Anywhere from 30 to 50% of individuals who sustain stroke experience cognitive impairments. Individuals with cognitive impairments after stroke are less likely to regain independence with activities of daily living than individuals without cognitie impairments after stroke. Loss of independence is associated with significant costs, as individuals with persistent disabilities require more rehabilitation services, and more resources to support their living, whether in institutional or community settings. Interventions ideally suitd for training individuals with cognitive impairments have the potential to promote independence, and reduce health care expenditures after stroke. The best time to initiate training to promote independence with daily activities is during acute rehabilitation. However, the best method for training remains unclear. Directed training maximizes the expertise of the rehabilitation practitioner, who identifies and prioritizes problematic activities, identifies barriers to performng these activities, generates strategies to address these barriers and instructs patients in these strategies, and repeats the process with a variety of problematic activities identified during the rehabilitation program. Guided training maximizes the expertise of the patient, by teaching the patient how to apply the same 4-step process themselves. Thus, the patients identify and prioritize activities, identify barriers to performing activities, generate their own strategies fo addressing these barriers, and learn this process through iterative practice. In doing so, guided training equips patients with "practical" skills that have the potential to generalize beyond activities addressed during the intervention program to novel problematic activities that arise after the intervention program, thereby promoting long-term independence. While evidence suggests that both training methods are feasible and beneficial for individuals with cognitive impairments, it is unclear which method may be superior in promoting independence after acute stroke.
The aim of the proposed pilot study is to examine the effects of directed training and guided training on independence with daily activities. The PIs predict that individuals with cognitive impairments in both groups will demonstrate significant improvement in independence with daily activities in the first 6 months after rehabilitation admission, but that individuals wh receive guided training will demonstrate significantly more improvement than individuals who receive directed training. At the end of this pilot study, the PIs will be able to identify optimal training methods for promoting independence, particularly among individuals with cognitive impairments engaged in acute rehabilitation. In addition, they will gather pilot data that will allw them to examine potential explanatory factors influencing treatment response, as well as begin to examine characteristics of individuals who benefit from these training methods. The PIs will use findings from the present study to refine their protocols before conducting future large scale clinical trials examining the efficacy of training methods in individuals with cognitive impairment after acute stroke.

Public Health Relevance

Individuals with cognitive impairments after stroke sustain significant disability in their daily tasks. The proposed study examines training methods to identify the best rehabilitation approach to help individuals with cognitive impairment gain more benefit from rehabilitation and potentially reduce their long-term disability.

National Institute of Health (NIH)
Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD)
Small Research Grants (R03)
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Study Section
Pediatrics Subcommittee (CHHD)
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Michel, Mary E
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University of Pittsburgh
Other Health Professions
Schools of Allied Health Profes
United States
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Urquhart, Joelle R; Skidmore, Elizabeth R (2014) Guided and directed cues: developing a standardized coding scheme for clinical practice. OTJR (Thorofare N J) 34:202-8
Rodakowski, Juleen; Skidmore, Elizabeth R; Reynolds 3rd, Charles F et al. (2014) Can performance on daily activities discriminate between older adults with normal cognitive function and those with mild cognitive impairment? J Am Geriatr Soc 62:1347-52