Strategy Training: How I do it.

A strategy that encourages your patient to think

So what is it?

Skidmore et al. discovered that patients with cognitive deficit have worse prognosis because of their reduced executive function (Skidmore et al., 2010). To increase patient’s rehab participation, Skidmore and other researchers discovered strategy training. Strategy training requires the therapist to ask open-ended questions to guide pt to solve problems to achieve their daily activities. To guide the patient, therapists encourage the pt to:

1. Make their own goal

2. Plan the steps to accomplish their goal

3. Do the steps

4. Check the feasibility of the plan.

Or simply: Goal. Plan. Do. Check.

Many studies have discovered the benefits of strategy training: Compared to patient who received usual training, patient from strategy training have higher FIM scores, increased executive function, and better quality of life (Skidmore et al., 2015; Wolf et al., 2016).

Who are the ideal candidates for Strategy Training?

Cognitive impairment (Especially executive function and limited attention span) and the absence of:

1. Severe aphasia

2. Memory deficit, especially dementia

3. Current psychiatric disorders and episodes, including substance-use disorder

I find strategic training to be most useful to build fundamental habits, especially sit-to-stand and stand-to-sit transfers. If patients can remember and demonstrate these transfer sequences, they are half way from discharged (in SNF or inpatient rehab).

Usually, when I conduct strategic training, I usually bring a sheet of paper and a pencil. Then I will ask the pt to make a list of steps to transfer from sit to stand, and vice versa. (The picture serves as a visual reference)

Considering that most patients have trouble performing stand-to-sit transfer, in this short essay, I will just ask my patient to first make a list of steps for stand-to-sit transfer and perform the transfer.

My patient is nicknamed as “Sarah Lee.” Sarah Lee has L cerebral hemisphere stroke, which resulted in impulsivity and limited attention span. She is a left handed lady who needed more than 5 verbal cues to perform 1 stand-to-sit transfer in her eval. (By the way, the script here are all taken from real dialog.)

Alice: Hi Sarah Lee! Can you list out the steps, so you can sit down safely? (I identified the goal for her.)

Sarah Lee:

1. Place your hands back on wheelchair

2. Make sure wheelchair is locked

3. Wheelchair is directly behind

4. Lower back on the chair

Let’s sit now!

Alice: Wait, how can you rearrange the order so you can sit down safer? (This is the advice portion)

Sarah Lee:

1. Make sure wheelchair is locked

2. Wheelchair is behind you

3. Place hands on wheelchair

4. Lower back on the chair

Alice: Let’s do the plan..

Sarah Lee Sits.

Alice: Let’s check our plan. Do you think the plan works?

Sarah Lee: No. I placed my hands on the armrests at different times. I am left handed, so I placed my left hand onto my armrest first, followed by my right hand.

Sarah Lee: So here is your changed plan:

1. Make sure wheelchair is locked

2. Wheelchair is behind you

3. Place Left hand on armrests

4. Right hand follows

5. Lower back on the chair

Let’s do if this plan works.

Sarah Lee stands and sit down by following the plan.

Alice: How do you like this plan? Anything you would like to change?

Sarah Lee: No change. I need to remember this.

Sarah Lee actually said that. I was so happy for her at the end of that session.

If patients have trouble planning the steps, we, as therapist, can act as their visual robots and have them to list out the steps. For example, I asked Sarah Lee to plan out the steps for a wheelchair to bed transfer, but she cannot list out the steps. So I act as her visual guide robots, so she can not only say the steps out loud, but also check the safety of each step. After 3 weeks of rehab-stay, I am proud to say that Sarah Lee was discharged at Modified Independent Level.

In conclusion, strategy training: Goal. Plan. Do. Check.

I hope this essay is useful for your practice.

There is going to be part two and three of the same topic coming soon:

Part 2: Self-instruction training with the addition of Strategy Training

Part 3: Strategy Training in real life (How you can apply the same therapeutic techniques to children and non-patients)

Please comment below or in Twitter or Facebook for questions.

Thank you!

Happy Weekend.

Reference:

Skidmore, E.R., Dawson., D.R., Butters, M. A., Grattan, E. S., Juengst., S. B., Whyte, E.M., Begley, A., Holm, M. B., & Becker, J. (2015) Strategy training shows promise for addressing disability in the first 6 months after stroke. Neurorehabilitation Neural Repair, 29, 668-676, doi: 10.1177//1545968314562113

Skidmore, E. R., Whyte, E. M., Holm, M. B., Becker, J. T., Butters, M. A., Dew, M. A., . . . Lenze, E. J. (2010). Cognitive and Affective Predictors of Rehabilitation Participation After Stroke. Archives of Physical Medicine and Rehabilitation,91(2), 203-207. doi:10.1016/j.apmr.2009.10.026

Wolf, T.J., Polatajko, H., Baum, C., Rios, J., Cirone, D., Doherty, M., & McEwen, S. (2016). Combined cognitive-strategy and task-specific training affects cognition and upper-extremity function in subacute stroke: An exploratory randomized controlled trial. American Jounral of Occupational Therapy, 70, 7002290010. http://dx.doi.org/19.5014/ajot.2016.017293