajot.46.10.917 [CrossRef]1463064
  • Schultz, S. & Schkade, J. K. (1994). Home health care: A window of opportunity to synthesize practice. Home and Community Health Special Interest Section Newsletter, 13(3), 1–4.
  • Taub, E. (1976). Movement in nonhuman primates deprived of somatosensory feedback. Exercise and Sport Sciences Reviews, 4, 335–374. doi:10.1249/00003677-197600040-00012 [CrossRef]828579
  • van der Lee, J. H., Beckerman, H., Knol, D. L., de Vet, H. C. & Bouter, L. M. (2004). Clinimetric properties of the motor activity log for the assessment of arm use in hemiparetic patients. Stroke, 35(6), 1410–1414. doi:10.1161/01.STR.0000126900.24964.7e [CrossRef]15087552
  • Wagner, J. M., Rhodes, J. A. & Patten, C. (2008). Reproducibility and minimal detectable change of three-dimensional kinematic analysis of reaching tasks in people with hemiparesis after stroke. Physical Therapy, 88(5), 652–663. doi:10.2522/ptj.20070255 [CrossRef]18326055
  • Wilson, D. J., Baker, L. L. & Craddock, J. A. (1984). Functional test for the hemiparetic upper extremity. American Journal of Occupational Therapy, 38(3), 159–164. doi:10.5014/ajot.38.3.159 [CrossRef]6711667
  • Winstein, C., Lewthwaite, R., Blanton, S. R., Wolf, L. B. & Wishart, L. (2014). Infusing motor learning research into neurorehabilitation practice: A historical perspective with case exemplar from the accelerated skill acquisition program. Journal of Neurologic Physical Therapy, 38(3), 190–200. doi:10.1097/NPT.0000000000000046 [CrossRef]24828523
  • Winstein, C. J. & Wolf, S. L. (2004). Task-oriented training to promote upper extremity recovery. In Stein, J., Harvey, R. L., Macko, R. F., Winstein, C. J. & Zorowitz, R. D. (Eds.), Stroke recovery and rehabilitation (pp. 267–290). New York, NY: Demos Medical.
  • Winstein, C. J., Wolf, S. L., Dromerick, A. W., Lane, C. J., Nelsen, M. A., Lewthwaite, R. & Azen, S. P. (2016). Effect of a task-oriented rehabilitation program on upper extremity recovery following motor stroke: The ICARE randomized clinical trial. Journal of the American Medical Association, 315(6), 571–581. doi:10.1001/jama.2016.0276 [CrossRef]26864411
  • Wolf, S. L., Winstein, C. J., Miller, J. P., Thompson, P. A., Taub, E., Uswatte, G. & Clark, P. C. (2008). Retention of upper limb function in stroke survivors who have received constraint-induced movement therapy: The EXCITE randomised trial. Lancet Neurology, 7(1), 33–40. doi:10.1016/S1474-4422(07)70294-6 [CrossRef]

Participant Demographics, Initial Level of Function, and Characteristics of the TOTE Home Intervention

CharacteristicParticipant 1Participant 2Participant 3Participant 4
GenderFemaleMaleMaleFemale
Age, years86546157
Time after cerebrovascular accident, years4.54.582
Cerebrovascular accident, typeIschemicIschemicHemorrhagicIschemic
Living situationLives with familyLives with familyLives with familyLives alone
Dominant sideRightRightRightRight
Affected sideRightLeftLeftRight
MMSE score28252430
Total time spent in TOTE Home, hours28.832.030.016.3
Average time spent per visit in TOTE Home, minutes57.564.060.057.6
Total repetitions completed during TOTE Home, n2,744.02,371.02,611.01,265.0
Average repetitions completed per visit during TOTE Home, n91.579.087.074.4

Comparison of Standardized Assessments for Each Participant and Change Score Summaries

Participants and assessmentsPretestPosttestFollow-up (1 month)Change pretest to posttestChange pretest to follow-up
Participant 1
  COPM Performance15.684.67.0
  COPM Satisfaction1.65.27.43.65.8
  FMA-UE343944510
  MAL Amount1.43.642.22.6
  MAL How Well1.63.43.41.81.8
  SIS recovery question3060703040
  FTHUE score13161330
Participant 2
  COPM Performance2.63.45.80.83.2
  COPM Satisfaction2.83.35.80.53
  FMA-UE45495146
  MAL Amount1.672.822.411.150.74
  MAL How Well2.822.333.19−0.490.37
  SIS recovery question930302121
  FTHUE score151315−20
Participant 3
  COPM Performance57.882.83
  COPM Satisfaction5.67.48.21.82.6
  FMA-UE485761913
  MAL Amount3.263.44.040.140.78
  MAL How Well3.594.04.330.410.74
  SIS recovery question5070602010
  FTHUE score16171610
Participant 4
  COPM Performance3.67.61046.4
  COPM Satisfaction1.89.4107.68.2
  FMA-UE5062621212
  MAL Amount4.084.774.890.690.81
  MAL How Well3.464.634.851.171.39
  SIS recovery question709599.92529.9
  FTHUE score15171722
Authors

Dr. Rowe is Assistant Professor, University of Central Arkansas, Conway, Arkansas. Dr. Neville is Professor, Texas Woman's University, Dallas, Texas.

The authors have no relevant financial relationships to disclose.

Address correspondence to Veronica T. Rowe, PhD, OTR/L, 4425 Tree House Drive, Conway, AR 72034; e-mail: thessingvr@aol.com.

Received: March 02, 2019
Accepted: August 23, 2019
Posted Online: October 25, 2019

10.3928/24761222-20191018-02

Sign up to receive

Journal E-contents