Self-Care

In OT, self-care often includes basic activities of daily living (ADLs). Can a patient complete tasks such as dressing, feeding, grooming, or bathing? After experiencing a stroke, the skills needed to perform these self-care ADLs may be impacted. Both physical and cognitive performance skills are necessary for self-care tasks. Physical skills may include: 

• balance

• postural control

• grasp/reach 

• object manipulation  

Cognitive skills include but are not limited to: 

• orientation and object recognition

• initiation

• sequencing

• task termination 

• judgment/safety awareness

• problem-solving

• awareness

Intensity With Self-Care

Increasing BDNF through high-intensity functional mobility training before performing a self-care task may enhance the patient's ability to make neuroplastic changes related to the activities. It may also help maintain task intensity should the ADL be appropriate to intensify. This method can be referred to as "priming," the intensified self-care task. For this program, upper (UBD) and lower body dressing (LBD) activities are recommended to practice with intensity. These activities include themes concerning task-specificity similar to other self-care ADLs (i.e., bathing and toileting). However, they do not raise safety concerns nor invade a patient's privacy to the same extent. Dressing can be practiced with extra clothing to avoid making patients feel uncomfortable. 

The purpose of intensifying self-care ADLs is to increase the challenge. Nevertheless, skills increase with practice, and practice can be done in multiple ways. Here, we discuss different forms of practice, including massed, distributed, blocked, and random. 

Unlike high-intensity functional mobility, self-care has more complex variables, including heavy use of the hands and cognitive demands. The upper extremities are almost exclusively cortical and modulated by the cerebellum, so a stroke affecting such brain regions makes it difficult to rehabilitate the affected upper extremity (Ackerman,1992). Motor learning strategies that use evidence-based approaches for memory and skill retention are recommended for remediating the upper extremity post-stroke with self-care tasks.

Types Practice and Motor Learning Strategies

Whole vs. Part Practice

Whole practice is recommended for most patients because it creates the most natural context and variability within the context. However, sometimes, an OT might need to target task subcomponents due to persevering deficits within a specific performance skill. In such cases, part practice may be warranted. Error-based learning is still recommended for these subtasks. For most patients who demonstrate severe cognitive deficits, it is recommended to focus on high-intensity functional mobility training rather than a specific performance skill via part practice. Doing so will provide the most functional gain for the patient within the limited time they have in rehab.    

Massed vs. Distributed 

Massed practice involves multiple repetitions with fewer breaks, whereas distributed practice involves fewer repetitions with breaks in between. Evidence favors mass practice for immediate skill acquisition and distributed practice for longer-term retention (Maier et al., 2019). For intensified self-care, massed practice is recommended initially. However, distributed practice should be included once the activity is performed with minimal struggle or the patient has skill acquisition, as it can help increase retention and carryover of skill.  

Cognitive demands are high in the early stages of skill acquisition (cognitive stage), and they reduce as skill mastery increases (autonomous stage). Evidence supports that early stages of skill acquisition should include massed and distributed practice, and task variability should be introduced as proficiency increases. Use the skill acquisition chart to help guide the progression of task variability and challenge.

Random vs Blocked Practice

Practice done with variability and random rotation is more effective with memory building, motor learning, and mastery of a given task (Gill et al., 2018).  Blocked practice can be used to increase skill acquisition, and variability should be added as soon as the patient is able to complete the task with minimal struggle or with trial and error. For example, UBD can be performed multiple times under conditions (blocked practice), or it can be performed with variability (different shirts, seated or standing). Random rotation of practice is most effective for generalizing skills, and this might include alternating between UBD, LBD, and any other activity that is needed for the patient to increase independence in self-care. The bottom line. The more success with variability, the higher the skill mastery. However, too much variability can interfere with attention, working memory, and task performance, leading patients to perceive themselves as unsuccessful. Use the skill acquisition chart, prompting hierarchy, and protocol to determine the most appropriate practice for each patient at a given time.  

Dressing can be practiced blocked or randomly. For example, complete an interval of high-intensity stepping and have the patient perform UBD multiple times through massed blocked practice. This is good for initial skill acquisition but has limited effects on skill retention (Hanlon, 1996; Maier et al., 2019). However, it may be effective in helping someone who has difficulty sequencing the dressing tasks and practicing it for the first time in rehab. Distributed practice is more effective for skill retention and can include multiple attempts with a dressing task and taking breaks in between. However, implementing distributed practice in the clinic or rehab can become impractical should the breaks consist of times of inactivity.   

"Stacking" Blocked Practice. Although technically a form of massed practice, a stacking blocked practice challenges multiple skills. This approach would look like running a functional mobility HIT session and alternating it with multiple attempts of the dressing task. Obtaining skill acquisition from this approach also includes a greater sense of novelty and allows the patient to break between tasks, reducing the mundane. Monitor heart rate throughout the increased challenge and use the skill acquisition chart to gauge when to assist or increase task variability.   

The End Goal is Random Practice 

Novelty and variability should be introduced to the patient as long as the patient can tolerate the sensorimotor adaptation through prediction errors. Novelty enhances memory formation, motor learning, and neuroplasticity (Hanlon, 1996). Introduce error augmentation throughout the sessions and observe if the patient is making the same error multiple times. Choose an error parameter (i.e., making the same error 3-5 times) and then assist as needed using a least-to-most approach. For example, support positioning should be used before completing the subpart of the task. Use the prompting hierarchy to identify the least-to-most invasive means for assistance.       

Keep the Intensity High With Challenge and Variability

Although intensity matters with neuroplasticity. Currently, there is no evidence to support that increasing the heart rate during self-care will enhance serum BDNF levels. However, aerobic exercise has been shown to enhance BDNF levels effectively. The aim of intensified self-care/dressing is to target task specificity while maintaining the target heart rate acquired from evidence-based stepping practice.  

What if My Patient has Poor Cognition?

In a study by Walker et al. (2003), they surveyed OTs to determine the most common barriers to dressing after a stroke. These mainly included cognitive-related challenges such as apraxia, neglect, memory, orienting clothing, and sequencing the affected side. For UBD, the backward chaining method is recommended over attempting to target individual subcomponents because it incorporates multiple components at once within the actual context. It can be performed with massed, distributed, blocked, or random practice. Use the backward chaining method and a most-to-least prompting approach to reduce excessive errors from occurring (West et al., 2014). Backward chaining involves the OT completing the initial steps in dressing that the patient cannot yet perform or the harder steps. As the dressing practice is repeated, reduce the assistance provided and have the patient increase independence in the steps they had not previously completed. For LBD, use the forward chain method with most to least assistance or prompting because the most difficult part of this task is toward the end, where balance is also challenged more significantly. However, depending on the skill deficits, LBD may be performed with either forward or backward chaining, depending on which subpart is most difficult. For example, if a patient's major limitation is threading clothing, use a backward chain. If the limitation is dynamic balance, use a forward chain. See the image below to illustrate the prompting hierarchy. This approach allows for increased practice and repetitions compared to having the patient spend excessive time dressing their affected limb inaccurately.           

Helpful Tips: 

• 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.   

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 or stacked blocked practice alternating between stepping practice and UBD. Progression of task variability is based on allotted error parameters (2-3 of the same mistake consecutively).    

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