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What do all these words mean?

Executive Functioning Skills guide everything we do.  From making decisions, to staying on track with an activity, to planning and prioritizing a task .  The ability to make a decision, plan it out, and act on it without being distracted is what allows us to accomplish the most mundane of tasks to the more complicated and multi-step actions.  Children with executive functioning issues will suffer in a multitude of ways.  Some kids have many deficits in EF and others fall behind in several or all areas. Everyone needs to develop and build executive functions as they grow.  Functional adults may still be struggling with aspects of executive functioning skills.  Executive dysfunction can interfere with independence and the ability to perform activities.  The cognitive skills are an interconnected web of processing that allows for self-regulation, planning, organization, and memory.

Executive Functioning Skills

As a related resource, try these self-reflection activities for kids .

What are executive functions?

Executive functioning skills:, cognitive flexibility.

• Check for smooth changes in tasks.
• Tally number of errors.
• Record number of verbal prompts (“Are you all done?”), physical prompts (pointing, etc.)

Executive function and handwriting

How to build executive function skills:

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Breaking Down Goals

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Loewenstein Occupational Therapy Cognitive Assessment

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Assess basic cognitive and visual perception skills

Link to Instrument

Instrument Details

Area of Assessment

Actual cost, populations, key descriptions.

• Used to measure basic cognitive skills to perform ADLs/IADLs, including orientation, visual perceptual/psychomotor abilities, problem solving skills and thinking operations (Stroke Engine).
• Scoring: 1= patient does not perform task 2= patient performs part of task 3= patient performs most of task 4= patient performs task well
• Higher score indicates less cognitive impairment

Number of Items

Time to administer.

45  minutes

30-45 minutes

Required Training

Instrument reviewers.

Reviewed by Heidi Jasper-Petrozzino and Kimberly Okechukwu in December 2016.

Considerations

Can be administered over multiple sessions.

Intellectual Disability

Normative data.

Intellectual Disabilities: (Jang et al, 2009; n=111 with intellectual disabilities, n=19 with no disabilities)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity

Poor  to  Excellent  correlations between LOTCA subscales and the Pictorial IQ Test (r = 0.26 to 0.63)

Adequate  correlation between Orientation and Pictorial IQ Test (r = 0.45)

Poor  correlation between Visual Perception and Pictorial IQ Test (r = 0.26)

Adequate  correlation between Spacial Perception and Pictorial IQ Test (r = 0.46)

Adequate  correlation between Motor Praxis and Pictorial IQ Test (r = 0.42)

Excellent  correlation between Visuomotor Organization and Pictorial IQ Test (r = 0.63)

Excellent  correlation between Thinking Operations and Pictorial IQ Test (r = 0.61)

Mixed Populations

Interrater/intrarater reliability.

Stroke and Brain Injury: (Katz et al., 1989; n=20 traumatic head injury patients, n=28 cerebrovascular accident patients)

• Excellent inter-rater reliability (ICC=0.82 to 0.97)

Internal Consistency

• Excellent  internal consistency for perception (Cronbach's alpha = 0.87)
• Excellent  internal consistency for visuomotor organization (Cronbach's alpha = 0.95)
• Excellent  internal consistency for thinking operations (Cronbach's alpha = 0.85)

Content Validity

Stroke and Brain Injury:  (Katz et al., 1989)

Subtests correlation coefficients range from 0.40 to 0.80, suggesting that assessment should be given in full, not individually.

Construct Validity

Stroke:  (Zwecker et al., 2002; n=66 with stroke)

• Adequate  correlation (r= 0.471, p<0.001)  between the LOTCA and the FIM cognitive subset  
• Excellent  correlation (r=0.666, p<0.001)  between the FIM cognitive subtest and the Mini Mental State Examination (MMSE)

More Instruments Like This

We have reviewed more than 500 instruments for use with a number of diagnoses including stroke, spinal cord injury and traumatic brain injury among several others.

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In order to execute these OT tests and assessments in practice, the associated materials/kits must be purchased.  

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• ADOLESCENT/ADULT SENSORY PROFILE Promotes self-evaluation of behavioral responses to everyday sensory experiences. Provides a standard method for professionals and individuals to measure and to profile the effect of sensory processing on functional performance.
• ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS) An observational assessment that allows for the simultaneous evaluation of motor and process skills and their effect on the ability of an individual to perform complex or or instrumental and personal activities of daily living (ADL). The AMPS is comprised of 16 motor and 20 process skill items.
• BAYLEY SCALES OF INFANT DEVELOPMENT (BSID) Used to identify the child’s developmental competencies and can be used to identify deficits in very young children across five major developmental domains.
• BEERY-BUKTENICA DEVELOPMENTAL TEST OF VISUAL-MOTOR INTEGRATION, 6th EDITION (BEERY VMI) Measures the extent to which individuals can integrate their visual and motor abilities. It is commonly used to identify children who are having significant difficulty with visual-motor integration.
• DEVELOPMENTAL TEST OF VISUAL PERCEPTION (DTVP-2) Used to assess children who may have visual perception deficiencies.
• EVALUATION TOOL OF CHILDREN'S HANDWWRITING Used for children in 1st through 6th grades to evaluate cursive and manuscript handwriting by looking at legibility and speed of handwriting.
• HAWAII EARLY LEARNING PROFILE (HELP) Used for infants, toddlers and young children to identify needs, track growth and development, and determining ‘next steps’ (target objectives).
• INFANT-TODDLER SENSORY PROFILE (SENSORY PROFILE 2) A questionnaire that is completed by an infant’s or toddler’s primary caregiver in order to gather information about the child’s sensory processing abilities.
• MILLER ASSESSMENT OF PRESCHOOLERS (MAP) To evaluate children of preschool age for mild – moderate developmental delays. Three core items are tested: sensory and motor abilities, cognitive abilities and combined abilities.
• MOTOR-FREE VISUAL PERCEPTION TEST (MVPT) A standardized test of visual perception. Unlike other typical visual perception measures, this measure is meant to assess visual perception independent of motor ability.
• PEABODY DEVELOPMENTAL MOTOR SCALE (PDMS-2) To assess the motor skills of children ages birth to 5 years old via gross motor, fine motor, and total motor and compare to normative values.
• PEDIATRIC EVALUATION OF DISABILITY INVENTORY (PEDI) Assess functional capabilities and performance, monitor progress in functional performance, and evaluate therapeutic or rehabilitative progress.
• SCHOOL FUNCTIONAL ASSESSMENT (SFA) Used to measure a student’s performance of functional tasks that support his or her participation in the academic and social aspects of an elementary school program (grades K–6). It was designed to facilitate collaborative program planning for students with a variety of disabling conditions.
• SENSORY INTEGRATION AND PRAXIS TESTS (SIPT) The Sensory Integration and Praxis Tests (SIPT) measure the sensory integration processes that underlie learning and behaviour.
• BRUININKS-OSERETSKY TEST OF MOTOR PROFICIENCY, SECOND EDITION (BOT-2) An individually administered test that uses goal-directed activities to measure a wide array of motor skills in individuals ages 4 through 21. The BOT-2 uses a subtest and composite structure that highlights motor performance in the broad functional areas of stability, mobility, strength, coordination, and object manipulation.
• VINELAND ADAPTIVE BEHAVIOR SCALES (VINELAND-II OR VABS) The Vineland is designed to measure adaptive behavior of individuals from birth to age 90.
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Occupational Therapy Practice Guidelines for Adults with Traumatic Brain Injury

In this article:

Recommendations

Methodology, evidence supporting the recommendations, benefits/harms of implementing the guideline recommendations, qualifying statements, implementation of the guideline.

• IOM National Healthcare Quality Report Categories

Identifying Information and Availability

Note from the National Guideline Clearinghouse : In addition to the evidence-based recommendations below, the guideline includes extensive information on the evaluation process and intervention strategies for people with traumatic brain injury (TBI).

Definitions for the strength of recommendations ( A–D, I ) and levels of evidence ( I–V ) are provided at the end of the "Major Recommendations" field.

Recommendations for Occupational Therapy Interventions for Adults with TBI

Interventions to improve arousal and alertness of people in a coma or persistent vegetative state.

• Multimodal sensory stimulation to improve arousal and enhance clinical outcomes ( A )
• Auditory stimulation, especially when completed in a familiar voice, to increase arousal in the short term ( B )
• Increased complexity, rather than intensity, of stimulation to increase intervention effectiveness ( C )
• Median nerve stimulation to improve arousal and alertness ( I )

Interventions to Improve Motor Function

• Exercise programs (aquatic, hand, and standard [e.g., balance]) to improve motor function ( A )
• Computer-based interventions (e.g., virtual reality, gaming systems, 3-demensional [3D] immersive games) to improve upper-extremity motor function and postural and dynamic balance ( B )
• Rehabilitation programs to improve motor function ( C )
• Multidisciplinary rehabilitation programs to improve motor function ( C )
• Qigong to increase physical activity, strength, and balance ( I )

Interventions to Improve Occupational Performance of People with Cognitive Impairments

• General memory interventions (involving restorative and/or compensatory approaches) to improve memory ( A )
• Attention regulation interventions with or without goal problem-solving training to improve attention and executive functioning ( A )
• Executive function strategy training such as goals management training and metacognitive strategy instruction to improve attention and executive functioning ( A )
• Training in encoding techniques to improve recall ( A )
• Training in use of cognitive assistive technology (except voice recorders and navigation devices) to improve memory ( A )
• Various memory-specific compensatory approaches to improve memory ( A )
• Use of compensatory interventions to improve multiple cognitive domains ( B )
• Cognitive interventions to improve self-awareness ( B )
• Computer-based interventions to enhance occupational performance ( I )
• General restorative and/or compensatory approaches to improve attention and executive dysfunction ( I )

Interventions to Improve Occupational Performance of People with Visual and Visual–Perceptual Impairments

• Scanning training to improve search skills when measured with digit search, computer tests, and a functional search task ( A )
• Cognitive rehabilitation to improve performance in neuropsychological measures focused on visual perception ( A )
• Scanning training accompanied by a visual and/or auditory stimulus to improve visual search skills and reading performance ( B )
• Vision therapy to remediate oculomotor signs and symptoms ( C )
• Cognitive compensatory strategies such as pacing, chunking, and self-talk to improve activity of daily living (ADL) performance ( C )
• Fresnel 40-diopter prism to improve visual field awareness and functional mobility ( C )
• Scrolling text to improve reading performance of people with reading difficulties as a result of hemianopsia ( C )
• Cognitive strategies focused on social skills training to improve the ability to name basic emotions, interpret comments, and determine whether a person is lying or being sarcastic ( I )
• Scanning as a standalone intervention to improve reading ( I )

Interventions to Improve Occupational Performance of People with Psychosocial, Behavioral, or Emotional Impairments

• Cognitive-behavioral therapy (CBT) interventions to address psychosocial, behavioral, and emotional impairments and to improve occupational performance ( A )
• Goal-directed outpatient rehabilitation to improve ratings of self-performance and satisfaction ( A )
• Goal-directed outpatient rehabilitation to improve goal attainment, occupational performance, psychosocial reintegration, and adjustment levels ( B )
• Aquatic exercise to improve tension, depression, anger, vigor, fatigue, and confusion ( B )
• Functional skills training to improve social participation, community reintegration, independent living, emotional well-being, and quality of life ( B )
• CBT modified to include mindfulness-based cognitive therapy (MBCT) to decrease depression and motivational interviewing to improve anxiety ( C )
• CBT administered in the virtual context to address psychosocial and emotional distress, anxiety, and depression ( C )
• Aerobic exercise to improve self-esteem, depression, quality of life, and community activity ( C )
• Group and individual-based education interventions to improve psychosocial, behavioral, and emotional skills and impairments ( C )
• Behavioral skills training to address behavioral functioning, anger, and community involvement ( C )
• Social skills training interventions to improve occupational performance ( C )
• Peer mentoring interventions to decrease avoidance coping, chaos in the home, alcohol abuse, and somatic symptoms of emotional distress and to improve health-related quality of life ( C )
• Peer mentoring interventions to improve perception of community integration, levels of anxiety and depression, satisfaction with social integration, or social activity levels ( I )
• CBT administered in the virtual context to address community integration and adaptive coping ( I )

Activity and Occupation-Based Interventions to Improve Performance of Everyday Activities and Areas of Occupation and Social Participation

• Activity-based interventions focused on client-centered goals and delivered in a relevant environmental context to improve occupational performance ( B )
• Multidisciplinary and interdisciplinary rehabilitation approaches to improve occupational performance and participation outcomes after moderate to severe TBI ( B )
• Training in social behaviors and decoding emotions to improve partner-directed behaviors such as reciprocal conversation skills ( B )
• Peer mentoring programs for people with moderate to severe TBI and their significant others to improve emotion-focused and avoidance coping and decrease chaos in the home environment, somatic symptoms, and alcohol abuse ( B )
• Social peer mentoring program focused on accessing the community to increase social contact and improve perceived social support; note that such programs may also increase depressive symptoms ( B )
• Virtual reality driving rehabilitation program to improve simulated driving performance in steering on open roads, turning, reacting to unexpected driving hazards, and adhering to traffic laws ( B )
• Use of landmark-based directions, rather than cardinal or right–left directions, to maximize performance in following a walking route in the community ( C )
• Social training programs to improve social participation ( I )

Definitions

Levels of evidence for occupational therapy outcomes research.

Note : Adapted from "Evidence-based medicine: What it is and what it isn't." D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, & W. S. Richardson, 1996, British Medical Journal, 312, pp. 71-72. Copyright © 1996 by the British Medical Association. Adapted with permission.

Strength of Recommendation

A –There is strong evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. Good evidence was found that the intervention improves important outcomes and concludes that benefits substantially outweigh harm.

B –There is moderate evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. There is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial.

C –There is weak evidence that the intervention can improve outcomes. It is recommended that the intervention be provided selectively on the basis of professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.

I –There is insufficient evidence to determine whether or not occupational therapy practitioners should be routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harm cannot be determined.

D –It is recommended that occupational therapy practitioners do not provide the intervention to eligible clients. At least fair evidence was found that the intervention is ineffective or that harm outweighs benefits.

Note : Criteria for level of evidence and recommendations (A, B, C, I, D) are based on standard language from the U.S. Preventive Services Task Force (2012). Suggested recommendations are based on the available evidence and content experts' clinical expertise regarding the value of using it.

Clinical Algorithm(s)

None provided

Disease/Condition(s): Traumatic brain injury (TBI)

Guideline Category: Counseling, Management, Rehabilitation, Treatment

Clinical Specialty: Family Practice, Neurology, Physical Medicine and Rehabilitation, Preventive Medicine, Psychiatry, Psychology

Intended Users: Advanced Practice Nurses, Nurses, Occupational Therapists, Physical Therapists, Physician Assistants, Physicians, Psychologists/Non-physician Behavioral Health, Clinicians, Social Workers, Speech-Language Pathologists

Target Population: Adults with traumatic brain injury (TBI)

Guideline Objective(s)

• To provide an overview of the occupational therapy process for individuals with traumatic brain injury (TBI) that is based on existing evidence of the effects of various occupational therapy interventions
• To help occupational therapists and occupational therapy assistants, as well as the individuals who manage, reimburse, or set policy regarding occupational therapy services, understand the contribution of occupational therapy in treating adults with TBI
• To help guide future decisions on areas for research by highlighting areas in which specific interventions lack evidence of a clear benefit or areas in which available interventions do not meet the specific needs of clients with TBI
• To serve as a reference for health care professionals, health care facility managers, education and health care regulators, third-party payers, and managed care organizations, and those who conduct research to advance care of people with TBI

Interventions and Practices Considered

• Interventions to improve arousal and alertness of people in a coma or persistent vegetative state during the coma recovery phase
• Interventions to improve motor function
• Interventions to improve occupational performance of people with cognitive impairments
• Interventions to improve occupational performance of people with visual and visual–perceptual impairments
• Interventions to improve occupational performance of people with psychosocial behavioral, or emotional impairments
• Activity and occupation-based interventions to improve performance of everyday activities and areas of occupation and social participation

Major Outcomes Considered

• Effectiveness of interventions
• Community integration/participation
• Daily life functioning
• Social and leisure participation
• Independence

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources) Hand-searches of Published Literature (Secondary Sources) Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

The following six focused questions framed the review of occupational therapy interventions for people with traumatic brain injury (TBI):

• What is the evidence for the effectiveness of sensory stimulation to improve arousal and alertness for people in a coma or persistent vegetative state after TBI?
• What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve motor function for individuals with TBI?
• What is the evidence that interventions to address cognitive impairments and skills improve occupational performance for people with TBI?
• What is the evidence that interventions to address visual and visual–perceptual impairments and skills improve occupational performance for people with TBI?
• What is the evidence that interventions to address psychosocial, behavioral, and/or emotional impairments and skills improve occupational performance for people with TBI?
• What is the evidence for the effectiveness of occupation- and activity-based interventions to improve everyday activities and areas of occupation and social participation for people with TBI?

Search terms for the reviews were developed by the methodology consultant to the American Occupational Therapy Association, Inc. (AOTA) Evidence-Based Practice (EBP) Project and AOTA staff, in consultation with the review authors of each question, and by the advisory group. The search terms were developed not only to capture pertinent articles but also to make sure that the terms relevant to the specific thesaurus of each database were included. Table G.1 in the original guideline document lists the search terms related to the population (people with TBI) and types of intervention included in each systematic review. A medical research librarian with experience in completing systematic review searches conducted all searches and confirmed and improved the search strategies.

Databases and sites searched included Medline, PsycINFO, CINAHL, and OTseeker. In addition, consolidated information sources, such as the Cochrane Database of Systematic Reviews, were included in the search. These databases are peer-reviewed summaries of journal articles and provide a system for clinicians and researchers to conduct systematic reviews of selected clinical questions and topics. Reference lists from articles included in the systematic reviews were examined for potential articles, and selected journals were hand searched to ensure that all appropriate articles were included.

Inclusion and exclusion criteria are critical to the systematic review process because they provide the structure for the quality, type, and years of publication of the literature that is incorporated into a review. Included articles were peer-reviewed scientific literature on participants with TBI published in English between 2008 and 2013 and within the scope of practice of occupational therapy. The review excluded data from presentations, conference proceedings, non–peer-reviewed research literature, dissertations, and theses. Studies included in the review provide Level I, II, and III evidence; Level IV and V evidence was included only when higher level evidence on a given topic was not found.

A total of 6,928 citations and abstracts were included in the reviews. For the question on coma, there were 1,130 references; for the motor question, 2,306 references; for the cognitive question, 694 references; for the vision question, 242 references; for the psychosocial and behavioral question, 1,512 references; and for the occupation question, 1,044 references. The consultant to the Evidence-Based Practice Project completed the first step of eliminating references on the basis of citation and abstract. The systematic reviews were carried out as academic partnerships in which academic faculty worked with graduate students to conduct the reviews. Review teams completed the next step of eliminating references based on citations and abstracts. The full-text versions of potential articles were retrieved, and the review teams determined final inclusion in the review on the basis of predetermined inclusion and exclusion criteria.

Number of Source Documents

A total of 132 articles were included in the final review describing 65 Level I, 29 Level II, 32 Level III, 3 Level IV, and 3 Level V studies.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Methods used to analyze the evidence.

Review of Published Meta-Analyses Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

The teams working on each focused question reviewed the articles according to their quality (i.e., scientific rigor and lack of bias) and levels of evidence. Each article included in the review was then abstracted using an evidence table that provides a summary of the methods and findings of the article. American Occupational Therapy Association, Inc. (AOTA) staff and the Evidence- Based Practice Project (EBP) consultant reviewed the evidence tables to ensure quality control. All studies are summarized in full in the evidence tables in Appendix H of the original guideline document.

The limitations of the systematic reviews are based on the design and methods of the individual studies, including small sample sizes, short intervention periods, limited use of standardized testing, inclusion of diagnoses other than traumatic brain injury (TBI), and short follow-up periods. In addition, many of the studies in the review included concurrent interventions, so separating the effects of a single intervention may be difficult, and the role of occupational therapy is seldom discussed in multidisciplinary interventions.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

A major focus of the American Occupational Therapy Association, Inc. (AOTA)'s Evidence-Based Practice (EBP) Project is an ongoing program of systematic review of multidisciplinary scientific literature, using focused questions and standardized procedures to identify practice-relevant evidence and discuss its implications for practice, education, and research. An evidence-based perspective is founded on the assumption that scientific evidence of the effectiveness of occupational therapy intervention can be judged to be more or less strong and valid according to a hierarchy of research designs, or an assessment of the quality of the research, or both. AOTA uses standards of evidence modeled on those developed in evidence-based medicine. This model standardizes and ranks the value of scientific evidence for biomedical practice using a grading system presented in the "Rating Scheme for the Strength of the Evidence" field. In this system, the highest level of evidence, Level I , includes systematic reviews of the literature, meta-analyses, and randomized controlled trials (RCTs). In RCTs, participants are randomly allocated to either an intervention or a control group, and the outcomes of both groups are compared. Other levels of evidence include Level II studies, in which assignment to a treatment or a control group is not randomized (cohort study); Level III studies, which do not have a control group; Level IV studies, which use a single-case experimental design, sometimes reported over several participants; and Level V studies, which are case reports and expert opinion that include narrative literature reviews and consensus statements.

The systematic reviews of research on people with traumatic brain injury (TBI) were supported by AOTA as part of the Evidence-Based Practice Project. AOTA is committed to supporting the role of occupational therapy in this important area of practice. The previous review on this topic was completed covering the time frame of 1986–2008. The current systematic reviews were updated for the period 2008–May 2013 because occupational therapy practitioners need access to the results of the latest and best available literature to support intervention within the scope of occupational therapy practice.

The six focused questions developed for the updated review were based on the search strategy of the previous review. Additional search terms were added to ensure comprehensive inclusion of the six questions. These questions were reviewed by review authors, an advisory group of content experts in the field, AOTA staff, and the consultant to the AOTA EBP Project.

Rating Scheme for the Strength of the Recommendations

Cost analysis.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

This practice guideline was reviewed by a group of content experts in traumatic brain injury (TBI) that included a consumer representative.

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

The final review included 132 articles. Studies included in the review provide Level I, II, and III evidence; Level IV and V evidence was included only when higher level evidence on a given topic was not found.

Number of Articles in Each Review at Each Level of Evidence

Potential benefits.

This document may be used to assist:

• Occupational therapists and occupational therapy assistants in providing evidence-based interventions to adults with traumatic brain injury (TBI)
• Occupational therapists and occupational therapy assistants in communicating about their services to external audiences
• Other health care practitioners, case managers, clients, families and caregivers, and health care facility managers in determining whether referral for occupational therapy services is appropriate
• Third-party payers in determining the medical necessity for occupational therapy
• Legislators; third-party payers; federal, state, and local agencies; and administrators in understanding the professional education, training, and skills of occupational therapists and occupational therapy assistants
• Health and social services planning teams in determining the need for occupational therapy
• Program developers; administrators; legislators; federal, state, and local agencies; and third-party payers in understanding the scope of occupational therapy services
• Occupational therapy researchers in this practice area in determining outcome measures and defining current occupational therapy practice in order to compare the effectiveness of occupational therapy interventions
• Policy, education, and health care benefit analysts in understanding the appropriateness of occupational therapy services for adults with TBI
• Policymakers, legislators, and organizations in understanding the contribution occupational therapy can make in health promotion, program development, and health care reform to support adults with TBI
• Occupational therapy educators in designing appropriate curricula that incorporate the role of occupational therapy with adults with TBI

Potential Harms

The studies that met the inclusion criteria for the systematic reviews did not explicitly report potential adverse events associated with the interventions evaluated in these studies. Before implementing any new intervention with a client, it is always prudent for occupational therapy practitioners to be aware of the potential benefits and harms of the intervention. Clinical reasoning based on a sound evaluation of the client's strengths and limitations and an understanding of the intervention should be exercised to determine the potential benefits and harms of an intervention for an individual patient. Finally, clinical reasoning is also required to translate the intervention protocols used in the studies reviewed into client-centered, clinically feasible interventions.

• This guideline does not discuss all possible methods of care, and although it does recommend some specific methods of care, the occupational therapist makes the ultimate judgment regarding the appropriateness of a given intervention in light of a specific person's or group's circumstances and needs and the evidence available to support the intervention.
• This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold or distributed with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the services of a competent professional person should be sought.
• It is the objective of the American Occupational Therapy Association, Inc. (AOTA) to be a forum for free expression and interchange of ideas. The opinions expressed by the contributors to this work are their own and not necessarily those of AOTA.

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

• Chart Documentation/Checklists/Forms
• Staff Training/Competency Material

For information about availability, see Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

Iom care need.

Living with Illness

Effectiveness

Patient-centeredness

Bibliographic Source(s)

Wheeler S, Acord-Vira A. Occupational therapy practice guidelines for adults with traumatic brain injury. Bethesda (MD): American Occupational Therapy Association, Inc. (AOTA); 2016. 47 p. [301 references]

Not applicable: The guideline was not adapted from another source.

Date Released

Guideline developer(s).

American Occupational Therapy Association, Inc. - Professional Association

Source(s) of Funding

American Occupational Therapy Association, Inc.

Guideline Committee

Composition of group that authored the guideline.

Authors : Steven Wheeler, PhD, OTR/L, CBIS, Associate Professor/Associate Chair, Division of Occupational Therapy, West Virginia University School of Medicine, Morgantown, WV, Affiliate Faculty, WVU Injury Control Research Center, Consultant, NeuroRestorative, Ashland, KY; Amanda Acord-Vira, MOT, OTR/L, CBIS, Assistant Professor, Division of Occupational Therapy, West Virginia University School of Medicine, Morgantown, WV

Series Editor : Deborah Lieberman, MHSA, OTR/L, FAOTA, Director, Evidence-Based Practice, Staff Liaison to the Commission on Practice, American Occupational Therapy Association, Bethesda, MD

Issue Editor : Marian Arbesman, PhD, OTR/L, President, ArbesIdeas, Inc., Consultant, AOTA Evidence-Based Practice Project, Clinical Assistant Professor, Department of Rehabilitation Science, State University of New York at Buffalo

Financial Disclosures/Conflicts of Interest

The authors of this practice guideline have signed a conflict-of-interest statement indicating that they have no conflicts that would bear on this work.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Golisz K. Occupational therapy practice guidelines for adults with traumatic brain injury. Bethesda (MD): American Occupational Therapy Association (AOTA); 2009. 258 p. [282 references]

This guideline meets NGC's 2013 (revised) inclusion criteria.

Guideline Availability

Electronic copies: Not available at this time.

Print copies: Available for purchase from The American Occupational Therapy Association (AOTA), Inc., 4720 Montgomery Lane, Bethesda, MD 20814, Phone:1-877-404-AOTA (2682), TDD: 800-377-8555, Fax: 301-652-7711. This guideline can also be ordered online from the AOTA Web site .

Availability of Companion Documents

The following is available:

• Occupational therapy practice framework: domain and process. 3rd ed. Bethesda (MD): American Occupational Therapy Association, Inc. (AOTA); 2014. Available to order from the American Occupational Therapy Association, Inc. (AOTA) Web site .

In addition, the following are available in the original guideline document:

• Occupational therapy process for adults with traumatic brain injury (TBI)
• Case studies for occupational therapy practice with adults with TBI
• Selected International Classification of Diseases (ICD)–9 and ICD–10 codes
• Selected Current Procedural Terminology (CPT) ® codes for occupational therapy evaluations and interventions for adults with TBI
• Constraint-induced movement therapy and adjunctive interventions

Patient Resources

None available

This NGC summary was completed by ECRI Institute on October 27, 2010. This NGC summary was updated by ECRI Institute on October 20, 2016.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.

National Guideline Clearinghouse (NGC). Guideline summary: Occupational therapy practice guidelines for adults with traumatic brain injury. In: National Guideline Clearinghouse . Excerpted from the original by the American Occupational Therapy Association , 2016. Available at: www.guideline.gov . Used with permission.

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Comments (5)

Please remember, we are not able to give medical or legal advice. If you have medical concerns, please consult your doctor. All posted comments are the views and opinions of the poster only.

Anonymous replied on Fri, 09/23/2016 - 2:17am Permalink

This is a great post which identifies the needs of such a specialized population. In particular, I found the paragraph which describes the use of environmental cues to reorient an agitated patient to exceptionally helpful. It is so important to consider the mental health of a patient in order to provide a holistic treatment. I've just published a blog on this subject for anyone interested in a brief overview on mental health in OT! 

http://jordanelizabethnichols.weebly.com/blog

Anonymous replied on Thu, 01/14/2016 - 11:52am Permalink

Print copies are available for purchase from The American Occupational Therapy Association (AOTA), Inc., 4720 Montgomery Lane, Bethesda, MD 20814, Phone:1-877-404-AOTA (2682), TDD: 800-377-8555, Fax: 301-652-7711. This guideline can also be ordered online from the AOTA website: http://myaota.aota.org/shop_aota/prodview.aspx?Type=D&SKU=2214

Anonymous replied on Wed, 01/13/2016 - 4:41pm Permalink

Thank You for sharing this valuable info. How can I get access to the original document of this guideline. Thanks 

Anonymous replied on Mon, 01/26/2015 - 2:31pm Permalink

I think they're referring to the original published document: http://www.guideline.gov/content.aspx?id=15287

Anonymous replied on Sat, 01/24/2015 - 10:14am Permalink

Could anybody tell me what they mean by 'the original guideline document' and where I might be able to find it? Thanks

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Home > Books > Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Life Skills in Occupational Therapy

Submitted: 07 October 2016 Reviewed: 10 March 2017 Published: 05 July 2017

DOI: 10.5772/intechopen.68462

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Occupational Therapy

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Occupational therapy is a health profession that uses the purposeful activities to achieve multiple and complex rehabilitation aims. The main goals of the occupational therapy are to support the reintegration of individuals in daily living skills as well as to increase their independence and autonomy. Interventions of occupational therapists have primarily focused on self-care, productivity, and leisure time activities. Since the life skills includes a wide range of abilities that enable a person to perform personal care and more complicated tasks such as traveling, shopping, community participation etc., occupational therapists provide life skills training programs to meet the needs of the clients. This chapter aims to contribute to the current understanding and practices of life skills from an occupational therapy perspective. The chapter starts with a brief discussion of the importance of life skills in occupational therapy. After this introduction, the first part takes a look at the definition of life skills and identifies core components of life skills. The second part describes assessment and interventions of life skills. The third one gives an overview about school life skills programs for children and adolescents. Finally, the last part explains some life skills programs in people with disadvantages.

• life skills
• independent living
• occupational therapy
• people with disadvantages

Author Information

Hatice abaoğlu *.

• Faculty of Health Sciences, Occupational Therapy Department, Hacettepe University, Ankara, Turkey

Özge Buket Cesim

Zeynep çelik.

*Address all correspondence to: [email protected]

1. Introduction

Today, depending on social, moral, ethical, or religious values, the lifestyles of societies are changing rapidly. Achieving essential life skills is crucial in order to adapt to changing environmental conditions and meet the demands. Life skills contribute to the development of self-efficacy, self-confidence, and self-esteem by helping people to understand and respond different situations [ 1 , 2 ].

Occupational therapy has a key role in the lives of people who deal with disabling or potentially disabling conditions. Occupational therapy interventions are in accordance with the needs, interests, and values that are of importance to the clients. To this end, occupational therapists offer a unique and holistic approach to enhance or enable participation in daily life activities. They use therapeutic activities by identifying client problems, goals, and treatment focus to improve independence in life skills and to promote quality of life [ 3 , 4 ].

In occupational therapy field, a skill is defined as a performance component acquired through training and practice. Skills contribute people to function as part of the community in which they belong [ 5 ]. Occupational therapists assist the clients to create individualized goals through life skills training. These goals include achieving skills such as banking/budgeting, shopping, meal preparation and planning, coping with stress, community access, assertiveness, and self-advocating. As life skills educators, occupational therapists use a client-centered approach to assess occupational performance areas and associated environmental factors. Life skills training can be given in the client’s home or in various community areas, such as banks, markets, streets, as individual trainings, or group workshops that provide opportunities for the clients to learn from each other where appropriate [ 6 ].

2. Life skills and core components

Life skills are those abilities that help to deal with challenges in life and to promote physical, mental, and emotional well-being and competence. There are a wide range of life skills and definitions are usually broad and generic. Life skills can be cognitive, behavioral, emotional, personal, interpersonal, or social. As such, the term “life skills” is often not precisely defined. According to World Health Organization (WHO), life skills are defined as “abilities for adaptive and positive behavior that enable individuals to deal effectively with the demands and challenges of everyday life.” The five main life skills areas defined by WHO Department of Mental Health are decision-making and problem-solving; creative thinking and critical thinking; communication and interpersonal skills; self-awareness and empathy; and coping with emotions and stress. UNICEF defines life skills as “psychosocial and interpersonal skills that help people make informed decisions, communicate effectively, and develop the coping and self-management skills needed for a healthy and productive life” [ 7 , 8 ].

These definitions are meant to apply on various topic related to health in general population. Life skills include knowledge, behavior, attitudes, and values that are desirable and necessary for life roles. If we consider explanation of life skills, we could say that life skills may be different across cultures. Nevertheless, the research studies and literature of life skills indicate that there are specific life skills. They comprise a set of core skills that improve people’s well-being and help them to be active and productive in the community. These skills may generally be classified in three basic dimensions: (a) cognitive skills, (b) emotional skills, and (c) communication and interpersonal skills ( Figure 1 ) [ 9 , 10 ].

Figure 1.

Life skill categories for children and adolescents.

Cognitive skills are decision-making, problem-solving, creative thinking, and critical thinking. Decision-making is important for health management through choosing different options about health status. Problem-solving is critical for coping with the problems which may cause stress in daily life. Creative thinking promotes problem-solving and decision-making and helps to provide adaptation and flexibility to daily life. Critical thinking analyses and assesses information such as attitudes and values which affects behavior [ 10 – 12 ].

Emotional skills compromise of self-awareness and self-management. Self-awareness includes self-esteem, self-evaluation, our likes and dislikes, and our weaknesses and strengths. Briefly, self-awareness is about our recognition of ourselves. Self-management includes time management, relaxation, and coping skills about stress and emotions such as anger [ 10 , 11 ].

Interpersonal and social skills are interpersonal relationship skills, communication, and social awareness. Interpersonal relationship skills may be able to make good relationships with friends and family members which provide mental and social well-being. Communication is important for expression of ourselves verbally or nonverbally in certain situations. Social awareness includes empathy, listening actively, and respecting group differences ( Figure 1 ) [ 10 , 11 ].

3. Assessment and interventions of life skills

In general practice, despite the fact that occupational therapists are more focused on rehabilitation and therapy rather than preventing strategies; in life skills training, this tendency decreases. For instance, the occupational therapist works with school aged adolescents in order to enhance their abilities to prevent them from drug, tobacco, and alcohol addiction. Further, occupational therapists provide life skills training for the immigrants that facilitate their coping, management, and employability skills. And of course, occupational therapy practitioners work with disadvantaged people like people with disabilities and drug users to rehabilitate them by improving their participation [ 13 ].

Life skills assessment can be done by observation, interviews, questionnaires, checklists, and standardized evaluations. Therapists are able to develop a checklist for certain person to follow the process. They can also apply questionnaires or checklists to screen life skills in a broad sense. Moreover, it is possible to employ a standardized test to define life skills in detail. The most commonly used standardized assessment instruments by occupational therapy practitioners are shown in Table 1 [ 14 – 17 ].

Table 1.

The assessment tools that used commonly in life skills evaluation by occupational therapists.

When assessing life skills, it is important to note that occupational therapy approaches are individual and person centered. Each group and each person has specific characteristics in the mean of occupation. Therefore, the occupational therapy assessment of the life skills is provided individually by employing the practical reference models either for general praxis, such as Model of Human Occupation (MOHO) [ 18 , 19 ], Person-Environment- Occupation Model (PEO) [ 20 – 22 ], and VdT Model of Creative Ability (MOCA) [ 23 , 24 ] or the ones that particularly developed for this use, such as Occupational Therapy Life Skills Curriculum Model [ 13 ], Life Skills Training Approach [ 25 ], and etc.

MOHO provides a framework (or model) for occupational therapist to understand how to use daily activities therapeutically to support people’s health. It seeks to explain how meaningful daily activities are motivated, patterned, and performed. MOHO focuses on the occupation in practice; the motivation for occupation; the patterning of occupational behavior/performance into routines and lifestyles; the nature of skilled performance; and the influence of the environment on occupational performance. It has assessments and intervention protocols, that are specific to itself, to support practitioner to understand the volition, habitation, roles, and performance capacity of the individuals. Life skills, in this model, are agent that both affect and are affected by the routines, roles, habits, and the capacity [ 18 ].

The fundamental belief of MOCA, which is an occupational therapy model, the motivation controls the action and the action is the manifestation or expression of motivation. According to Vona du Toit, humans develop a variety of skills in a sequential sequence as environmental/social/relationship/occupational demands change and influence them throughout the lifespan. That is why, action is examined by four skills of people. These are personal management, social ability, work ability, and use of free time. The role of the occupational therapist is to identify the client’s current level of creative ability and how much independence s/he has at that level. This enables the therapist, team, client and/or carers to understand what the client is motivated for and the extent of his/her skills for doing things that s/he finds meaningful and is motivated toward. With this understanding, intervention can be offered to elicit motivation and participation in order to facilitate growth toward the next (higher) level of ability. In the case of a client with dementia, intervention is provided to maintain level of ability and prevent deterioration for as long as possible [ 26 ].

PEO model describes the interaction among person, environment, and occupation for clear understanding of occupational performance. The person component of this model is seen holistically as a combination of mind, body, and spiritual qualities. And also, each person has both learned and initiate skills in order to accomplish in occupational performance. The environment where the individual use their abilities to engage in occupation has four subscales: cultural, socioeconomic, institutional, physical, and social. Last but not the least, the occupation is a composite of activities and tasks that are necessary to function in life [ 20 ].

Occupational Therapy Life Skills Curriculum Model is created for promoting the nonpatient population via a unique, nontraditional occupational therapy role focusing on primary prevention, and community health and enhancement. This model includes a program, that is, named leisure skills/career development, for children of ages between 4 and 22. And the program divides the age bands to three: fantasy-exploration stage, tentative choice stage, and final realistic stage. Meantime, there are academic skills and leisure skills program for each of the stages both of them have specific subprograms [ 13 ].

After choosing the most appropriate approach for the patient and completing the evaluations, occupational therapists navigate the session to the intervention. The life skills training programs are created in order to increase one’s participation in social, intellectual, creative, and physical activities. The life skills training programs can be administered as individually or modular. Programs such as social skills training, emotional skills training, and behavioral skills trainings can be considered as modular because, for example, social skills training generally contains social participation skills, interpersonal skills, assertiveness training, communication skills, etc. The individual trainings typically facilitate development of abilities in the three main component areas of daily living by developing daily organization and time management; personal health including sleep, medication management, healthy eating, and avoiding addictions; self-monitoring; stress management and relaxation techniques; leisure exploration and development; communication and relationships; managing public transport and mobility; conflict resolution skills; managing money; career exploration and planning; study, prevocational, and work readiness training; and vocational reintegration skills. The group trainings, generally, are provided after the need analysis of the group. In the life skills training for schizophrenics, for example, focus points of training are generally about interpersonal communication, nutrition, time management, etc., while the life skills training programs for homeless are about social action, individual justice, employment, money management, etc. [ 27 – 29 ].

4. Life skills in children and adolescents

Life skills trainings improve skills to create proficiency for human development and to indigenize appropriate behaviors that provide to deal with the difficulties of daily life in children and adolescents. Life skills also help children and adolescents to improve their psychosocial competence which is important to deal with challenges of daily life, promotion of health, and for well-being. Specially, where the health issues are associated with behaviors which cause inadequacy to cope with personal and social challenges powerfully, developing of psychosocial competence may be an important way to contribute well-being and health. Therefore, teaching of life skills to children and adolescents is one of the core elements to develop psychosocial competence [ 10 ].

Life skills training supports constructive behavior about health, relationships, and well-being. Optimally, it is critical to perform this training when the children and adolescents are at young age before adverse behaviors. Trainings of life skills are based on general life skills and their practice in connection with social and health issues. Methods and approaches such as cognitive-behavioral skills training techniques, didactic teaching methods, group discussion, brainstorming, and role play can be used in teaching of life skills [ 10 , 27 ].

There are many evidence-based life skills programs which provide education about many issues, such as drug abuse prevention or preventing violence which are related with life skills. For example, the life skills training (LST) program which is a primary prevention program for adolescent drug abuse created positive behaviors about alcohol, tobacco, and other drug use. This program included drug resistance skills, self-management, and social skills. Methods which are used in this program were instruction, reinforcement, feedback, practice of the skill, and behavioral homework assignments [ 30 , 31 ]. Another evidence-based program about life skills is coping skills training for youth with diabetes mellitus which was conducted by Grey and her colleagues. Role play about situations such as managing food choices, giving feedback, using of social problem-solving, and working with small groups are the methods which were used in this training. Results of this training showed that teenagers in the coping skills training program were likely able to cope with diabetes mellitus and other medical situations, and indicated less negative effect of diabetes on quality of life [ 32 ]. HIV prevention intervention which is done in Zimbabwe with adolescent female orphans is also an important research. In this intervention, HIV and health knowledge (e.g., condom use) and issues related to culture, gender, sexual, and physical violence were the topics in life skills curriculum of this research. According to the results of this study, participants earned personal hope and value, and effective communication skills [ 33 ].

The objective of the life skills education is to help children and adolescents to understand themselves, reach personal satisfaction, live life better, and achieve their goals. This education is essential for the personal and academic development of children and adolescents. Therefore, considering of the certain strategies for life skills education may affect the impact of the education. These strategies are:

Doing the education in schools because of the possibility to reach many children and adolescents and long- and short-term evaluation.

Providing the education at young ages.

Making the education part of the school curriculum.

Using tested, evidence-based, well design life skills programs.

Using an evaluation system for education.

Determining objective of the education through need analyses.

Inclusion of both knowledge and social attitudes and values.

Improvement of all teachers, principals, other staff members about the topic of life skills education.

Using methods such as role play, feedback about performance, practice of skills instead of just using didactic teaching.

Starting with skills learning in nonthreatening situations and progressively moving on the practice of skills in high-risk situations.

Creating the education with a multidisciplinary group such as professionals from schools, public health, and social services.

Apart from these strategies, conducting publicity campaigns to promote support and expectations of life skills education and publishing papers about education may increase the effect of life skills education [ 10 , 34 ].

Mission of the school is to educate children and adolescents to be healthy, social skilled, responsible, and informed. With the school-based prevention and youth development programs, this mission is undergird [ 35 ]. Many teachers experience that many children in schools have poor social and communication skills because of computers and televisions [ 36 ]. Therefore, as we mentioned above, it is an important strategy to give life skills educations in schools. There are many life skills education programs for different age groups in many schools around the world. Some of them are: Promoting Alternative Thinking Strategies (PATHS); The School Mental Health Program (SMHP); The Smoking Prevention Program; The GOAL Program; UNESCO and Government of Ghana Life Skills Alcohol and Drug Prevention Program; Life Skills and Positive Prevention Programme; The Life Skills Training (LST) program; The Problem-Solving Program [ 10 , 12 , 27 , 37 – 40 ]. For deeper explanation about the context of educations, you can find an example of school-based life skills education sessions about prevention of cigarette smoking in Figure 2 [ 39 ].

Figure 2.

School-based life skills education sessions about prevention of cigarette smoking [ 39 ].

Life skills are like physical skills in the way of learning methods, through modeling and practice. Many of the life skills learned in sport are quotable to other life areas. These skills may include: the abilities to show performance under pressure; communicate; meet challenges; set goals; solve problems; handle failure; work with a group; and receive feedback. Therefore, sport participation which provides psychosocial development may contribute to life skills in children and adolescents [ 41 ]. Although there is not enough research focusing the effect of sports on life skills development, there is growing interest about the development of life skills through sport in children and adolescents and sport psychology. Many athletes have begun to understand the importance of using sport psychology strategies and techniques to improve their nonathletic life. One study which is about teaching life skills through sport, mentioned a program which calls Sports United to Promote Education and Recreation (SUPER). The objective of the program was to show participants the importance of physical and mental skills for sport and life and the existence of the effective student-athlete role models. In this program, topics such as similarities and differences of life skills and sport, being a good listener, speaking with the group were taught to the participants who are sport leaders. And these leaders taught students sport skills and life skills related with sport, coached the students to increase their sport performance [ 42 ]. Sport-based life skill education is also important on adolescents’ prosocial values. According to a research study which is conducted by Brunelle, Sport-Based Life Skill Program had a positive effect on adolescents’ prosocial values such as social responsibility, empathy, social interest, and that the community service experience affected the adolescents’ levels of social responsibility and confidence positively. This study suggests that when sport is integrated with life skills and community services, prosocial values are improved in adolescent volunteers. Therefore, sport may serve to develop character and values when combined with life skills programs [ 43 ]. Influence of sport on life skills development occurs in different levels ( Figure 3 ). According to Gould and Carson, in first level sport may prevent youth from getting into trouble and from involving in risky activities. In second level, role models such as sport coaches may affect positively to their athletes about life skills. Third level is more influential level. Because it includes teaching of life skills by coaches. Through this teaching, participants can transfer these skills to nonsport domains. In fourth level, the coach does not only teach skills for sport but provides and works the athlete to transfer these skills beyond sport [ 44 ].

Figure 3.

Levels of life skills development through sport [ 44 ].

5. Life skills for disadvantaged groups

Life skills programs enhance skills of vulnerable adolescent and young adult populations. These programs generally include a formal curriculum, along with a combination of group education, peer mentorship, one-to-one support, coaching, and experiential learning [ 45 ]. “Coaching” in which therapists guide people to examine their goals and identify changes to their performance [ 46 ], is one of these programs. It involves tailored, experience-based support in learning life skills and self-management strategies, and seeks to enhance people’s self-efficacy and skill development by providing opportunities to learn new skills, make decisions, experience successes, and take calculated risks [ 47 ]. Life skills programs need to be intentionally designed. These programs offer experiential opportunities by providing new insights, self-realizations, and positive yet realistic views of the future to equip them with knowledge, skills, and confidence, and to motivate them to engage in new life directions [ 48 ].

Vulnerable children such as orphans, sexually exploited children, street children, and working children may need for life skills interventions. Although life skills play an important role in determining how children cope with difficult conditions, little is known about life skills interventions with vulnerable young people. Children with low socioeconomic backgrounds have a low self-concept and lack of self-efficacy and life skills. Their belief in their own abilities value is decreased due to the low attendance of school and the difficulties in school life [ 7 , 49 ].

The term street children refers to a diverse group of young people dislocated from family, school, and community, who tend to work, congregate and/or live in inner city areas. Poverty in developing countries, associated with the collapse of rural economies and migration into overburdened urban environments, is the root cause of the street child phenomenon [ 50 ]. Life skills programs are necessary for health promotion and well-being for these groups. Life skills may include to identify health problems and the ways to prevent them, to analyze factors that impact growth and development from adolescence to adulthood, to describe the relationship between health and adolescent choices, to assess factors that influence emotional self-management and relationships with the environment [ 51 ].

Another disadvantaged group is individuals with addictions. It is supported by research that life skills training are the most effective approach in school-based drug prevention programs. The life skills training program for adolescent drug use focuses on the social and emotional factors that promote substance use. Separate curricula have been developed for students from different age groups as supportive interventions in schools. The program consists of three main components: drug resistance skills, personal self-management skills, and general social skills [ 52 , 53 ].

Deaf individuals face many challenges during school years and during the transition to independent living. Research on the life skills in these individuals is very limited. Life skills training should be designed to meet the needs of deaf individuals. In a study, life skills training for vulnerable deaf adults includes money management and consumer awareness, food management, personal appearance and hygiene, health (e.g., knowing the symptoms and treatment of various illnesses), housing (e.g., knowledge of renters rights and obligations), housekeeping, educational planning, transportation, legal knowledge (rights when arrested, function of a lawyer), job seeking skills, job maintenance skills, knowledge of community resources, emergency and safety, interpersonal skills, pregnancy, parenting, and childcare [ 54 ].

People with schizophrenia are a disadvantaged group because of stigma. Negative labeling has an impact on public attitudes toward people with schizophrenia. Negative labeling has a strong negative effect on the way people react emotionally to someone with schizophrenia as a result of increasing the preference for social distance. Furthermore, people with schizophrenia have social withdrawal, employment problems, reduced social, or recreational activities. Life skills training for people with schizophrenia may include daily living activities, money management, communication and social skills, home management, community life skills, etc. [ 55 – 58 ].

Life skills training are also important for homeless people. Homeless individuals may experience problems with unemployment, loss of income, lack of social security, inadequate access to social support and health services, disability, substance abuse, or suicide attempts. Because life skills such as managing money, shopping, cooking, running a home, and maintaining social networks are essential for living independently. Some homeless people do not have all of these skills, because they never acquired them or lost them through extended periods of homelessness. The aim of the training is to promote self-sufficiency in homeless people. Life skills can be classified into three broad categories: (1) social skills (e.g., interpersonal skills, avoiding or dealing with neighbor disputes, developing self-confidence and social networks), (2) independent living skills (e.g., managing a household, budgeting, appointment keeping and contacting services, dealing with bills, and correspondence), and (3) core or basic skills (e.g., numeracy, literacy, and information technology). For example, a study is showed that homeless youth may need to personnel hygiene (body odor and sweating), oral health (including bad breath), oily skin and acne, unwanted or oily hair, feminine hygiene, piercing maintenance, budgeting and finance, and soft skills (motivation, self-awareness, and ability to work with others) [ 59 , 60 ].

In the literature, there are different life skill training programs designed other disadvantaged groups such as criminals and refugees. Disadvantaged individuals face social, economic, and cultural challenges throughout their lives. A disadvantaged group may face multiple challenges. Some difficulties can be overcome or changed more easily than others. Because the difficulties that individuals experience and the ways in which they deal with them are different between the groups, life skills interventions may change from group to group. The ability to overcome difficulties in everyday life depends largely on the development of life skills. Life skills include skills that enable people to cope with their life, difficulties, and changes [ 61 – 63 ].

In summary, there is no definite classification of what psychosocial skills may be at the core of life skills, nor is there any clarity about the relationship of these skills to each other. However, it is seen that the skills defined as life skills are cognitive, emotional and behavioral, even though they are classified by different persons and institutions in different ways. These skills are vital to maintaining a productive and healthy lifestyle, having meaningful and satisfying roles, and promoting well-being. For this reason, it is quite natural that occupational therapy, which aims to promote functional independence of individuals in their daily life skills, includes life skills and related training programs.

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Occupational Therapy Interventions for Adults Living With Serious Mental Illness

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Elizabeth Griffin Lannigan , Susan Noyes; Occupational Therapy Interventions for Adults Living With Serious Mental Illness. Am J Occup Ther September/October 2019, Vol. 73(5), 7305395010p1–7305395010p5. doi: https://doi.org/10.5014/ajot.2019.735001

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Occupational therapy practitioners have education, skills, and knowledge to provide occupational therapy interventions for adults living with serious mental illness. Evidence-based interventions demonstrate that occupational therapy practitioners can enable this population to engage in meaningful occupations, participate in community living, and contribute to society. Systematic review findings for occupational therapy interventions for adults living with serious mental illness were published in the September/October 2018 issue of the American Journal of Occupational Therapy and in the Occupational Therapy Practice Guidelines for Adults Living With Serious Mental Illness. Each article in the Evidence Connection series summarizes evidence from the published reviews on a given topic and presents an application of the evidence to a related clinical case. These articles illustrate how research evidence from the reviews can be used to inform and guide clinical decision making. Through a case story, this article illustrates how current evidence is applied for effective occupational therapy intervention with an adult living with serious mental illness.

Rosa is a 42-yr-old woman who was diagnosed with schizophrenia at age 23 yr. She completed her high school education but is currently unemployed. Rosa never married and has no children. Her parents are deceased, and she is close to her sister and brother-in-law, who live several states away. During the first 10-yr period after her initial diagnosis, she had three admissions to the local general hospital’s inpatient unit for acute episodes; the interventions included medication stabilization and discharge referrals to local mental health services. After her first hospitalization, Rosa attempted to live in an independent apartment but was unable to manage her self-care and household responsibilities. For the past 5 yr, Rosa has lived in a supported-housing, one-bedroom apartment, managed by the local community mental health agency.

Rosa currently participates in the Assertive Community Treatment (ACT) program to address her stated wellness and employment goals. Doug is the ACT team occupational therapy practitioner, collaborating with Inez, the occupational therapy assistant, for intervention implementation.

• Occupational Therapy Evaluation and Goal Setting

Doug began the occupational therapy evaluation by administering the Canadian Occupational Performance Measure (COPM; Law et al., 2014 ) to determine Rosa’s strengths and challenges in occupational performance and complete her occupational profile ( American Occupational Therapy Association [AOTA], 2017 ). Doug learned that Rosa’s roles include sister and participant in an ACT program. Rosa reported wishing to live in an independent apartment but acknowledged needing assistance from supported housing staff. She reported not socializing with any other residents. With assistance from local vocational rehabilitation services, she worked briefly in several cleaning jobs. Rosa described leaving these jobs because of difficulty with supervisors and coworkers, but she was unable to be more specific about her work challenges. During the COPM assessment, Rosa shared being very dissatisfied with her social participation and unemployment. Rosa voiced wanting to “have friends to connect with” and find a job that she “could do for many years.”

To gain additional information to support Rosa’s community participation, Doug administered several assessments for the analysis of occupational performance ( AOTA, 2014 ), including the Allen Cognitive Level Screen–5 (ACLS–5; Allen et al., 2007 ) and the Routine Task Inventory–Expanded (RTI–E; Katz, 2006 ). The score of 5.0 on both indicated that Rosa experiences difficulty with abstract thinking and uses trial-and-error problem solving ( Allen et al., 1995 ). Rosa will benefit from visual demonstrations accompanied by verbal explanations. Use of concrete explanations and examples will assist Rosa’s planning ahead for potential problems.

Results of the Weekly Calendar Planning Activity ( Toglia, 2015 ) supported the findings from the ACLS–5 and RTI–E, demonstrating Rosa’s limited ability to monitor her own performance and difficulty in complex thinking for performance. Combined assessment results indicated that Rosa needed assistance to develop strategies for establishing and maintaining daily and weekly routines as well as balancing work, rest, leisure, and social participation. Environmental cues can promote Rosa’s success in her home and future work environments. Structured daily and weekly routines, incorporating work and meaningful social interactions, will support and maintain Rosa’s recovery. A brief summary of assessment results is presented in Table 1 .

On the basis of Rosa’s interests, goals, and assessment results, Doug collaborated with Rosa to develop intervention goals. Rosa willingly participated in occupational therapy interventions with Doug and Inez to address employment and social participation. Goals included securing competitive employment through an Individual Placement and Support (IPS) model of supported employment, achieving independence in self-care and transportation to support employment (activities of daily living and instrumental activities of daily living tasks), and participating in social and leisure activities in the community. Doug reviewed the evidence from the September/October 2018 issue of the American Journal of Occupational Therapy (see D’Amico et al., 2018 ; Noyes et al., 2018 ) and AOTA’s Occupational Therapy Practice Guidelines for Adults Living With Serious Mental Illness ( Noyes & Lannigan, 2019 ), incorporating that evidence into Rosa’s occupational therapy intervention plan.

• Intervention Implementation

On the basis of the strength of the evidence and findings from the systematic reviews, the following interventions were implemented to address Rosa’s goals (Doug’s intervention implementation included two sessions per week for 12 wk):

Doug collaborated with Rosa to facilitate her referral to the IPS program sponsored by the local community mental health agency ( Areberg & Bejerholm, 2013 ; Campbell et al., 2010 , 2011 ; Catty et al., 2008 ; Heslin et al., 2011 ; Kinoshita et al., 2013 ; Kukla & Bond, 2013 ; Michon et al., 2014 ; Modini et al., 2016 ; Twamley et al., 2008 , 2012 ; Wong et al., 2008 ).

Individual sessions with Rosa focused on skill development for effective workplace grooming and dressing and using public transportation to travel to work independently (Lindström et al., 2012 ; Roldán-Merino et al., 2013 ).

Rosa attended occupational therapist–led groups at the ACT program to increase social participation ( Cook et al., 2009 ; Štrkalj-Ivezić et al., 2013 ; Tatsumi et al., 2012 ), with one group intervention using cognitive–behavioral therapy (CBT) to directly address social skills ( Rus-Calafell et al., 2013 ).

Intervention 1

Rosa requested that Doug accompany her on initial appointments with the IPS team to share results of her occupational therapy evaluation. This collaboration addressed making the best possible match between her strengths, skills, and challenges and the requirements of her desired job. Inez visited several potential work settings with Rosa and provided onsite job coaching while Rosa learned the tasks of her chosen retail job.

Intervention 2

During sessions with Inez, Rosa identified workplace requirements for grooming and clothing. Inez accompanied Rosa to visit several secondhand clothing stores, where Rosa purchased appropriate clothing for the retail job. Inez assisted Rosa to create a chart of grooming tasks to be completed daily for her work shifts. Rosa added scheduled times for each task, producing a printed schedule to follow. She posted this chart in her apartment bathroom.

Intervention 3

Inez assisted Rosa in identifying the public transportation route from her apartment to the retail store. Inez accompanied Rosa on a trial run, after which Rosa completed successfully three independent trials of public transportation to the store.

Intervention 4

Doug led occupational therapy social participation groups within the ACT program. Rosa attended six group sessions, participating in the CBT approach to improve her workplace social interactions. She completed role-plays enacting conversations with coworkers and supervisors. Rosa reported feeling more able to engage in workplace conversations and to communicate her needs to the supervised housing staff.

Through use of evidence-based, occupation-focused, and client-centered occupational therapy interventions, Rosa met her goals by the end of her 4-mo intervention plan. Rosa performed her employment responsibilities with decreasing job coaching by Inez. Rosa excitedly reported working at her retail job 2 days per week. She credited Inez with “teaching me all the steps,” stating that she knew how to do all the job tasks now. At 4 mo, Rosa no longer required onsite job coaching but continued to meet weekly with Inez to discuss work performance concerns.

Rosa reported managing communication at her workplace, such as feeling comfortable asking questions of her direct supervisor when needed. She also reported considerable improvement in her use of structured routines to effectively complete self-care activities before going to work, sharing her supervisor’s comment that her appearance at work contributed to her employment success. Rosa also described successfully using public transportation for work. Rosa made plans to meet two peers from the social skills group socially after discharge. She described having “a much easier time knowing what to say” to coworkers at her job, which made her feel more confident.

Doug and Inez met with Rosa at the end of 4 mo for reevaluation of her daily living, social participation, and employment goals. Rosa intended to continue the IPS program as support for maintaining her job. Rosa requested continuing attendance in therapeutic groups to address communication and employment concerns because of her desire to seek employment with greater responsibilities. She reviewed other discharge recommendations and community resources with Doug and Inez. Together, they researched opportunities for increasing social interactions in her community through the local community recreation and adult education centers.

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Assessment Results

Note. ACLS–5 = Allen Cognitive Level Screen–5; COPM = Canadian Occupational Performance Measure; RTI–E = Routine Task Inventory–Expanded; WCPA = Weekly Calendar Planning Activity.

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The impact of occupation-based problem-solving strategies training in women with breast cancer

Sedef Şahin.

Faculty of Health Sciences, Department of Occupational Therapy, Hacettepe University, Samanpazarı, 06100 Ankara, Turkey

Mine Uyanık

Associated data.

Please contact the first author for data requests.

By identifying the occupations of women with breast cancer who have performance problems, to examine the impact of the application of occupation-based problem-solving strategies (OB-PSS) training on cancer-related fatigue, depression, and quality of life.

The study comprises 22 women outpatients in the clinic. Socio- demographic and Clinical Features Information Collection Form, Canadian Occupational Performance Measure (COPM), Cancer Fatigue Scale (CFS), Beck Depression Inventory (BDI), The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire C-30 and BR23 (EORTC QOL-C30 - EORT QOL-BR23) tests have been applied to survivors. OB-PSS training was conducted on a face-to-face basis once a week for 6 weeks.

When activity distribution results in accordance with the performance areas are studied, women with breast cancer were seen to suffer problems mostly in their most productive areas (housework management). As a means of solving these performance problems, they developed adaptive strategies like including additional new steps to these activities. Statistically meaningful results have been obtained between measurements before and after the treatment process through all tests ( p  < 0.01).

Conclusions

OB-PSS provides positive gains in women with breast cancer in terms of a reduction in the degree of cancer-related fatigue and depression, and a progress in performance and satisfaction levels particularly in activities where performance problems are experienced and an improvement in quality of life. OB-PSS training could be used as an appropriate rehabilitation approach for coping with problems in women’ life with breast cancer.

Cancer is a serious and chronic disease, as well as being a disease-bearing uncertainty, bringing to one’s mind death in great suffering and pains and leading to feelings of panic and anxiety [ 1 ] . Breast cancer is the type of cancer which is most prevalent in women in the world [ 2 ]. Life expectancy in survivors with breast cancer has been increased thanks to early diagnosis and more effective treatment of cancer with the help of current developments. The increase in the number of surviving breast cancer patients after treatment leads to an increase in secondary problems accompanied by the disease and its treatment [ 3 ]. Among those are both physical and psychological symptoms such as pain, fatigue, exhaustion, anxiety, limitation in daily routines and lack of participation [ 4 , 5 ]. It is known that people’s life quality is adversely affected in the case of one or more of these symptoms [ 6 ].

Considering the increase in the number of cancer patients in recent years, there is a growing need for further research into the determination of problems people experience during their daily routines and their intervention methods. As each and every disease and its symptoms will tend to vary from one person to another, the severity of these symptoms and the degree of capability to cope with them will also be different. Involving individual-oriented and holistic approaches, occupational therapy (OT) is a rehabilitation area which has a growing interest within studies in this field [ 7 – 9 ]. Considering the studies carried out into the effectiveness of OT interventions, it has been observed that procedures like problem solving strategy (PSS), which are conducted towards activities in which survivors experience performance problems, positively influence individual coping skills [ 8 – 10 ]. The importance of effectiveness of individual coping skills in increasing one’s activity and role performance is also an issue that has been strongly emphasized in recent years [ 9 , 10 ].

PSS was originally developed as a therapy for depression and adapted later for use in medical settings [ 11 , 12 ]. It has been used to help cancer patients develop and evaluate various solutions to the difficulties they encounter in life [ 10 ]. PSS consists of various steps such as detecting the problem, choosing a meaningful, purposeful and observable target, brainstorming possible solutions, identifying the advantages and disadvantages of each and every possible solution, deciding on the solution, implementation and assessment in accordance with the feedback obtained [ 10 , 11 ]. In OB-PSS, the problem is identified using COPM, which is one of the holistic approaches in the field of OT, from amongst all the activities in the fields of self care, productivity and free time performance and all other PSS steps are monitored. The most important component of PSS is individual activation, in which the therapist does not offer specific solutions. Thus, the individual becomes the active director of recovery.

The objective of our study, which is based upon the hypothesis that there is a lack of adequate research into the influences of activity-based applications on cancer patients, is to establish the fact that women with breast cancer experience performance problems, and to study the influence of OB-PSS on activity performance and satisfaction, cancer-based fatigue, depression and quality of life.

Selection and description of participants

The study was conducted at the outpatient Oncology Clinic of the University Hospital, by convenience sampling from May 2016 to May 2017. Criteria to get involved in the study: (1) being women between 18 and 64 years of age, (2) diagnosed as stage 1 or 2 breast cancer stage, (3) having received chemotherapy in the last 6 months, (4) being cooperative. Non-participation criteria: (1) having been diagnosed with breast cancer at stages 3–4, (2) having received radiotherapy in the last 6 months, (3) having another secondary chronic disease, (4) having received hormone therapy in the last 9 months, (5) being a part of any other rehabilitation program.

During the study period, the patients who applied to the clinics were screened as potential participants. 25 women were eligible and of these, three women subsequently met exclusion criteria: had started to receive the radiotherapy at the same time during the study. Therefore, total 22 women who applied to the as outpatients with breast cancer diagnosis were included in the study (the sample number has turned out to be 22, taking the error margin as 5% ( p  = 0.05) at an 80% strength through statistical power analysis).

Women with participant criteria were given the rating scales that are described in detail below. OB-PSS was conducted one session (60–90 min) per week for 6 weeks. Participants were assessed again with the same scales after the intervention and the results were compared.

Measurements

Socio-demographic and clinical features form.

So as to comprehensively evaluate women with breast cancer, with a compilation from other similar studies, an information collection form was specifically designed and used to examine socio-demographic features such as age, gender, duration of disease (months), number of cures, cancer stage, medication, marital status, educational status, occupation, present condition in terms of employment.

Primary outcomes

Canadian occupational performance measure.

COPM, a standard measurement tool was used to identify the occupational performance problems of survivors with breast cancer and measure their sense of satisfaction [ 13 ]. The COPM is a client-centered measure that examines self-perceived changes through semi-structured interview in the occupational performance according to three occupational performance areas (self-care, productivity, and leisure) [ 14 ]. It has been translated into more than 20 languages in over 35 countries and is commonly used in occupational therapy departments. The test-retest reliability of the COPM is within the acceptable range; intra-class correlation coefficients for patients with chronic diseases and obtained coefficients ranging from 0.73 to 0.93 [ 15 – 17 ].

In COPM, individuals are firstly asked to identify the problematic activities regarding self-care, productivity and leisure, which they normally do, want to do or are restrained from doing in their daily routines. At the second stage, they are asked to give points between 1 and 10 on the likert scale for each of the activities they have identified (1-Not important, 10-Very important). At the third stage, everyone was asked to choose at least 1 and at the most 5 most important activities and then give a point for each activity between 1 and 10 on the likert scale for performance and satisfaction. Performance and satisfaction scores are determined by dividing the sum of performance and satisfaction scores to the number of activities the individual considers important [ 18 , 19 ].

Secondary outcomes

Cancer fatigue scale.

CFS was used to evaluate the fatigue level of survivors with breast cancer. This scale was developed in Japan by Okuyama et al. in 2000. It examines fatigue physically, emotionally and cognitively from a tri-dimensional perspective. CFS was proved to be a valid and reliable tool used to evaluate fatigue both in survivors with breast cancer and in other various types of cancer patients [ 20 – 24 ]. The items in this scale which consists of 15 items is scored between 1 (never) and 5 (always). The score interval for physical function sub-heading is between 0 and 28, for emotional function sub-heading 0–16 and for cognitive function sub-heading between 0 and 16. Maximum total score is 60 points. A high score is the indication of a higher cancer-related fatigue level [ 20 ].

Beck depression inventory

BDI was used to determine depression levels of survivors with breast cancer. This scale was developed by Beck et al. in 1961 [ 25 ]. It evaluates the physical, emotional, cognitive and motivational symptoms observed during depression. Each item is scored between 0 and 3. The points given for each item are added up to calculate the depression score. A high score means that the severity of depression is high [ 25 ].

The European Organization for Research and Treatment of Cancer quality of life

In our study, EORTC-QOL C30 and BR-23 life quality assessment tests, which are recommended by World Health Organization to be used in the assessment of life quality of cancer patients, and their various versions designed for specific cancer types have been used [ 26 ]. EORTC-QOL C-30 test is made up of 30 items under three sub-headings, which are general well-being, functional difficulties and symptom control. First 28 items are scored between 1 (none) and 4 (high), and the last two items between 1 (too bad) and 7 (perfect) on the likert scale. Total score may range between 0 and 100. Items 29 and 30 are related with general well-being. High scores in this section indicate a high life quality, whereas low ones refer to a low life quality. Lower scores in the functional and symptoms domains point to high life quality, while high points come to mean low life quality [ 27 ].

EORTC QOL BR-23 is a test made up of 23 items each of which is scored between 1 (none) and 4 (high) on the likert scale, used to assess the quality of life of survivors with breast cancer under two headings, functional and symptoms [ 28 ]. Low scores mean high life quality, while high scores denote to low life quality [ 29 ].

Intervention

PSS is a method in which development of skills and strategies in cancer patients are encouraged and certain adaptations are made in line with personal needs [ 10 ]. OB-PSS was given to the participants by the authors. The authors and the participants identified problematic activity together with COPM. The authors (therapists) provided guidance by describing the steps involved in the OB-PSS. The authors and the participants found the solution to the problem in this method together again. Later, the participants experienced of the solution way in their real environment on routine life. The authors received feedback from the participants about their experiences. As a result of this interactive method, the professionals give the individual a chance to choose and try to solve the problem-solving strategy in their activity practice. OB-PSS training was conducted in 4 stages totally in 6 sessions.

• Stage 1: Setting a measurable, realistic and attainable goal for the solution of activities that involve performance problems
• Stage 2: Considering and studying the pros and cons of possible solutions by making a brainstorming through the Canadian Model of Occupational Performance
• Adaptation of the activity, making alterations to one or more of the following: who (involving another person), where (making a change in the place), when (changing the time), how (altering the way of application) and what (adding up new steps at the beginning or end of the activity).
• Finding out the new activity,
• Planning the steps of the activity (in accordance with priority),
• Bringing together activity-related information and resources
• Stage 4: Revising the problem-solving process which has been activated with the OB-PSS training, receiving feedback about individual’s experiences and making alterations to the course of action when necessary.

Statistical method

Data were analyzed using IBM the Statistical Package for the Social Sciences (SPSS) version 23.0 software. The variables were investigated using visual (plots/histograms) and analytical methods (Kolmogorov-Smirnov Test) to determine whether or not they are normally distributed (normal =  P  > .05, not normal =  P  < .05). Paired student-t and Wilcoxon signed rank test were used to test the mean differences between at the beginning and at the end of the intervention. Significance was set an alpha level of 0.05. Quantitative data were described with mean ± standard deviation (X ± SD), qualitative data were described with percent (%) values.

In the analysis of qualitative data of activities, MAXODA 11.0 version was used and content analysis was made [ 30 ]. The approach uses a systematic and reproducible process to encode the manifest content of a text, followed by the number of data added to each code [ 31 ].

Twenty two women with breast cancer between ages 46.77 ± 7.99 years participated in this study. Their average duration of disease is found to be 5.77 ± 2.52 (2–12) months and average total number cures taken 5.68 ± 3.21 (2–16) months. Other demographic data are illustrated in Table  1 .

Findings related to the demographic information about women ( N  = 22)

When all the activities determined in accordance with COPM are studied with reference to performance domain distribution, women with breast cancer were seen to suffer mostly from productivity problems (45.5%), followed by self-care (40.9%) and leisure (13.6%) problems. Totally 110 different self-care, productivity and leisure activities were defined, all which survivors wanted to perform yet had difficulty to do so, and OB-PSS training was carried out in line with these identified activities. All the activities that were defined are shown in Table  2 .

All the activities with performance problems determined by COPM

Note: COPM Canadian Occupational Performance Measure

When the results of the OB-PSS steps applied to survivors are examined, performance problems were seen to have been experienced in a total of 110 activities which were identified by COPM. 110 different targets were defined for solutions to the problems that were identified. During the solution process of these problems and evaluations obtained from their feedback, in 12 activities out of all 110, it was seen that survivors failed to come up with any solution to their performance problems in their activities. In the process of establishing the action plan for the solution to performance problems, it was seen that 58.19% of the survivors preferred to make adaptations to the activities by either making them easier or more fun. In all 103 adaptive strategies that were developed as solutions to problems, 33.9% of them were found to make changes to ‘what’ and 28.2 of them to ‘how’ of the activity (Table  3 ).

Findings concerning OB-PSS steps ( N  = 110 activities)

Note: OB-PSS Occupation-based problem solving strategies

When the results of the activity performance and satisfaction are examined after the OB-PSS training, a statistically significant increase was found ( p  < 0.01). The differences between the results of tests – CFS for fatigue levels, BDI for depression levels, EORTC-QOL-C30 and BR-23 for quality of life – before and after intervention were statistically significant ( p  < 0.01) (Table  4 ).

Comparison of COPM, CFS, BDI and EORTC-QOL averages according to pre and post interventions

Note: COPM Canadian Occupational Performance Measure, CFS Cancer Fatigue Scale, BDI Beck Depression Inventory, The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire C-30 and BR23 (EORTC QOL-C30 - EORT QOL-BR23); COPM and CFS averages (Paired student-t test), BDI and EORTC-QOL averages (Wilcoxon signed rank test); * p  < 0.01

After identifying the activities of women with breast cancer that involve performance problems, following the OB-PSS training towards these activities carried out on women, it was observed that their activity performances and satisfactions as well as life qualities improved, but that their cancer-related fatigue and depression levels declined. In fact, as far as we know, this is the first study that shows the effects of OB-PSS on activity performance and satisfaction, fatigue, depression and quality of life in patients with breast cancer.

For a better understanding of functionality levels of survivors, it is important to determine what activities women with breast cancer mostly take part in during their daily routines and at what stage of these activities they encounter with problems. COPM is a scale that acts as a guide in person-based interventions that are to be carried out towards activity priorities and performance problems of survivors. In studies carried out into various cancer types, late middle-aged or elderly individuals mostly reported performance problems related to self care activities, while on the other hand middle-aged adults stated that they suffer from productivity problems beginning from the initial stages of treatment [ 32 , 33 ]. In their studies aiming at the improvement of activity problems in women with breast cancer, Lyons et al. examined the strategies and discovered that patients mostly encounter with problems in paid or unpaid activities [ 8 ]. Considering the results of our study, participants of which are adult individuals with cancer at early stage, individuals were found to suffer from activity performance problems mostly in managing household activities (sweeping the floor, hanging curtains, cooking etc.). This shows great similarity to literature results and our study thus may serve to advancing the activity programs of clinicians and academicians working in the rehabilitation field.

PSS is a method that involves coping with problems or symptoms as well as difficulties faced in disease management, or making changes in life styles against them for better self-management. Various strategies are used in solving the problems that have been identified [ 34 ]. Lyons applied PSS to 80 activities in a study he conducted on 16 women with breast cancer as they were receiving chemotherapy, and stated that 40% of these activities worked well through activity adaptation as a way of solution [ 10 ]. In our study, it was seen that 58% of the participants chose an adaptive strategy of making changes to the implementation steps of the activity, which is supportive of similar studies in the literature as a consequence.

When studies into problems that lead to activity limitations in individuals with breast cancer are considered, due to the fact that certain side effects like fatigue, depression, nausea and shortness of breath, which influence functionality are seen in the early stages of the disease, it is said that the existence of movement restriction in the upper extremities as a result of the incomplete activity can cause problems in the activity performance [ 35 , 36 ]. Considering the activities during which the participants experienced problems, it was seen that most of them needed the movement of upper extremities. Following the OB-PSS training, although movement limitation of individuals tended to prevail, it was established that their activity performance and satisfaction levels improved significantly thanks to the solution options developed through adaptive strategies. This improvement is highly important both for the patient and the therapist from the clinical point of view.

Fatigue and depression are the most frequent symptoms in cases of cancer. It has been suggested that problem solving strategies have been beneficial in improving the cognitive reconstructing strategy in males with local prostate cancer diagnosis and controlling the symptoms that are caused by cancer [ 37 ]. Another study on the physical and psychological effects that arose in 132 women with breast cancer also indicated that PSS were positively contributive to the process [ 38 ]. Our study has shown that OB-PSS has been effective in reducing the level of both depression and fatigue in women with breast cancer. We therefore recommend the use of OB-PSS within rehabilitation practices to be used against fatigue and depression that are commonly seen in survivors with breast cancer.

There are currently several studies into the evaluation of quality of life and effectiveness of intervention in cases of breast cancer [ 39 – 41 ]. One of these studies suggested that, after the application of chemical agents, almost all the women with breast cancer had impaired body perceptions, which affected their degree of overall life quality, and 20–25% of them had physical dysfunction and 30% of them suffered from sexual dysfunction [ 40 ]. As the continuity of daily routines is quite important, diversification of such practices in the rehabilitation process is necessary so as to positively influence the quality of life in women with breast cancer by making their lives more meaningful. OB-PSS training is an approach which backs up the formulation of solution options for the continuity of daily routines involving performance problems. Following the intervention process, we too have concluded that OB-PSS training has had positive influences on the parameters of quality of life as regards the individual’s functional and symptomatic conditions in both breast and other types of cancer.

As for the limitations involved in our study, firstly, the age distributions of the individuals included were not suitable for the examination of the treatment effectiveness by age. Secondly, although the number of samples is enough to show the statistical difference, we think it would be better to show the effectiveness of the intervention approach with the larger number of participants. Thirdly, behavioral changes have not been monitored through detailed observation in individual’s real-life environment (physical, social and cultural factors), which we regard as a negative point. In this context, it will make significant contributions to the interdisciplinary team with the expertise and experience in the oncological rehabilitation, with the OB-PSS training in which the detailed analysis of environmental factors is included in the larger number of survivors with breast cancer. Lastly, the lack of a control group can be said to be a limitation of our study. Therefore, we recommend that these limitations be considered in the planning of further studies with higher level of evidence.

The activities that women with stage 1 and stage 2 breast cancer mostly experience performance problems are productivity, self-care and leisure time issues. Survivors who have performance problems in certain activities usually come up with solutions through developing adaptive strategies. With the improvement of these strategies, cancer-related fatigue and depression level in survivors has declined, while their activity performance, satisfaction and quality of life levels improved. Based on these results, it has been concluded that OB-PSS training could be used as an appropriate rehabilitation approach in women with breast cancer.

Acknowledgements

Authors are thankful to the all participants.

Abbreviations

Authors’ contributions.

SŞ: Conception and design, provision of study materials of patients, collection and assembly of data, data analysis and interpretation, article writing, review and editing. MU: Conception and design, data analysis and interpretation, review and editing. Both authors read and approved the final manuscript.

No funding was received.

Availability of data and materials

Ethics approval and consent to participate.

The study has been found to be ethically appropriate by the Hacettepe University Ethical Commission of Noninvasive Clinical Research with the confirmation number GO15/730.

Consent for publication

Those who volunteered to take part in the study were provided with information about the study and each signed an informed consent form.

Competing interests

The authors declare that they have no competing interests.

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Contributor Information

Sedef Şahin, Phone: 00 90 533 626 37 88, Email: moc.liamtoh@88nagzayarakfedes .

Mine Uyanık, Phone: 00 90 312 305 25 60, Email: rt.ude.epettecah@kinayum .

Muscle Overactivity in the Upper Motor Neuron Syndrome: Assessment and Problem Solving for Complex Cases: the Role of Physical and Occupational Therapy

Affiliations.

• 1 Drucker Brain Injury Center, MossRehab Hospital, 60 Township Line Road, Elkins Park, PA 19027, USA. Electronic address: [email protected].
• 2 MossRehab Outpatient Center, 60 Township Line Road, Elkins Park, PA 19027, USA.
• PMID: 30626513
• DOI: 10.1016/j.pmr.2018.03.006

The role of the physical or occupational therapist in addressing muscle hyperexcitability is to carefully assess the implications that the abnormal tone has on function, especially active movement patterns. A thorough evaluation that includes neurologic and nonneurologic attributes allows the clinician to determine the most efficacious treatment interventions, especially when considering severity and chronicity of deficits. A holistic assessment that includes patient factors and resources guides the clinician's plan of care to allow for optimal functional outcomes.

Keywords: Occupational; Physical; Spasticity; Therapy; Upper motor neuron syndrome.

Copyright © 2018 Elsevier Inc. All rights reserved.

Publication types

• Motor Neuron Disease / complications*
• Motor Neuron Disease / rehabilitation*
• Muscle Spasticity / complications*
• Muscle Spasticity / rehabilitation*
• Occupational Therapy*
• Physical Therapy Modalities*