727120

research-article2017
OTJXXX10.1177/1539449217727120OTJR: Occupation, Participation and HealthRowe and Neville

Article

OTJR: Occupation, Participation and

Health
Task Oriented Training and Evaluation at 2018, Vol. 38(1) 46–55
© The Author(s) 2017
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DOI: 10.1177/1539449217727120
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Veronica T. Rowe1 and Marsha Neville2

Abstract
Principles of experience-dependent plasticity, motor learning theory, and the theory of Occupational Adaptation coalesce
into a translational model for practice in neurorehabilitation. The objective of this study was to explore the effectiveness of
a Task Oriented Training and Evaluation at Home (TOTE Home) program completed by people with subacute stroke, and
whether effects persisted 1 month after this training. A single-subject design included a maximum of 30, 1hour sessions of
training conducted in participants’ homes. Repeated target measures of accelerometry and level of confidence were used to
assess movement and confidence in weaker arm use through baseline, intervention, and follow-up phases of TOTE Home.
Four participants completed TOTE Home and each demonstrated improvement in movement and confidence in function.
The degree of improvement varied between participants, but a detectable change was evident in outcome measures. TOTE
Home, using client-centered, salient tasks not only improved motor function but also facilitated an adaptive response
demonstrated in continued improvement beyond the intervention.

Keywords
stroke, rehabilitation, occupational therapy

Stroke is the fifth leading cause of death in the United States TOT is based on behavioral neuroscience as well as recent
and is a major cause of serious long-term disability models of motor control and motor learning. TOT programs,
(Kochanek, Xu, Murphy, & Arias, 2014). About 800,000 such as the Accelerated Skill Acquisition Program (ASAP;
people in the United States have a stroke each year Winstein et al., 2013), have been suggested for clinical prac-
(Mozaffarian et al., 2015). Upper extremity (UE) hemipare- tice (Winstein, Lewthwaite, Blanton, Wolf, & Wishart, 2014;
sis is a common reason for disability in about half of the Winstein & Wolf, 2004) utilizing principles of motor learn-
stroke survivor population (Kelly-Hayes et al., 2003). ing theories (Bass-Haugen, Mathiowetz, & Flinn, 2008).
Neuroscience research has identified specific principles Although the evidence supports TOT within laboratory envi-
shown to improve hemiparesis through experience-depen- ronments, more research is needed to examine the translation
dent plasticity (Kleim & Jones, 2008). A review article by of these principles into everyday practice.
Kleim and Jones (2008) summarized recent findings sup- The occupational therapy theory of Occupational Adaptation
porting 10 principles upon which neurorehabilitation should (OA) (Schkade & Schultz, 1992; Schultz & Schkade, 1992) is a
be based. These principles include use it or lose it, use it and theory within which to view TOT. OA states that humans have a
improve it, specificity, repetition, intensity, time, salience, personal desire to engage in occupations and a demand from
age, transference, and interference. their environment to complete occupations that lead to a press
One treatment model incorporating these principles of for mastery, which requires adaptation (Schkade & Schultz,
neuroplasticity is Task Oriented Training (TOT). When 1992; Schultz & Schkade, 1992). When following the theory of
applied to clinical practice, TOT has been described by Lang OA in a TOT program, the therapist designs interventions that
and Birkenmeier (2014) as “involving the active, repetitive will facilitate the client’s adaptive responses. These methods
practice of functional activities to learn or relearn a motor may include facilitation of sensorimotor, cognitive, and psycho-
skill” (p. xi). Task oriented implies the participant is engag- social processes that the client may use when facing challenging
ing in salient behavioral experiences that directly replicate
the sensorimotor skill needed to successfully execute the 1
University of Central Arkansas, Conway, USA
motor skill for completing the task. Training implies that the 2
Texas Woman’s University, Dallas, USA
behavioral experiences are not just repetition of the same
Corresponding Author:
sensorimotor skill but involves progressive challenges to a Veronica T. Rowe, University of Central Arkansas, 201 Donaghey Ave,
participant’s capabilities and involves tasks that are mean- Conway, AR 72035, USA.
ingful to the participant (Lang & Birkenmeier, 2014). Email: [email protected]
Rowe and Neville 47

situations. The therapist and client collaboratively identify informed of the inclusion criteria. Participants were included if
meaningful activities and tasks to fulfill the client’s desire for they exhibited UE hemiparesis but met minimal movement cri-
mastery. For the adaptive process to occur, OA theory proposes teria in the weaker arm and hand. The minimal movement cri-
the activity or task must have meaning to the client and present teria were established in the Extremity Constraint Induced
the client with the just right press for performance. The therapist Therapy Evaluation (ExCITE) trial (Winstein et al., 2003). It
initially provides help in managing the environment during was necessary for participants to have a minimal amount of
training, then progressively decreases the level of assistance movement in their weaker arm and hand to begin to engage in
provided to promote the individual’s adaptive processes through TOT activities. Other inclusion criteria included having mini-
graded, independent problem-solving, and ultimately mastery mal cognitive deficits as demonstrated by a 24 or higher on the
of performance of the desired activity. Although TOT training Mini-Mental Status Exam (MMSE) (Folstein, Folstein, &
focuses on task performance, OA enhances TOT to address the Fanjiang, 2002). Cognition needed to be relatively intact for
client’s intrinsic desire to master meaningful tasks and activi- participants to perform the necessary independent problem-
ties. OA leads to mastery of meaningful tasks and activities, a solving required of this TOT program. The participants could
sense of self-efficacy that then theoretically leads to a further identify at least five specific tasks they wished to achieve with
desire of mastery. The internalized process where humans desire their weaker arm and hand. This was determined with the
to engage in occupation and its relationship to client’s desire for Canadian Occupational Performance Measure (COPM) (Law
mastery is the essence of OA. et al., 2005). It was essential to have participants who could
Most of the research to date on TOT has been conducted in identify and wanted to improve movement of their weaker arm
controlled research environments and clinics (Lang et al., and hand in specific activities. They had to be at least 21 years
2016; Waddell, Birkenmeier, Moore, Hornby, & Lang, 2014; of age and able to communicate in English. The time frame of
Winstein et al., 2016). Further research is needed to explore recovery was 2 to 12 months after their stroke, which would
the effectiveness of translating current TOT programs to more classify them in a subacute level of recovery, and they were not
naturalistic contexts, such as participants’ homes. This trans- receiving occupational therapy treatment. This parameter was
lation can be enhanced with the theoretical guidance of OA chosen to prevent confounds of spontaneous recovery, alternate
and neuroplasticity principles embedded in motor learning therapies occurring at the same time, and that participants had
theory. Thus, the aim of this study was to explore the effec- returned to their home environment.
tiveness of a TOT program and evaluation at home completed Exclusion criteria included UE pain that interfered with
by people with subacute stroke, and whether effects persisted activities of daily living, requiring maximal assistance for
1 month after this training. The intervention in this study is a mobility, arm or hand injury (unrelated to the stroke), UE
TOT program with standardized evaluations conducted in amputations, inability to participate due to any illness, social
participants’ homes; thus it is referred to as TOTE Home or geographical reason (unsafe and/or too far away from the
(Task Oriented Training and Evaluation at Home). therapist), and any other diagnosis or limiting conditions that
would affect participation.

Method
Procedures
Study Design
Evaluations. Repeated measures of target behaviors included
A single-subject design was used to assess repeated mea- UE movement (accelerometry) and self-efficacy. These out-
sures of arm motor movement (accelerometry) and self-effi- comes were measured at baseline (8 consecutive days), dur-
cacy throughout baseline, intervention, and follow-up phases ing intervention (1 day a week for 10 weeks), immediately
of the TOTE Home. In this design, the participant acts as his following the intervention (8 consecutive days), and at
or her own control and data are analyzed to compare change 1-month follow-up (8 consecutive days). Accelerometry
during the baseline, intervention, and follow-up phases. recordings were downloaded by the therapist at the end of
Target behaviors were assessed repeatedly at baseline (eight each of the 8 consecutive days for baseline, post-interven-
data points over 8 days), during the intervention (10 data tion, and 1-month follow-up. During intervention, the thera-
points over 10 weeks), as a follow-up when the intervention pist downloaded data after each day of the week in which the
ended (eight data points over 8 days), and 1 month after the accelerometer was worn. Participants independently com-
intervention (eight data points over 8 days). The procedures pleted the Brief Self-Efficacy Scale on the same days in
followed in this study were in accordance with the ethical which accelerometry was recorded for baseline, post-inter-
standards of the university. vention, and 1-month follow-up. During the intervention, the
therapist recorded the participant’s response to the Brief
Self-Efficacy Scale.
Participants UE movement was measured using Actigraph’s Bluetooth®
Following approval of the institutional review board, partici- Smart wGT3X-BT wireless activity monitor (ActiGraph,
pants were recruited through local clinicians who were Pensacola, FL). Accelerometry to measure arm movement
48 OTJR: Occupation, Participation and Health 38(1)

provides an objective, real-world index of the weaker arm The intervention during each of the training sessions was
activity and has good psychometric properties (Uswatte et al., modeled after the protocol outlined in Winstein et al., (2013);
2005; Uswatte et al., 2006). Accelerometry is a valid and reli- however, it occurred in the participant’s home setting and
able measure of UE activity used in stroke research that is involved tasks in the participant’s natural environment.
well-established (Bailey, Klaesner, & Lang, 2014; Lang, Participants were offered a mitt to wear on the less affected
Edwards, Birkenmeier, & Dromerick, 2008; Lang, Wagner, hand during the time outside of therapy to promote use of the
Edwards, & Dromerick, 2007; Uswatte et al., 2005; Uswatte more affected UE. Appropriateness and safety were addressed
et al., 2006; Uswatte et al., 2000). The Actigraph has been in regard to wearing the mitt (Wolf et al., 2006).
shown to be sensitive and collect accurate data on UE move- During each intervention session, the participant chose
ment for research purposes (André, Didier, & Paysant, 2004; activities they wanted to do with their weaker arm and hand.
Bailey et al., 2014; Bailey & Lang, 2013; Lang et al., 2008; The therapist and participant would collaboratively perform
Lang et al., 2007; Uswatte et al., 2005; Uswatte et al., 2006; task and movement analyses for each task in the participant’s
Uswatte et al., 2000). This provided an objective measure of natural environment to determine the key movement dys-
the amount of movement of the participant’s weaker arm and functions or impairments. The goal of the intervention train-
hand outside of therapy. Each participant wore an Actigraph ing was to focus attention and effort directly on the
on both wrists for 8 days at baseline, post-intervention, and at problematic area to facilitate skill acquisition instead of a
follow-up, as well as once weekly, for 24 hours, during the compensatory strategy (Winstein et al., 2013).
intervention. Wearing the Actigraph on both arms was sug- Experience-dependent neuroplasticity principles (e.g., rep-
gested by Uswatte and colleagues (Uswatte et al., 2000; etition, intensity) were used to drive progression and build
Uswatte et al., 2005; Uswatte et al., 2006) to calculate ratio motor capacity (Kleim & Jones, 2008). Training was collab-
measures (data from the stronger arm are reported elsewhere). orative and interactive with the participant providing problem
Acceleration (as measured by the Actigraph) was sampled and identification as feasible (e.g., “What is keeping you from
analyzed with techniques suggested by Bailey and Lang completing that task in the way that you want?”) and solutions
(2013) and Uswatte et al. (2000), which include the use of a through self-assessment and therapist feedback/suggestions.
threshold filter. Specifically, the threshold-filtered recordings The repetition of practice, along with participant problem-
measured the duration of movement accurately and with very solving and self-assessment, led to confidence building and
little variability (Uswatte et al., 2000). Step counts were based empowerment in this participant-driven intervention. These
on accelerometer data. In this study, it is the movement of the aspects were embedded in the training and education during
weaker arm that was recorded as “steps.” Number of steps per each session (Winstein et al., 2013). Most of the intervention
day were analyzed. involved the participant working on goals independently out-
Confidence of using the weaker arm was assessed once a side of therapist and participant meetings. These activities
day, on the same days UE movement was recorded, with a encouraged specific practice in the home or community envi-
Brief Self-Efficacy Scale. A specific goal was chosen by ronment (Winstein et al., 2013).
each participant at the beginning of the study and agreed to The manual titled Upper-Extremity Task-Specific Training
be appropriate to work on throughout the study. The Brief After Stroke or Disability by Lang and Birkenmeier (2014)
Self-Efficacy Scale was used as an assessment of the partici- was also utilized to give a general overview of task-specific
pant’s perceived confidence in completing the chosen goal. training for the UE and to help guide each activity the partici-
The Brief Self-Efficacy Scale was originated in the pant chose to work on. For activities not included in this
Interdisciplinary Comprehensive Arm Rehabilitation manual, the therapist analyzed the activity using the same
Evaluation (ICARE) study (Winstein et al., 2013) as a mea- format that is represented in the manual. At the end of each
sure of the participant’s confidence in functionally using the session, a daily task-specific training summary page was
weaker arm and hand. On this scale, during each phase of the completed to document the total number of repetitions and
study, the participant was asked to provide a number between the total minutes on task completed as counted manually and
0 and 10 in response to the question, “How confident are you recorded by the therapist. This manual and the documenta-
that you can (fill in specific priority task activity)?” All tion forms accompanying each task assisted in standardizing
assessments were conducted in the participants’ homes. the intervention.
See Figure 1 for a schematic outline of the methodologi-
Intervention. TOTE Home included a maximum of 30 ses- cal procedures of this study.
sions of training with one-on-one, therapist and participant
meetings, two to three times per week, for 1 hour each time,
Data Analysis
for a maximum of 10 total weeks. The same therapist (who is
also the first author) completed all trainings. This therapist Visual examination of the data was utilized to assess the tar-
has had extensive experience in neurorehabilitation in vari- get behavior outcomes of the study (repeated measures of
ous clinical settings as well as research studies involving participant self-efficacy ratings on a priority task and UE
TOT and constraint induced movement therapy. movement as measured by accelerometry). Graphic analysis
Rowe and Neville 49

Figure 1. Schematic of procedures.

Note. TOTE = Task Oriented Training and Evaluation; MMSE = Mini-Mental Status Exam; CESD-R = Center for Epidemiologic Studies Depression
Scale–Revised; COPM = Canadian Occupational Performance Measure.

and visual inspection are the traditional analytic tools used to stroke within 12 months and had completed their home
present and interpret the results of single-subject design health and outpatient occupational therapy. Six of the 10
research (Kazdin & Tuma, 1982; Ottenbacher & York, 1984). participants recruited were excluded due to the inability to
Target behaviors of self-efficacy and movement with accel- meet the minimal movement criteria, and/or other inclu-
erometry were analyzed within-phase and between-phase sion criteria. See Table 1 for specific demographic descrip-
(baseline, intervention, post-intervention, and 1-month fol- tions and characteristics of each participant’s TOTE Home
low-up; Portney & Watkins, 2009). intervention.
The change between phases was analyzed using effect
sizes. Assessing the degree of change is a clinically practical
way to interpret this data (Ferguson, 2009). Effect sizes focus Self-Efficacy Ratings of Priority Task
on the magnitude of change between phases rather than Participants 1 and 4 exhibited the greatest change in ratings of
whether differences are statistically significant (Kromrey & their confidence of performing their chosen priority tasks as evi-
Foster-Johnson, 1996). The effect size, or amount of change denced by visual inspection and statistically by the large effect
between phases, was calculated with a g-index (Cohen, 1988). size calculated between all stages of the study. Visual examina-
The g-index was calculated using the proportion of scores tion of the ratings from Participant 1 on her level of confidence
above the scores at baseline. In interpreting the g-index, a for brushing her teeth trended very low at baseline, steadily
higher proportion of data points in the intervention compared improved with a positive trend during the TOTE Home inter-
with the baseline was desirable because an increase in the tar- vention and post-evaluation, and reached almost complete con-
get behavior was wanted. The size of the effect was rated as fidence at the 1-month follow-up. This trend was justified with
small if the index was less than .3, medium if the index was .31 a g-index = 1 for each comparison between baseline with inter-
to .5, and large if the index was greater than .51 (Cohen, 1988). vention, post-intervention, and follow-up. Even though
Data were recorded and organized into charts and graphs uti- Participant 4 started the study at a higher level of function and
lizing SSD for R, which is a statistical software package spe-
confidence, visual inspection of her positive trend in confidence
cific to single-subject designs (Auerbach & Schudrich, 2013;
showed improvements by rating herself with complete confi-
The R Project for Statistical Computing, n.d.).
dence at post-evaluation and 1-month follow-up and were also
justified with a large effect size (g-index = 1 for each compari-
Results son between baseline with intervention, post-intervention, and
follow-up). Both Participants 2 and 3 did not appear to improve
Participant and Intervention Characteristics in their levels of confidence as much as the other participants
Four eligible participants, from 10 screened, were recruited when visually examining their trends over time. In fact, they had
and consecutively enrolled. Each participant had a first only medium effect sizes for their changes in confidence levels.
50 OTJR: Occupation, Participation and Health 38(1)

Table 1. Participant Demographics and Characteristics of TOTE Home Intervention.

Participant 1 Participant 2 Participant 3 Participant 4

Sex Female Male Male Female

Age (years) 86 54 61 57
Months post CVA 4.5 4.5 8 2
CVA type Ischemic Ischemic Hemorrhagic Ischemic
Living situation Lives with family (daughter Lives with family (wife, Lives with family (wife) Lives alone
and son-in-law) daughter, 2 grandsons)
Dominant side Right Right Right Right
Affected side Right Left Left Right
MMSE 28 25 24 30
CESD-R 13 39 4 17
SAFER Home 9 6 6 6
Priority task identified Brushing teeth Buttoning shirt Buttoning shirt Normal right hand
use in work
Total time spent in TOTE Homea 28.8 32.0 30.0 16.3
(hours)
Average time spent per visit in TOTE 57.5 64.0 60.0 57.6
Homea (minutes)
Total no. of repetitions completed 2,744.0 2,371.0 2,611.0 1,265.0
during TOTE Homea
Average no. of repetitions completed 91.5 79.0 87.0 74.4
per visit during TOTE Homea

Note. TOTE = Task Oriented Training and Evaluation; CVA = Cerebral Vascular Accident; MMSE = Mini-Mental Status Exam; CESD-R = Center for Epidemiologic Studies
Depression scale–Revised; SAFER Home v3 = Safety Assessment of Function and Environment for Rehabilitation.
a
Designates items counted and recorded manually by the therapist.

Participant 2 demonstrated an improvement in his confidence to quantitative assessment of arm motor movement. It is difficult
button his shirt as compared with his baseline ratings and mostly to determine through accelerometry if a change in his motor
maintained that same amount of confidence throughout the activity was due to a change in his resting tremor and ataxia or
study (g-index = .4 comparing baseline with intervention, due to intentional, purposeful movements. Participant 3 showed
g-index = .5 comparing baseline with post-intervention and with the most positive trend at his post-evaluation and maintained
follow-up). Participant 3 rated increased confidence in button- improvements at his 1-month follow-up (g-index = −.3 com-
ing his shirt throughout the TOTE Home intervention with some paring baseline with intervention, g-index = .5 comparing base-
improvement and maintenance of performance at post-evalua- line with post-intervention and with follow-up). Participant 4
tion and 1-month follow-up (g-index = .4 comparing baseline had a large positive trend in UE movement during the TOTE
with intervention, g-index = .5 comparing baseline with post- Home intervention and maintained this improvement through-
intervention and with follow-up). See Figure 2 for a visual out post-evaluation and 1-month follow-up (g-index = .3 com-
examination of the ratings. paring baseline with intervention, g-index = .4 comparing
baseline with post-intervention and to follow-up). See Figure 3
for a visual analysis of the number of steps.
Accelerometry Recordings
The amounts of movement varied for each participant over the
Discussion
course of the study. Visual analysis of the trends in weaker arm
movement changes were confirmed with the small to medium The aim of this study was to explore the effectiveness of a
effect size when compared with baseline. Participant 1 had the TOT program and evaluation at home completed by people
most positive improvement in trend starting with the TOTE with subacute stroke, and whether effects persisted 1 month
Home intervention and a maintenance of this improvement after this training. The TOTE Home intervention was based
throughout the rest of the study (g-index = .4 comparing base- on current motor learning theory, principles of experience-
line with intervention, g-index = .5 comparing baseline with dependent neural plasticity, and the theory of OA.
post-intervention and with follow-up). Data from participant 2 The TOTE Home intervention was found to be an effec-
should be analyzed with caution for the varied trend that is tive TOT regimen to increase motor movement in the hemi-
exhibited with visual examination (g-index = .4 comparing paretic UE in this single-subject research study design.
baseline with intervention, g-index = −.5 comparing baseline Contemporary motor learning theory procedures that
with post-intervention, and g-index = 0.0 comparing baseline enhance neural plasticity made up the rehabilitative inter-
with follow-up). His ataxic movements confounded the vention in this study. Motor learning theory has evolved to
Rowe and Neville 51

Figure 2. Self-efficacy ratings of priority task—Descriptive visual analysis with slope.

combine neural science, cognitive/information processing, Relation of TOTE Home With Other Studies
and psychological components of motivation and self-effi-
cacy. This theory was extended when combined with the TOTE Home had some similar results as other recent stud-
theory of OA from occupational therapy, which focuses on ies involving TOT (or task-specific training, such as:
the intrinsic value of the task. The translation of motor Waddell et al., 2014; Winstein et al., 2016). The repetition
learning research into applied neurorehabilitation practice and intensity of training that occurred in TOTE Home con-
has most recently supported advances in sustainable and tributed to the improvement in motor function similar to
generalizable gains in motor skills and associated behaviors the findings of Waddell et al., 2014. The ASAP of task-
(Winstein et al., 2014). The results of the TOTE Home fur- specific training from the ICARE national, randomized,
ther advance the support for TOT for gaining UE motor clinical trial (Winstein et al., 2013) was used as the model
movement and OA. for TOTE Home and both studies noted improvements
52 OTJR: Occupation, Participation and Health 38(1)

Figure 3. Actigraph steps—Descriptive visual analysis with slope.

after TOT (Winstein et al., 2016) with the focus on impair- using client-centered, occupation-focused interventions. It
ment, task specificity, intensity, engagement, collabora- is possible that components of TOT (such as those listed
tion, client-direction, and client-centered care. The ICARE above) are aspects of and contribute to the makeup of usual
study reported no significance in improving motor func- occupational therapy treatment. TOTE Home advanced the
tion or recovery beyond either an equivalent or a lower use of the ASAP training beyond the integration of motor
dose of usual and customary care of UE rehabilitation learning, neuroscience, and the psychology of behavior
(Winstein et al., 2016). However, there was an improve- change to include implementation in the home environ-
ment noted in all groups that received occupational therapy ment. This led to participation in meaningful, relevant
in the ICARE randomized clinical trial (RCT). This could tasks/activities and promoted ongoing adaptation beyond
be evidence that the occupational therapy treatment the time spent during the intervention of TOTE Home,
assessed in each arm of the ICARE study was effective by which could have contributed to the positive outcomes.
Rowe and Neville 53

The demographics of the participants in ExCITE and valued role. The physical and social environment interaction
ICARE were similar to the sample studied in TOTE Home also played a major factor in facilitating or hindering prog-
(Winstein et al., 2004; Winstein et al., 2013). Sex and hand ress. Activities within specific living environments were pur-
dominance did not affect participation. Specifically, for sued based on participant’s motivation and encouragement
TOTE Home, the participants represented males and females from others. The depth of analysis of the impact of the physi-
equally. Hand dominance may have played a role in the out- cal and social environment is beyond the scope of this article
comes as Participants 1 and 4 (whose dominant hand was and the authors have a second article under review.
affected) showed more improvement than Participants 2 and
3 (whose nondominant hand was affected). The ExCITE trial
OA—Relative Mastery
showed no significant differences for concordance or discon-
cordance in regard to hand dominance (Wolf et al., 2006). Although the motor learning theory provides the principles in
However, in TOTE Home, the tendency to use the dominant which to base a TOT intervention, the theory of OA provides
hand could have aided recovery by increasing the repetition a framework for interpreting the progress of each participant.
and intensity of practice with the affected hand. Previous studies utilizing the theory of OA with clients who
Both the ExCITE and ICARE RCTs were based on and have had a stroke have found clients being discharged to less
guided by motor learning theory (Winstein et al., 2016; Wolf restrictive settings (Gibson & Schkade, 1997), an increase in
et al., 2006; Wolf et al., 2008). TOTE Home was modeled dynamic standing endurance with participation in meaningful
after these trials. Motivation to recover functional motor tasks (Dolecheck & Schkade, 1999), and improved functional
movement was pervasive throughout the ExCITE, ICARE, mobility along with increased internal adaptation, generaliza-
and TOTE Home studies, which contributed to success using tion, and relative mastery (Johnson & Schkade, 2001).
the motor learning theory. In TOTE Home, the amount of adaptation experienced by
the participants appeared to be directly related to the amount
of relative mastery that was achieved. This is most evident in
UE Movement Outcomes participant’s ability to problem solve, that is, identifying
All participants in TOTE Home demonstrated an increase of areas that need improvement, figuring out ways to improve
UE movement of the weaker arm and hand, as recorded by upon deficits, altering the environment to facilitate that “just
accelerometry, from baseline to 1-month follow-up. Several right challenge,” and utilizing repetition and intensity of
differences were noted between study phases in Actigraph practice to gain motor skills. Self-efficacy was also a com-
recordings with mostly medium effects. Most participants mon theme that pertained to all participants. The more confi-
showed an increase in the amount of movement recorded by dent the participants felt in their abilities, the more satisfied
number of Actigraph steps from baseline, through interven- and successful they were with their performance.
tion, and to post-intervention. Most improvements were at
least maintained or increased through 1-month follow-up.
Strengths and Weaknesses
With current evidence suggesting increases in activity to
reduce the risk of stroke, this is a critical finding on the over- This study implemented several aspects of current evidence-
all importance of therapy to increase motor function and par- based practice from the fields of neuroscience, psychology,
ticipation in meaningful occupations. and physical rehabilitation. TOTE Home occurred in the par-
ticipant’s home, which makes it convenient for clients and
appropriate for activities in the natural environment to be
Home Environment addressed. Encouraging adaptation in the participant’s home
TOTE Home utilized tasks that were meaningful to the par- setting also facilitates ongoing adaptation beyond when the
ticipants and specifically defined by each participant and structured therapy sessions end. Participants may be more
therapist together within the participant’s home environment. likely to continue working independently in their home set-
Participants understood and became a collaborative partner ting that they are familiar with, rather than try to translate
with the therapist. The participants did this by identifying work and effort done in a clinic to home. Although more par-
goals and assessing progress with the therapist that directly ticipants would be needed to better validate TOTE Home to
related to activities in the participant’s home. Interestingly, a larger population, this sample was equally representative of
the chosen tasks worked on during TOTE Home were fre- sexes and hand dominance. Implementing 30 treatment ses-
quently derived from participants’ identified occupational sions may also not be representative of traditional home
roles within their social and cultural environment (such as health occupational therapy length of service; however, it
grandmother, seamstress, father, handyman, husband, gar- allowed proof of concept. We are also unable to identify the
dener, and utility worker) to help guide intervention. It was exact “dosing” or amount of intensity of the intervention in
the roles that the participant valued that seemed to give the terms of both time and resources that would justify the out-
tasks meaning. Tasks were graded to the appropriate chal- comes. In addition, the accessibility of the intervention to the
lenge level for each participant within their individually general post-stroke population may be limited.
54 OTJR: Occupation, Participation and Health 38(1)

Although the single-study design is an excellent one in Auerbach, C., & Schudrich, W. Z. (2013). SSD for R: A com-
which to begin evaluating an intervention using participants as prehensive statistical package to analyze single-system data.
their own controls and following their progress over time, it Research on Social Work Practice, 23, 346-353.
does have some limitations. Some research has found that the Bailey, R. R., Klaesner, J. W., & Lang, C. E. (2014). An accelerom-
etry-based methodology for assessment of real-world bilateral
use of pedometers to monitor step counts in healthy older adults
upper extremity activity. PLoS ONE, 9(7), e103135.
with slower gait speeds is problematic (Martin, Krc, Mitchell,
Bailey, R. R., & Lang, C. E. (2013). Upper-limb activity in adults:
Eng, & Noble, 2012). It is difficult to generalize much beyond Referent values using accelerometry. Journal of Rehabilitation
the participants studied here without a larger sample. Replication Research & Development, 50, 1213-1222.
of this intervention with more participants would also help in Bass-Haugen, J., Mathiowetz, V., & Flinn, F. (2008). Optimizing
establishing a better baseline of movement when using acceler- motor behavior using the occupational therapy task-oriented
ometry. Some research has found that the use of step count in approach. Philadelphia, PA: Lippincott, Williams, & Wilkins.
accelerometry may not be as accurate with slower walking pace. Cohen, J. (1988). Statistical power analysis for the behavioral sci-
ences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum.
Dolecheck, J. R., & Schkade, J. K. (1999). The extent dynamic
Conclusion standing endurance is effected when CVA subjects perform
The results from the single-subject design implemented in personally meaningful activities rather than nonmeaningful
TOTE Home can help to advance neurorehabilitation prac- tasks. Occupational Therapy Journal of Research, 19, 40-54.
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example of contributing to the health of stroke survivors by intervention with patients with cerebrovascular accident: A
improving their UE movement. clinical study. American Journal of Occupational Therapy, 51,
The overall goal of TOTE Home was adaptation. This was 523-529.
demonstrated as using meaningful occupations within a par- Johnson, J. A., & Schkade, J. K. (2001). Effects of an occupation-
ticipant’s own occupational environment to increase health based intervention on mobility problems following a cerebral
vascular accident. Journal of Applied Gerontology, 20, 91-110.
through the adaptive use of his or her affected UE. By engag-
Kazdin, A. E., & Tuma, A. H. (1982). Single-case research designs.
ing in activities that were at the “just right challenge,” the
San Francisco, CA: Jossey-Bass.
participants regained old or established new routines, habits, Kelly-Hayes, M., Beiser, A., Kase, C. S., Scaramucci, A.,
and performance in activities related to their personal roles D’Agostino, R. B., & Wolf, P. A. (2003). The influence of
within their own environment. Ultimately, relative mastery gender and age on disability following ischemic stroke: The
enabled the participants to continue to adapt to occupational Framingham study. Journal of Stroke & Cerebrovascular
challenges that will affect them throughout his or her lifes- Diseases, 12, 119-126. doi:10.1016/S1052-3057(03)00042-9
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a model easily replicated in practice. dent neural plasticity: Implications for rehabilitation after brain
damage. Journal of Speech, Language, and Hearing Research,
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Kochanek, K. D., Xu, J. Q., Murphy, S. L., & Arias, E. (2014).
This study was approved by ClinicalTrials.gov Identifier Mortality in the United States (NCHS Data Brief No. 178).
(NCT02852369) and Texas Woman’s University Institutional Hyattsville, MD: National Center for Health Statistics, Centers
Review Board (Protocol: 18009). for Disease Control and Prevention, U.S. Department of Health
and Human Services.
Declaration of Conflicting Interests Kromrey, J. D., & Foster-Johnson, L. (1996). Determining the effi-
The author(s) declared no potential conflicts of interest with respect cacy of intervention: The use of effect sizes for data analysis
to the research, authorship, and/or publication of this article. in single-subject research. Journal of Experimental Education,
65, 73-93.
Funding Lang, C. E., & Birkenmeier, R. L. (2014). Upper-extremity task-spe-
cific training after stroke or disability: A manual for occupational
The author(s) received no financial support for the research, author-
therapy and physical therapy. Bethesda, MD: AOTA Press.
ship, and/or publication of this article.
Lang, C. E., Edwards, D. F., Birkenmeier, R. L., & Dromerick, A.
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