Capstone Project Final Report

Literature Review

Occupational therapy has a unique role in supporting individuals with acquired brain injury throughout the rehabilitation process and as they integrate back into society. According to a systematic review conducted by Radomski et al. (2016), a variety of cognitive based interventions, such as memory and task-training, have strong evidence supporting their effectiveness in promoting occupational performance in individuals with traumatic brain injury.  Along with this, the use of daily functional task training has been shown to have at least moderate evidence supporting their use in promoting a return to ADLs in this population (Mohapatra & Kulnik, 2021). Occupational therapists are also equipped to evaluate a variety of factors to promote occupational participation in a variety of medical and community settings (Lam Wai Shun et al., 2017).

However, literature has shown that after an acquired brain injury, leisure and social participation can be significantly impacted due to a variety of factors such as physical disability, communication disability, fatigue, lack of access, and social stigma (Northcott et al., 2016; Wise et al., 2010).  Furthermore, qualitative research has identified that some individuals with acquired brain injury undergoing rehabilitation in  traditional medical settings do not feel that their psychosocial needs are being met by their healthcare providers (Wenzel et al., 2021).

Within this population, it is also known that significant cognitive impairments can relate to these functional and social deficits as well. Occupational therapists are also uniquely equipped to address such cognitive impairments through cognitive training individualized for clients. One such method to achieve this is through the Cognitive Orientation to Occupational Performance (CO-OP) approach. This approach focuses on global and specific cognitive strategy training for individuals with stroke and TBI and has been shown to demonstrate improved outcomes for specific (trained) and non-specific (untrained) tasks (Dawson et al., 2009; McEwen et al., 2015). This emphasizes that this approach is particularly helpful for generalizing the strategy to other areas of a client’s life where they may be having trouble, including social participation.

Along with being an effective cognitive intervention, participants who have undergone CO-OP training have stated that they appreciated how the approach differs from more traditional rehabilitation and focuses on areas that they want to improve while equipping them with the skills to address these areas independently (McEwen et al., 2010). Occupational therapists who have used the CO-OP approach with individuals with acquired brain injury have also stated that use of the approach has only enhances their practice. They have stated that the approach allows for a client centered, problem solving and guided discovery intervention that translates well to real life skills for the patient at home (Chui et al., 2020). This shows that the CO-OP approach has improved the therapeutic experience and perceived outcomes from both the client and therapist perspective and would be beneficial for use with the acquired brain injury population.

Apart from diagnoses such as stroke and traumatic brain injury that can cause significant cognitive and functional deficits, it is suggested that CO-OP is also a feasible intervention for use with individuals suffering from post-concussion syndrome or mild traumatic brain injury (Hunt et al., 2019). While individuals facing concussion or mild traumatic brain injury may not face as severe motor or cognitive deficits, they can still face a multitude of barriers such as persistent symptoms and decreased executive functioning skills that can limit their ability to engage in their normal daily routine. CO-OP can contribute to post-concussion recovery by giving patients a structured avenue to evaluate their own performance and develop strategies to not only decrease their symptoms but improve their performance in daily activities (Hunt et al., 2019).

These findings have contributed towards the formation of the current capstone project and have guided the development of the projects found within. The literature described here provides justification for use of CO-OP in an outpatient neurorehabilitation setting, along with use for the post-concussion population. As such, the current capstone project sought to identify further training and experience in utilizing the approach to evaluate and treat these populations in the outpatient neurorehabilitation setting.

Project Objectives

This project was designed to address two components. The first was to obtain additional education and training in the CO-OP approach to provide justification to the partnering site on how the approach can be used in its daily treatment sessions. The second component was to demonstrate competency in conducting a needs assessment to identify potential program development opportunities that I could assist with. As a result of that needs assessment, my program development for this capstone focused on obtain additional training and education on OT’s role in post-concussion care.

The learning objectives that were developed to achieve these goals are as follows…

1.     Demonstrate understanding of stroke population and process of addressing cognitive deficits through healthcare system and literature review.

2.     Demonstrate professionalism and effective communication skills while working with professionals.

3.     Demonstrate competency in conducting a needs assessment at site to develop further clinical skills and assist in program development.

4.     Design and implement program development project to assist with site needs.

5.     Develop foundational understanding of cognitive interventions (i.e. CO-OP/Guided Discovery) that can be used with the stroke population.

6.     Gain clinical experience and develop tools/resources to implement cognitive interventions (i.e. CO-OP/Guided Discovery) with patients.

7.     Disseminate information learned through capstone.

Methods and Results

The first step of the capstone project was to establish an understanding of the stroke population that was serviced by the clinic. To do this, I developed a brief interview questionnaire based on existing research and site-specific questions that were relevant to the capstone project. The interview focused on gathering information on the types of symptoms patients experienced, their work and employment status and aspiration, their life at home, social and community participation, mental health, and engagement in therapy. This information was used as a baseline to further inform later steps in the capstone process to ensure that the work was meeting the needs of the clinic and their patients.

Secondly, a needs assessment was conducted at the clinic to identify further program development needs. This was done through formal and in-formal interviews with the therapists and clinical directors at Memorial Hospital Belleville to identify needs for additional programming with-in the OT department. From this needs assessment, it was determined that the clinic would benefit from developing additional resources to effectively evaluate and treat the post-concussion population that the clinic sees. Another need that was identified was to identify a network of healthcare providers to whom the clinic could provide additional education and information that would increase the number of referrals the OT department receives to evaluate and treat post-concussion patients.

To address these needs, additional information on post-concussion rehabilitation was gathered through continuing education courses and discussions with other clinicians in the greater St. Louis area. As a result of addressing these needs, multiple resources were provided to the outpatient clinic and OT department to improve their ability to effectively evaluate and treat the post-concussion population.

This included a binder which contained examples and explanations of various assessment and treatment methods that can be used by the OT department, as well as a list of clinicians and therapists in the greater Saint Louis area that could be potential sources of referrals for post-concussion patients. Furthermore, two presentations were recorded for the clinic to use internally and share with potential sources of referrals. The first presentation highlighted OT’s role in post-concussion syndrome care and provided examples of areas that an OT can effectively evaluate and treat. This presentation is to be shared with internal therapists and clinicians to provide additional education. Another two presentations were provided to the OT department specifically, that outlines what a post-concussion evaluation should look like and other treatment considerations for OT. Furthermore, an EPIC “smartphrase” template was created for the clinic to use as a guideline for a post-concussion evaluation. Lastly, an educational pamphlet was revised and created to be given to therapists, clinician, and patients to further education individuals on OT’s role in concussion care and seek potential referrals.

Lastly, the capstone project sought to gain education, training, and experience in utilizing the CO-OP approach with clients in the outpatient neurorehabilitation setting. This was done because as part of the needs assessment, therapists identified that they would like to have more cognitive-based resources in the clinic to provide effective treatments. To accomplish these goals, training in the CO-OP approach was completed through the International Cognitive Approaches Network (ICAN). This training provided a comprehensive overview of all elements of the CO-OP approach and is used to train therapists interested in pursuing certification in CO-OP.

When this training was completed, patients at the clinic who may benefit from use of the CO-OP approach were identified and asked if they would like to trial use of the CO-OP approach in the clinic. Two patients agreed and completed several treatment sessions which can be outlined in more detail in their associated case studies that were created from the experience. Upon completing treatment sessions with the patients, the capstone students experience was outlined and provided via brief case studies to document how CO-OP could be used effectively in the clinic. A presentation was also provided to the clinic to highlight the core components of CO-OP and provide additional education. As a result of these efforts, therapists at the clinic were able to gain an overview of the CO-OP approach and see how a top-down cognitive based treatment approach could be used in the clinic, as well as identify next steps to pursue their own continuing education in the CO-OP approach.

Sustainability

With the resources that I provided, the clinical occupational therapy staff at Memorial Hospital Belleville Orthopedic and Neuroscience Center have increased capacity to evaluate and treat the post-concussion population. The clinic also has a details list of “next steps” to take once the capstone is completed to ensure that the educational materials created end up in the right hands to increase the number of referrals the clinic receives for post-concussion patients. Given that post-concussion patients often do not receive adequate rehabilitation services to treat their condition, it is important for occupational therapists to advocate for their profession and scope of practice. This was addressed through the current capstone project but should also be explored further in educational settings so that students entering these fields have a better baseline understanding of OT’s role in this area.

Regarding CO-OP, the clinical staff have reported an increased understanding of the benefits and uses of the CO-OP approach in practice and have been provided a detailed outline of the education and certification process that is necessary for them to complete in order to use it in daily practice. Therapists at the site have reported verbal interest in this aspect of the project and stated that they plan to reference these materials in the future if they decide to pursue certification in the CO-OP approach. In terms of providing additional education in OT schools, I think it would be beneficial for students to gain more hands-on experience practicing the core components of CO-OP. In practice, CO-OP is often mis-understood and under-utilized. Providing OT students with more comprehensive education and practice using the CO-OP approach by licensed therapists would be beneficial for the profession by helping students and therapists to practice at the top of their licenses and utilize a variety of treatment approaches to meet their client’s needs. 

References

Chui, A., Mazzitti, D., Nalder, E., Cameron, D., Polatajko, H. J., & Dawson, D. R. (2020, 2020/02/17). Therapists’ experience of the cognitive orientation to daily occupational performance (CO-OP) approach: Shifting from conventional practice. Scandinavian Journal of Occupational Therapy, 27(2), 133-141. https://doi.org/10.1080/11038128.2018.1483424

Dawson, D. R., Gaya, A., Hunt, A., Levine, B., Lemsky, C., & Polatajko, H. J. (2009). Using the Cognitive Orientation to Occupational Performance (CO-OP) with Adults with Executive Dysfunction following Traumatic Brain Injury. Canadian Journal of Occupational Therapy, 76(2), 115-127. https://doi.org/10.1177/000841740907600209

Hunt, A. W., Paniccia, M., Mah, K., Dawson, D., & Reed, N. (2019). Feasibility and Effects of the CO–OP Approach™ in Postconcussion Rehabilitation. The American Journal of Occupational Therapy, 73(1), 7301205060p7301205061-7301205060p7301205011. https://doi.org/10.5014/ajot.2019.027995

Lam Wai Shun, P., Bottari, C., Ogourtsova, T., & Swaine, B. (2017). Exploring factors influencing occupational therapists’ perception of patients’ rehabilitation potential after acquired brain injury. Australian Occupational Therapy Journal, 64(2), 149-158. https://doi.org/10.1111/1440-1630.12327

McEwen, S., Polatajko, H., Baum, C., Rios, J., Cirone, D., Doherty, M., & Wolf, T. (2015). Combined Cognitive-Strategy and Task-Specific Training Improve Transfer to Untrained Activities in Subacute Stroke:An Exploratory Randomized Controlled Trial. Neurorehabilitation and Neural Repair, 29(6), 526-536. https://doi.org/10.1177/1545968314558602

McEwen, S. E., Polatajko, H. J., Davis, J. A., Huijbregts, M., & Ryan, J. D. (2010, 2010/01/01). ‘There's a real plan here, and I am responsible for that plan’: participant experiences with a novel cognitive-based treatment approach for adults living with chronic stroke. Disability and Rehabilitation, 32(7), 541-550. https://doi.org/10.3109/09638280903180189

Mohapatra, S., & Kulnik, S. T. (2021). Kitchen-related tasks used in occupational therapy during rehabilitation of adults with acquired brain injury: A systematic review. British Journal of Occupational Therapy, 84(1), 22-41. https://doi.org/10.1177/0308022620950975

Radomski, M. V., Anheluk, M., Bartzen, M. P., & Zola, J. (2016). Effectiveness of Interventions to Address Cognitive Impairments and Improve Occupational Performance After Traumatic Brain Injury: A Systematic Review. The American Journal of Occupational Therapy, 70(3), 7003180050p7003180051 -7003180050p7003180059. https://doi.org/10.5014/ajot.2016.020776