Cognitive strategies bring increased Functional outcomes

Many people after spending time in rehab for their stroke still have trouble performing everyday tasks once returning home. The big troublesome areas in chronic stroke are bathing and dressing, with 68% and 59% of people having continued difficulty, respectively, at 1 yr poststroke. People also self-report needing high levels of assistance with instrumental activities of daily living, including meal preparation (77%), housekeeping (70%), and shopping (52%), 1 yr poststroke (Hartman-Maeir et al., 2007). As clinician we try to be occupation-based with our interventions and assessments, but the majority of stroke rehab is focused on the physical impairments.

Virtual reality (VR) has started to become a widely used intervention for motor rehabilitation especially for upper extremity impairments. VR is good at focusing on the physical impairments but doesn’t always address the outcomes for functional impairments such as bathing or dressing.

Metacognitive strategy training (MCST) interventions, a class of interventions that use cognitive strategy use to overcome performance deficits, are top–down and seek to elicit change directly on functional outcomes (Polatajko et al., 2012). Cognitive strategies are pertinent for aiding in learning new ways to perform functional tasks for patients after stroke. MCST interventions have building evidence for positive outcomes on both trained and untrained tasks within the stroke population (McEwen et al., 2009, 2010, 2015). 

Researchers, A. Boone, T. Wolfe, and J. Engsberg, developed an intervention, MetacogVR, that consists of a bottom-up, VR motor rehabilitation component and a top-down, cognitive strategy use practiced within client-chosen goals in people with stroke. The rationale is that direct improvements in motor impairment when drawn on during task performance and guided by cognitive strategy use may lead to greater functional performance than either approach in isolation. MetacogVR integrates impairment and function through the application of three key active ingredients: movement repetitions, guided discovery, and cognitive strategy use. The MetacogVR approach is innovative because it draws on the strengths of impairment-based approaches for remediation of upper extremity impairment and the strengths of cognitive strategy use for achieving improvements in activity performance; pairing of the two approaches was hypothesized to have both summative and interactive effects (Boone et al, 2019). MetacogVR is feasible for adults with chronic stroke. The effect of MetacogVR is best captured through measures of upper extremity motor performance, occupational performance, and participation (Boone et al, 2019).

As clinicians we need to be looking for interventions that allow us to be holistic and evidence based to reach the highest outcomes. Interventions like, MetacogVR, gives us the ability to address the physical impairment along with the functional impairment to allow our patients to reach their goal of independence. We should have equal percentages of gains when looking at both physical and functional. These researchers just give one example of how you can create multi-dimensional interventions that promote the biggest gains. If you are a clinician that loves technology, be resourceful and creative of how to use both technology and functional components to benefit you patients.

Ashley Gatewood, MOT, OTR/L, CSRS

References

Anna E. Boone, Timothy J. Wolf, Jack R. Engsberg; Combining Virtual Reality Motor Rehabilitation With Cognitive Strategy Use in Chronic Stroke. Am J Occup Ther July/August 2019, Vol. 73(4), 7304345020p1–7304345020p9. doi: https://doi.org/10.5014/ajot.2019.030130

Hartman-Maeir, A., Soroker, N., Ring, H., Avni, N., & Katz, N. (2007). Activities, participation and satisfaction one-year post stroke. Disability and Rehabilitation, 29, 559–566. https://doi.org/10.1080/09638280600924996

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, 104–109. https://doi.org/10.5014/ajot.2012.001784

McEwen, S. E., Polatajko, H. J., Huijbregts, M. P., & Ryan, J. D. (2009). Exploring a cognitive-based treatment approach to improve motor-based skill performance in chronic stroke: Results of three single case experiments. Brain Injury, 23, 1041–1053. https://doi.org/10.3109/02699050903421107