International Journal of Environmental Research and Public Health Article Effectiveness of the Functional and Cognitive Occupational Therapy (FaCoT) Intervention for Improving Daily Functioning and Participation of Individuals with Mild Stroke: A Randomized Controlled Trial Tal Adamit 1,2 , Jeffrey Shames 2 and Debbie Rand 1,* 1 Department of Occupational Therapy, Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel; [email protected] 2 Maccabi Health-Care Services, Tel-Aviv 6812509, Israel; [email protected] * Correspondence: [email protected] Abstract: Background: Mild stroke can cause subtle cognitive–behavioral symptoms, which although might be hidden, can restrict community reintegration and participation. Cognitive rehabilitation programs exist for stroke but not specifically for mild stroke and the research evidence varies. The Functional and Cognitive Occupational Therapy (FaCoT) intervention was developed specifically for this population. Objective: To examine the effectiveness of FaCoT intervention for improving daily functioning and participation compared with standard care. Method: A single blind randomized controlled trial with assessments pre (T1), post (T2) and 3-month follow-up (T3). Individuals Citation: Adamit, T.; Shames, J.; in the FaCoT group received 10 weekly sessions practicing cognitive and behavioral strategies. Rand, D. Effectiveness of the The Canadian Occupational Performance Measure (COPM) was the primary outcome measure, Functional and Cognitive IADL-questionnaire, Reintegration to Normal Living questionnaire (RNL) were secondary measures. Occupational Therapy (FaCoT) Results: In total, 66 community-dwelling individuals with mild stroke were randomly allocated Intervention for Improving Daily to FaC T(n = 33, mean (SD) age 64.6 (8.2), 33% women), or control group (n = 33, mean (SD) age Functioning and Participation of o Individuals with Mild Stroke: A 64.4 (10.8), 45% women). Time X Group interaction effects were found for the COPM performance Randomized Controlled Trial. Int. J. (F(1.4,90.3) = 11.75, p < 0.000) and satisfaction (F(1.5,96.8) = 15.70, p < 0.000), with large effect size 2 Environ. Res. Public Health 2021, 18, values. Significant between-group effects were found for RNL (F = 10.02, p < 0.002, ïP = 0.13). Most 7988. https://doi.org/10.3390/ participants in FaCoT achieved a clinically important difference in COPM between T1–T2, T1–T3, ijerph18157988 and in RNL between T1 to T3 compared with the control group. Conclusions: FaCoT intervention is effective to improve daily functioning, participation and satisfaction of individuals with mild stroke Academic Editor: Paul B. Tchounwou compared with standard care, therefore FaCoT should be implemented in community rehabilitation settings. Received: 29 June 2021 Accepted: 26 July 2021 Keywords: stroke rehabilitation; cognitive–functional interventions; PROMs; participation Published: 28 July 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in 1. Introduction published maps and institutional affil- iations. Despite the high prevalence of mild stroke, very few studies have focused on this sub- group. A stroke is considered “mild” when neurological deficits (such as muscle weakness or dysarthria) are minimal, or Basic Activities of Daily Living (BADL) (dressing, bathing) is only minimally affected [1–3]. Therefore, mild strokes can be easily overlooked and many individuals do not benefit from rehabilitation services after acute care hospitaliza- Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. tion [4,5]. These individuals experience difficulties in Instrumental Activities of Daily This article is an open access article Living (IADL) (such as shopping or driving), productivity and leisure [6]. Participation, is distributed under the terms and considered involvement in life situations [7], is an important indicator of human health and conditions of the Creative Commons well-being [8]. Low levels of participation, restricted family and social involvement, and Attribution (CC BY) license (https:// difficulties re-integrating into meaningful occupations [9,10] have been reported, leading creativecommons.org/licenses/by/ to decreased satisfaction and low quality of life detected even up to 18-months post mild 4.0/). stroke [9,11,12]. Int. J. Environ. Res. Public Health 2021, 18, 7988. https://doi.org/10.3390/ijerph18157988 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021, 18, 7988 2 of 10 These difficulties are presumably due to the subtle, and often hidden, cognitive and emotional–behavioral symptoms [5,13]. Cognitive deficits include mainly deficits in higher cognitive abilities [14,15], termed executive functions, such as planning, decision making and self-control. Executive functions are crucial for performing complex daily functions, especially in novel situations such as shopping, driving and working [16]. The behavioral–emotional symptoms can include irritability, apathy, difficulty expressing emotions, response inhibition and restlessness [2,13]. Individuals with mild stroke may also experience low self-efficacy [17], which is a decreased belief in their own ability to perform premorbid significant occupations [18]. Low self-efficacy has been associated with depression, disability and decreased quality of life, assessed 6-months post mild stroke [19,20]. Cognitive–functional occupational therapy interventions, which do not focus on im- proving specific cognitive deficits but rather on improving daily activities, have been developed for individuals with traumatic brain injury and stroke [21–23]. The Multicon- text Approach [24] and The Cognitive Orientation to Daily Occupational Performance (CO-OP) [25] for example, include teaching individuals to use cognitive strategies to im- prove daily activities (termed occupational performance). Cognitive strategies are tools, procedures or methods used to accomplish goals [26]. Clinical studies, which tested the effectiveness of these interventions, have demonstrated improvement in occupational per- formance of individuals with stroke [25] (not mild stroke) and traumatic brain injury [27] but samples are very small, follow-up periods are short and research evidence is limited. In addition, these interventions do not address the unique behavioral-emotional changes, which are apparent in addition to the executive function deficits after mild stroke. The Functional and Cognitive Occupational Therapy (FaCoT) intervention (pronounced—FACT), theoretically anchored [28–32] was developed to focus on the unique characteristics of individuals with mild stroke, specifically experiencing executive function deficits and emotional-behavioral symptoms [33,34]. FaCoT includes practicing the use of cognitive and behavioral strategies to overcome these deficits/symptoms. This study aimed to examine the effectiveness of FaCoT to enhance occupational performance and participation of individuals with mild stroke compared with standard care. 2. Materials and Methods 2.1. Participants A single-blind-randomized controlled trial (RCT) with assessments pre (T1) and post (T2) intervention and at 3-month follow-up (T3) were conducted by assessors (experi- enced occupational therapists) who were blind to group allocation. This trial followed the Consolidated Standards for Reporting Trials (CONSORT) statement for Randomized Trials [35,36] and was registered in ClinicalTrials.gov (accessed on 20 July 2021) registration (NCT02925637). The study was approved by the Helsinki committee and University Ethics committee, and all participants provided written informed consent before their participa- tion. Community-dwelling individuals with mild stroke were recruited from a community- based Health Care Service between March 2017 and February 2020. Inclusion criteria were: (1) age >18 years, (2) sustained a stroke in the last 36 months, (3) mild stroke severity [National Institutes of Health Stroke Scale (NIHSS) ≤ 5 points and/or independence in BADL], (4) independence in daily living prior to the stroke, (5) ability to understand and speak the language (Hebrew), (6) without other neurological or psychiatric conditions. Sample size was calculated based on the primary outcome measure in G-Power analyses for F-test ANOVA repeated measures with 80% power and significance level of 0.05. To account for 15% dropout, at least 30 participants per group had to be recruited. 2.2. Randomization Participants were approached by phone and eligible participants were invited for the assessment session (T1). Following T1, stratified random sampling was performed using Int. J. Environ. Res. Public Health 2021, 18, 7988 3 of 10 a block (6) randomization procedure (ratio 1:1). Participants were stratified into either higher (≥23 points) or lower (≤22 points) cognitive status using the Montreal Cognitive Assessment (MoCA) [37], a valid and reliable [38] cognitive screening tool. Participants were informed their allocation by phone. 2.3. Outcome Measures Patient-Reported Outcome Measures (PROMs) [39] were used to quantify partici- pant’s perception of their functional status. The primary outcome measure aimed to assess occupational performance (daily functioning). We used the Canadian Occupational Perfor- mance Measure (COPM) [40], which is a well-known occupational therapy tool, commonly used for interventional studies [25,41], valid and reliable for people with stroke [42]. This semi-structured interview is used to identify problems and detect change over time in performance