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.
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).
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.
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
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
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.
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Participant Demographics, Initial Level of Function, and Characteristics of the TOTE Home Intervention
|Characteristic||Participant 1||Participant 2||Participant 3||Participant 4|
|Time after cerebrovascular accident, years||4.5||4.5||8||2|
|Cerebrovascular accident, type||Ischemic||Ischemic||Hemorrhagic||Ischemic|
|Living situation||Lives with family||Lives with family||Lives with family||Lives alone|
|Total time spent in TOTE Home, hours||28.8||32.0||30.0||16.3|
|Average time spent per visit in TOTE Home, minutes||57.5||64.0||60.0||57.6|
|Total repetitions completed during TOTE Home, n||2,744.0||2,371.0||2,611.0||1,265.0|
|Average repetitions completed per visit during TOTE Home, n||91.5||79.0||87.0||74.4|
Comparison of Standardized Assessments for Each Participant and Change Score Summaries
|Participants and assessments||Pretest||Posttest||Follow-up (1 month)||Change pretest to posttest||Change pretest to follow-up|
| COPM Performance||1||5.6||8||4.6||7.0|
| COPM Satisfaction||1.6||5.2||7.4||3.6||5.8|
| MAL Amount||1.4||3.6||4||2.2||2.6|
| MAL How Well||1.6||3.4||3.4||1.8||1.8|
| SIS recovery question||30||60||70||30||40|
| FTHUE score||13||16||13||3||0|
| COPM Performance||2.6||3.4||5.8||0.8||3.2|
| COPM Satisfaction||2.8||3.3||5.8||0.5||3|
| MAL Amount||1.67||2.82||2.41||1.15||0.74|
| MAL How Well||2.82||2.33||3.19||−0.49||0.37|
| SIS recovery question||9||30||30||21||21|
| FTHUE score||15||13||15||−2||0|
| COPM Performance||5||7.8||8||2.8||3|
| COPM Satisfaction||5.6||7.4||8.2||1.8||2.6|
| MAL Amount||3.26||3.4||4.04||0.14||0.78|
| MAL How Well||3.59||4.0||4.33||0.41||0.74|
| SIS recovery question||50||70||60||20||10|
| FTHUE score||16||17||16||1||0|
| COPM Performance||3.6||7.6||10||4||6.4|
| COPM Satisfaction||1.8||9.4||10||7.6||8.2|
| MAL Amount||4.08||4.77||4.89||0.69||0.81|
| MAL How Well||3.46||4.63||4.85||1.17||1.39|
| SIS recovery question||70||95||99.9||25||29.9|
| FTHUE score||15||17||17||2||2|