Feasibility Testing of a Complex Intervention for Motor and Activity Limitations in Persons with Stroke

The sequelae of stroke can take a variety of forms, but frequently motor and cognitive deficits are immense barriers to successful life participation. The culmination of physical, psychosocial, and cognitive deficits impedes return to meaningful life activities. Historically, motor deficits in neurologic populations have been addressed through an impairment-based, bottom-up approach. A bottom-up approach addresses a client’s deficit without recognition of its influence on daily tasks. For example, virtual reality (VR) interventions are successfully using technology therapeutically to develop engaging, client-centered environments to ameliorate impairments. While this model has consistently reported significant change in the targeted impairment, there is little evidence of associated changes in occupational performance. In contrast, a top-down approach promotes a holistic tactic where client-chosen activities are the basis of therapy sessions. Cognitive Orientation to daily Occupational Performance (COOP) and the Multicontext treatment approach, types of metacognitive strategy training (MCST) interventions, are top-down, client-driven approaches that empower the client to implement cognitive strategies for conquering occupational limitations. Importantly, MCST interventions have demonstrated significant functional changes on both trained and untrained goals, indicating the ability of clients to transfer learned skills. Little is known of the effects of a combining an impairment-based intervention with cognitive strategy use. It is hypothesized that through application of cognitive strategies and improved upper extremity motor performance, there will be improved occupational performance in persons with stroke (PWS). Therefore, the purpose of this project was to evaluate the feasibility and preliminary effect of a complex intervention, MetacogVR. A series of three studies was conducted (Chapters 2-4). In the first study (Chapter 2), we conducted a series of three focus groups with key stakeholders including PWS, caregivers, and occupational therapists. The purpose of this study was to gather qualitative data to determine the extent to which MetacogVR was perceived as being acceptable and practical by those who would be either receiving it or administering it. Resulting data were analyzed using inductive qualitative content analysis. Results support MetacogVR as being acceptable in terms of motivation, client-centeredness, and level of intensity. Further, it was perceived as being practical due to low-cost of equipment and the small amount of space necessary for the intervention. In the second study (Chapter 3), we administered an abbreviated version of MetacogVR with five PWS. The purpose of this study was to gather additional qualitative data to allow for revision of MetacogVR, as needed, and to gather quantitative data on the number of repetitions achieved as well as the motivation, engagement, and satisfaction of the PWS. Findings revealed an average of 423 repetitions achieved in each VR session and quantitative data indicated high levels of motivation, engagement, and satisfaction with MetacogVR. In the third and final study (Chapter 4), we evaluated the preliminary effect of MetacogVR. The full, 12-week intervention was administered to ten PWS. Assessments of occupational performance, upper extremity motor performance, cognition, and self-efficacy were conducted pre- and post-intervention. Results showed positive, significant changes with measures of actual performance of trained and untrained goals, client perceptions of performance with trained goals, satisfaction with trained and untrained goals, and upper extremity motor performance. Collectively, these three studies support MetacogVR as being feasible and having a clinically meaningful effect of primary outcome measures of actual occupational performance, client perceptions of performance, and motor performance