DESIGN TYPE AND LEVEL OF EVIDENCE: Level I: Pilot randomized controlled trial. Limitations (appropriateness of study design):

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1 CRITICALLY APPRAISED PAPER (CAP) FOCUSED QUESTION Does the Cognitive Orientation to daily Occupational Performance (CO-OP) approach increase clients performance on goals more than a standard occupational therapy approach poststroke? Polatajko, H. J., McEwen, S. E., Ryan, J. D., & Baum, C.M. (2012). Pilot randomized controlled trial investigating cognitive strategy use to improve goal performance after stroke. American Journal of Occupational Therapy, 66, CLINICAL BOTTOM LINE: The effectiveness of the CO-OP approach to improve goal performance in adults poststroke was investigated in this pilot study. The researchers aimed to determine whether the CO-OP approach is a more effective approach to poststroke rehabilitation compared to a standard occupational therapy approach when addressing client-identified goals. The CO-OP approach is a client-focused intervention approach to therapy, whereas a standard occupational therapy approach is highly therapist-driven. Study participants received intervention guided by either the CO-OP approach or the standard approach. Results indicated that the performance of the participants who received the CO-OP approach to intervention improved more than those receiving the standard approach to intervention. The authors hypothesize the increase in performance is related to the higher level of autonomy that the CO-OP approach allows, enabling the participants to attain higher level skills. RESEARCH OBJECTIVE(S) List study objectives. 1. Is there a difference in performance improvements on self-selected goals when comparing CO-OP intervention to standard occupational therapy (SOT) in adults at least 6 months poststroke? (p. 105) 2. What is the direction and magnitude of the difference? (p. 105) DESIGN TYPE AND LEVEL OF EVIDENCE: Level I: Pilot randomized controlled trial Limitations (appropriateness of study design): 1

2 Was the study design type appropriate for the knowledge level about this topic? Circle yes or no, and if no, explain. YES/NO Previous research by our includes three studies using single-case methods. These studies provide preliminary evidence of CO-OP s capacity to improve performance in adults with stroke. (p. 105) SAMPLE SELECTION How were subjects selected to participate? Please describe. Recruitment was completed using the Cognitive Rehabilitation Research Group database and patients discharged from the Rehabilitation Institute of St. Louis. Inclusion Criteria Participants were required to be at least 6 mo[nths] poststroke and living in the community and to have a National Institutes of Health Stroke Scale score of 13 or less, an IQ score of 80 or more, and no more than minimal aphasia. (p. 105) Exclusion Criteria N/R SAMPLE CHARACTERISTICS N = 20 % Dropouts 12 (60%) of participants withdrew from the study prior to completion #/ (%) Male 42.1% #/ (%) Female 57.9% Ethnicity Disease/disability diagnosis Stroke Check appropriate : < 20/study 20 50/study /study /study /study INTERVENTION(S) AND CONTROL GROUPS Add s if necessary Group 1 2

3 Brief Description Cognitive Orientation to daily Occupational Performance (CO-OP) is a client-centered cognitive approach emphasizing the use of global strategies (Goal-Plan-Do-Check) and domain-specific strategies to meet familiar and novel goals. Setting Who Delivered? Frequency? Duration? Outpatient occupational therapy Two experienced occupational therapists trained in the CO-OP approach 10 sessions; 1 hour each Group 2 Brief Description Standard occupational therapy (SOT) is a therapist-driven approach to treatment, including interventions incorporating tasks and exercises as a means to achieve goals. Setting Who Delivered? Frequency? Duration? Outpatient occupational therapy Two experienced occupational therapists Maximum of 10 sessions; 1-hour sessions Intervention Biases: Circle yes or no and explain, if needed. Contamination YES/NO Contamination did not occur as therapists in the SOT were not trained in the CO-OP intervention approach. Co-intervention YES/NO Participants only received intervention associated with the intervention they were assigned to with the study. Timing YES/NO Both s received 10 treatment sessions over the relatively short time of 10 weeks. Site YES/NO Use of different therapists to provide intervention YES/NO Two therapists were assigned to the control and two therapists to the intervention. 3

4 MEASURES AND OUTCOMES Complete for each relevant measure when answering the evidence-based question: Name of measure, what outcome was measured, whether the measure is reliable and valid (as reported in article yes/no/ [not reported]), and how frequently the measure was used. Canadian Occupational Performance Measure (COPM) Outcome Measured: The degree to which participants felt they met their meaningful goals. The COPM reported clients perception of their performance and satisfaction related to established goal areas. Reliability/Validity: The COPM has demonstrated test retest reliability of.89 in people with stroke. (p. 106) Frequency: Completed by participants pre-intervention and post-intervention. Performance Quality Rating Scale (PQRS) Outcome Measured: The PQRS reported the therapist s perception of the client s performance related to established goal areas. Reliability/ Validity: Interrater reliability in the stroke population was estimated using intraclass correlation coefficient at.71. (p. 106) Frequency: Completed by therapists pre-intervention and post-intervention. Cognitive Rehabilitation Research Group (CRRG) standard battery of physical, health status, and neuropsychological tests Outcome Measured: Outcomes were used to compare participants who withdrew from the study with those who had complete data on age, gender, education, NIHSS (NIH Scale/Score) score, and the CRRG neuropsychological assessment battery. (p.106) Reliability/Validity: Frequency: Completed prior to intervention Measurement Biases Were the evaluators blind to treatment status? Circle yes or no, and if no, explain. YES/NO No, the therapists providing the intervention also were completing the evaluation process. Recall or memory bias. Circle yes or no, and if yes, explain. YES/NO No, because the measurements presented participant and therapist perceptions of performance, not relying on recall or memory. A scoring bias may have been present as the treating therapist completed the PQRS. RESULTS List results of outcomes relevant to answering the focused question Include statistical significance where appropriate (p < 0.05) 4

5 Include effect size if reported Results of the PQRS and the COPM indicate statistically significant improvement in the area of performance in the CO-OP intervention compared to the SOT treatment (PQRS: U = 0.0, p = 0.02; COPM: U = 0.0, p = 0.02). A statistically significant difference was not indicated between s for participant satisfaction on the COPM (U = 5.0, p = 0.38). Authors could not draw a conclusion regarding the direction of treatment effect due to satisfaction scores spanning both positive and negative numbers. Was this study adequately powered (large enough to show a difference)? Circle yes or no, and if no, explain. YES/NO No, due to the study s small sample size. Were appropriate analytic methods used? Circle yes or no, and if no, explain. YES/NO Yes. The authors justify their selection of nonparametric Mann-Whitney U and simple linear regression due to the small sample size and ordinal level data. Were statistics appropriately reported (in written or table format)? Circle yes or no, and if no, explain. YES/NO The results were reported in both written and table format. CONCLUSIONS State the authors conclusions that are applicable to answering the evidence-based question. The authors concluded that the CO-OP approach to intervention improved participant performance poststroke compared to standard occupational therapy intervention. These results may be related to the client-centeredness of the approach and the ability of the CO-OP approach principles to be transferred to novel tasks. The authors suggest additional research be conducted with a larger sample size to statistically strengthen the results. This work is based on the evidence-based literature review completed by Gina Czmowski, OTR, and Sarah Nielsen, PhD, OTR/L, Faculty Advisor, University of North Dakota. CAP Worksheet adapted from: Critical Review Form Quantitative Studies M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, 1998, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA.Contact: 5