Protocol

OT-based HIT Decision Chart

Note. Think of functional mobility as a foundational skill that helps to increase the quality and activity tolerance for other occupations. Use the outcome measures and decision criteria to prioritize training sessions and types of practice. 

Evaluation 

The evaluation should consist of the most comprehensive assessments for the OT-based HIT protocol. The outcome measures help to identify the various components of the MOHO, including volition, habituation, performance capacity, and how they interact with the environment. Assessments should be separated between multiple disciplines within the interdisciplinary team to save time and productivity. The COPM should be conducted in its entirety on evaluation and discharge.        

Intervention 

Throughout all interventions, patient engagement should be the focus. Use the Volition Tool to determine the patient's behavior toward goal orientation. The Volition Tool combines the Transtheoretical Model of Change and the Skill Acquisition Chart to promote patient engagement through SMART goal setting. 

High-intensity functional mobility should be trained with higher priority than occupations that require more cognitive load to complete. The value of minimizing the cognitive load with high-intensity functional mobility allows the patient to obtain a higher dosage of practice measured through stepping and heart rate. 

For this program, the minimal requirement for patients to begin intensified self-care (UBD/LBD) is a BBS score of 10-20. This allows the patient to compensate for cognitive deficits as measured by either the MoCA <26/30 or AMPAC cognitive section (-cog) of <22/24. These scores from the MoCA are derived from findings by Zietemann et al. (2018) and Durant et al. (2016) related to MoCA and ADL/functional independence. Because cognition is one of the major inhibitors to self-care independence, it is essential to consider. Intensifying ADLs should include UBD and LBD and should initially take place with blocked practice for skill acquisition, add variability or distributed practice for skill retention, and randomly rotate for transference and mastery. 

Instrumental ADLs can be implemented throughout high-intensity training with the primary focus on high-intensity stepping. Use of upper extremities should be incorporated with a challenge to postural stability. Upper extremity practice is also appropriate for intensified IADL training, depending on the hand's level of function.  

For instance, For the affected upper extremity, use the PREP2 scores or the CIMT grade four to identify predictive hand rehabilitation (Kwakkel et al., 2015). The PREP2 can be thought of as the prediction guide of hand rehabilitation, and the rule of 10 or CIMT grade four can be thought of as the minimal results to begin training the hand via occupation and task-specific shaping. With PREP2 predictions of good or greater, place a high priority on upper extremity task-specific training through shaping. For PREP2 predictions of poor or lower, place a lower priority on the hand and focus on other skills needed for independence, such as balance, walking, and self-care. Just as with intensified self-care, start with a massed practice of stacking blocked practice sessions that alternate between high-intensity stepping and upper extremity occupation-based or task-specific shaping. As the hand demonstrates improvements with functional use, transition to increase variability with practice until random rotation practice can be achieved. Set an allotted error parameter (i.e., 2-3 failed attempts) with the task requirements. And use the skill acquisition chart to determine whether assistance is needed. When assisting, use the prompting hierarchy with least-to-most assistance unless severe cognitive deficits are displayed, then use most to least. In most cases, poor cognition will also be associated with poor functional ability. 

Overall, the interventions designed in this program are intended to set parameters and means to progress such parameters. The intervention style is left open-ended to meet the needs of each patient and capitalize on the unique therapeutic style of each OT.       

Weekly outcome measures

Increase challenge

Monitor heart rate and RPE. Prime the intensified ADL, IADL, or occupation-based shaping task with goal-oriented high-intensity stepping. Increase variability by increasing the degrees of freedom, type of object used, task sequence, task speed, or adding weights to challenge postural control, limb advancement, or arm maneuverability. If intensity is not maintained within the ADL, IADL, or occupation-based shaping task, alternate between goal-oriented stepping and the less intense task. Remember, variability within a task is the goal, and intensity is just one variable to enhance skill development. The benefit of aerobic activity is higher production of BDNF for neuroplastic changes, which is a desired therapeutic effect. However, learning can be obtained without being within the target heart rate. This is why OT-based HIT takes the approach of progressing massed and blocked practice to random practice, as random practice has shown to be the most beneficial for skill generalization. Use target heart rate to prime the intensified occupation and increase variability based on the parameter of the allotted rule for error.

 Example of Practice Progression

Helpful Tips: 

• Use the Volition Tool!

• Prime the aerobic zone with high-intensity functional mobility training. 

• Least-to-most assistance on skill acquisition chart and prompting hierarchy to increase error-based learning. 

• Patient with poor orientation for the task, Low MoCA, or AMPAC-cog score: backward chaining (UBD) or forward chaining (LBD) with most-to-least assistance to reduce excessive errors. Remember to prompt fade by reducing assistance as the patient progresses with skill acquisition.

• If the skill is retained and transferred and the patient is ready to move on, MOVE ON! and progress toward other meaningful goals that the patient has been practicing to set. They will have plenty of distributed practice training to maintain their skills.    

1. Early stages (1-2 days) of skill acquisition: use massed practice (use-dependent learning and sensorimotor adaptation). 

2. Mid stages (3-7 days) of skill retention: use distributed practice for (skill carryover) or stacked blocked practice alternating between stepping practice and non-stepping occupations. Progress task variability based on allotted error parameters (i.e., 2-3).

3. Later stages (7+ days) of skill transference: use random practice to increase challenge, error augmentation, and skill generalization. 

In OT-based HIT, 

• Skill acquisition is obtained when the activity can be successfully completed with trial and error.

• Skill retention is obtained when the activity has a successful carryover effect, practiced on a different day from when the skill was initially acquired. 

• Skill transference is obtained when the activity is performed successfully under different contexts. These may include but are limited to place, position, time, task sequence, or task demands. It is crucial to consider the patient's goals for the activity. If they are satisfied with their skills and performance and they have an independence level that reasonably reduces the burden of care, do not continue to transfer the skills into unnecessary contexts, as doing so would undermine the purpose of the patient obtaining engagement through goal-orientated behaviors.           

Schedule Example  

Key -> indicates directional for when specific practice should occur, <--> indicates nondirectional  

Week one.

Day 1. HIT functional mobility -> UBD blocked practice   

Day 2. HIT functional mobility -> LBD blocked practice -> carryover with UBD for skill retention  

Day 3. HIT functional mobility -> other non-stepping occupations (shaping task, IADL) -> carryover with UBD and LBD at the end of session 

Day 4. HIT functional mobility -> alternate with UBD and add variability based on allotted error parameters

Day 5. HIT functional mobility -> alternate with LBD and add variability based on allotted error parameters 

Day 6. HIT functional mobility -> non-stepping occupations (shaping task, IADL) -> UBD and LBD with variability.

Day 7.  OT shower. Focus on skill retention and carryover. Conduct weekly outcome measures. Reassess skills and move forward if the patient has skill transference with ADLs. 

Note. If skill acquisition has been obtained, reduce blocked practice with self-care and maintain distributed practice with variability before or after the session, as deemed appropriate. Otherwise, blocked practice may still be needed for skill acquisition, which varies from patient to patient. Monitor progress and increase progression parameters to challenge the patient further. 

Week two. 

Day 1. HIT functional mobility -> introduce new, more advanced occupations for skill acquisition via blocked practice (e.g., UE shaping toward more fine motor grasp).   

Day 2. HIT functional mobility <--> increase variable practice and randomly rotate between retained skills. Add task variability based on allotted error parameters (can easily be completed with an OT shower). 

Day 3. HIT functional mobility -> introduce new, more advanced occupations for skill acquisition via blocked practice (e.g., UE shaping toward more fine motor grasp).       

Day 4. HIT functional mobility -> introduce new, more advanced occupations for skill acquisition via blocked practice (i.e., IADLs, UE shaping, or ADLs that still need improvement).   

Day 5. HIT functional mobility <--> increase variable practice and randomly rotate between retained skills. Add task variability based on allotted error parameters.

Day 6. Perform home eval, or practice skills in simulated home context 

Day 7. OT shower and weekly outcome measures. 

Note. recycle through week one or two as needed if the patient requires additional time for practice and skill proficiency. HIT should be performed 3-5 times per week (Crozier et al., 2018). Moderate intensity is recommended for 150 minutes per week, and vigorous (high) intensity is 75 mintues (American College of Sports Medicine, 2019). The goal is to get as much as possible and monitor the challenge during and recovery process between sessions   

Discharge 

Send them home with skills!