Physiotherapist Anisha Rehmtulla (left) and occupational therapist Catherine Chuang (far right) work with a patient. (Photograph by Kevin Van Paassen).
For years, physiotherapist Anisha Rehmtulla took the conventional approach with her stroke patients. She would set goals for them, assess their mobility and give them exercises to strengthen an arm or help them walk unassisted. She’d direct them through their tasks – “Try to keep your feet apart. Now lift your leg.”
She has recently taken a completely different approach with her patients at St. John’s Rehab at Sunnybrook. It starts by asking patients what their own goals are. Depending on the patient’s particular situation, the goal may be as simple as getting in and out of bed on their own, or as complex as returning to play golf.
An elderly patient, for example, recently mentioned he wanted to get back to woodworking. And there was that young father who said the most important thing to him was to be able to take care of his toddler again. “Okay,” Anisha would then say. “So how do you think you can do that?”
Rather than being therapist- driven, that new approach – cognitive orientation to daily occupational performance, or CO-OP for short – “puts the patient in the driver’s seat,” explains Beth Linkewich, director of the Regional Stroke Centre and North and East GTA Stroke Network at Sunnybrook.
CO-OP was first developed in the late ’90s for children with skills learning challenges. A decade ago, Sara McEwen, scientist with a physiotherapy background, began to adapt the approach for stroke patients. After conducting several studies to show that CO-OP works theoretically, Sara and Beth have teamed up to assess how it can be applied in a real-world rehab setting, where time is more limited.
In October 2016, Sara, Beth and their colleagues secured a grant from the Canadian Institutes of Health Research to support training of occupational therapists, physiotherapists, nurses, speech therapists and other therapy assistants at St. John’s Rehab in the COOP approach. Patients are now being helped with CO-OP, and the goal is to train enough staff to be able to offer it to everyone.
The CO-OP approach uses a problem-solving strategy that has four steps: Goal, Plan, Do, Check. Therapists also use guided discovery, rather than telling patients what to do.
First, stroke patients set goals and are then guided to create their own plans to achieve those goals.
For example, the father who wanted to take care of his toddler recognized that he would need to carry the child, this despite reduced control and weakness on one side of his body. In physiotherapy, he practised carrying a sandbag up stairways. In occupational therapy, he would practise drawing with his finger across an iPad, so he’d be able to play games with his son.
Since CO-OP was introduced, patients are much more engaged in therapy, as they work together with therapists to better develop the best learning strategies.
With CO-OP, not only do patients define what they want to work on, they’re also defining how they want to do it. They have to write down or verbalize the steps in their plan. For patients who want to dress themselves and put a foot into a pant leg, for instance, Catherine Chuang, an occupational therapist at St. John’s Rehab, might ask, “What do you think you can do to achieve that?” The patient might suggest bringing her foot to her lap, which will then be added to the plan. It’s an approach that’s analogous to the ancient saying about teaching someone to fish instead of just giving the fish.
When patients leave rehab and go back home, their therapists are not there to coach them through each step. With CO-OP, however, earlier studies conducted by Sara showed that patients tend to continue making gains post-therapy, likely because they have been shown how to solve problems on their own.
“It builds confidence,” explains Sara. “If I can’t do something, it doesn’t mean that I should give up. It means I have to go back to my plan and change something. Maybe I need to put my hand in a different place or maybe I need some adaptive equipment.” Eventually, patients start breaking down all tasks with an open-minded, can-do approach.
But that’s not to say implementing CO-OP has been easy. “As physiotherapists, we’re so used to telling patients what to do,” says Anisha. “It’s hard for us to stand back and let them try to figure it out for themselves.”
Sara remembers feeling trepidation years ago, when she first used the CO-OP approach. Asked what his goals were, her patient, a man in his 40s, talked about helping his wife around the yard, but when he mentioned his personal goal to bike again, his eyes really lit up.
“He wanted to have that sense of speed again,” recalls Sara. “I was terrified. Here’s someone who was walking at a snail’s space, with a cane, wanting to get on a bike.”
Incredibly, after five hour-long sessions, she watched as her patient pedalled down the street, turning corners and managing inclines.
“He had to take a leap of faith and I had to take a leap of faith,” says Sara. “And the result was amazing.”
After a stroke, patients are learning how to move with major weakness or partial paralysis. They may have memory loss and cognitive issues.
During their stay at the rehab centre, patients experience a holistic approach. They will have access to a health-care team that includes:
- an occupational therapist to enable patients to return to their daily tasks such as dressing, bathing and cooking
- a physiotherapist to help patients maximize their physical functions such as getting in and out of bed, walking and climbing stairs
- a speech-language pathologist to address communication changes and swallowing concerns
- nurses available to patients around the clock to help manage all activities, medications and appointments
- a psychiatrist to talk about mental health challenges including feelings of anxiety or depression
- a dietitian to educate patients regarding healthy eating after a stroke
- a social worker to provide support and coordinate the care that patients will need after they leave rehab
- a physiatrist to provide medical support for the patient’s rehabilitation and recovery