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USING CO-OP WITH INDIVIDUALS WITH PARKINSONS DISEASE AND MILD COGNITIVE

IMPAIRMENT

Using Cognitive Orientation to Occupational Performance (CO-OP)


with Individuals with Parkinsons Disease and Mild Cognitive Impairment
Kristine Barrios
Katie Jackson
Kaitlin Jones
Danielle Oberg
University of Utah

USING CO-OP WITH INDIVIDUALS WITH PARKINSONS DISEASE AND MILD COGNITIVE
IMPAIRMENT

Introduction
Parkinsons disease is a chronic, progressive condition of the central nervous system. As
the disease progresses it predominantly impacts motor control and coordination and is defined by
the following symptoms: rigidity, bradykinesia, postural instability, and resting tremors. Along
with the motor symptoms, individuals are significantly impacted by physiological and cognitive
impairments associated with the disease.
The psychological and cognitive impairments impact daily function for individuals with
Parkinsons disease (PD). It is common for individuals with PD to have or experience symptoms
of depression or anxiety (Secker & Brown, 2004). Cognitive difficulty has been categorized in
individuals with PD as mild cognitive impairment (MCI) or dementia. It is estimated that 60% of
individuals with PD experience cognitive and psychological symptoms which can be the largest
concern for some individuals with PD and can extensively reduce quality of life (Pandya, Kubu
& Giroux, 2008).
Cognitive and psychological symptoms include problems with executive function skills
which result in difficulty with problem solving, planning, and starting and completing activities
or tasks. This may cause difficulty performing daily activities such as work, managing finances,
or completing grocery shopping. Executive functioning impairments among individuals with PD
have also been shown to create difficulty with social problem solving (Anderson et al., 2013).
This can affect participation in social activities and also strain personal relationships. MCIs have
also been shown to affect the ability to complete activities of daily living, including cleaning,
bathing, dressing and eating. This is due to difficulty with attention, memory, and organization
(Perneczky et al., 2006).

USING CO-OP WITH INDIVIDUALS WITH PARKINSONS DISEASE AND MILD COGNITIVE
IMPAIRMENT

These challenges can impact the entire family of an individual with PD both emotionally
and financially. Much of the distress of caregivers stems from the cognitive and psychological
symptoms of PD (Pandya, Kubu, & Giroux, 2008). Many times the caregiver becomes
responsible for the individuals activities of daily living which can be very stressful. Other times
additional services are brought in to help which can be financially draining.
While many patients report frustration due to cognitive symptoms, the majority of the
treatment and research for PD is focused primarily on motor symptoms associated with the
disease. Currently there is a lack of knowledge and research regarding effective treatments to
increase daily functioning by targeting the cognitive deficits that create difficulty with daily
function. Specifically, treatments with focus on planning, problem solving, attention,
organization, and memory need to be explored. Research is needed to identify beneficial
treatment approaches to address MCI and increase daily functioning for individuals with PD.
Background
The purpose of this study is to investigate the effectiveness of using the Cognitive
Orientation to Occupational Performance (CO-OP) model of intervention to improve
occupational performance and quality of life for individuals with PD and MCI. The CO-OP
method of intervention assumes that cognition plays a key role in the acquisition of occupational
skills and the development of occupational competence. CO-OP implements the use of cognitive
strategies to solve problems with performance and allow for development of occupational
competence (Polatajko et al., 2001). CO-OP was originally developed by Polatajko et al. for the
treatment of children with Developmental Coordination Disorder (DCD) in the 1990s. The COOP approach to intervention uses a framework of Goal, Plan, Do, Check as presented by
Meichenbaum (Missiuna, Mandich, Polatajko, Malloy-Miller, 2001). This process involves the

USING CO-OP WITH INDIVIDUALS WITH PARKINSONS DISEASE AND MILD COGNITIVE
IMPAIRMENT

client establishing a goal, creating a plan to complete the goal, carrying out the plan, and
checking whether the goal was accomplished. The use of cognitive strategies to accomplish a
goal is a key feature of the CO-OP approach. To promote generalization and transfer of cognitive
strategies, the CO-OP approach emphasizes the use of guided discovery. Guided discovery
involves guiding the client by asking questions that enable active problem solving by the client
(Missiuna et al., 2001). Unique aspects of CO-OP intervention include client performance of
tasks within a natural context and the presence of a caregiver during therapy to support and
reinforce learning. CO-OP has been implemented with individuals of all ages with various motor
or cognitive difficulties that impair occupational performance.
As mentioned, the use of cognitive strategies is a vital component of the CO-OP
approach. There are many definitions which describe cognitive strategies. An overarching
definition for a cognitive strategy is a mental plan of action that helps a person to learn, problem
solve, and perform (Toglia, Rodger, Polatajko, 2012). Cognitive strategies are used to promote
skill acquisition and generalization. Individuals may use a variety of cognitive strategies in order
to problem solve, learn, and improve occupational performance. Cognitive strategies can be
directed at the task, the environment, or the person (Toglia et al., 2010). Within CO-OP, there are
two types of strategies used: global and domain specific. Global strategies are used to coordinate
other strategies and are used in a variety of situations, such as Goal-Plan-Do-Check. Domain
specific strategies are task specific and tend to vary by individual (e.g. verbal mnemonics)
(Polatajko & Mandich, 2005). In a study conducted by Sangster, Beninger, Polatajko, &
Mandich (2005), they examined the effects of the CO-OP method on strategy use with children
with Developmental Coordination Disorder (DCD). Participants were placed into two treatment
groups, one received CO-OP and the other received a current occupational therapy approach.

USING CO-OP WITH INDIVIDUALS WITH PARKINSONS DISEASE AND MILD COGNITIVE
IMPAIRMENT

Participants received 10 individualized treatment sessions over the course of the study. Results
from the study showed that the children who received treatment using CO-OP were able to use
and generate more cognitive strategies. The study implicates that using the CO-OP method helps
individuals to better use cognitive strategies in order to solve problems with occupational
performance and make positive gains in overall performance and satisfaction.
The CO-OP method has also been used with a variety of other populations across a
variety of ages such as with children with Aspergers syndrome (Rodger & Vishram, 2010),
adults post-traumatic brain injury (TBI) (Dawson et al., 2009), and adults post-stroke (Polatajko,
McEwen, Ryan, & Baum, 2012; McEwen, Polatajko, Davis, Huijbregts, & Ryan, 2010). In all of
these studies, participants were taught, over the course of 10-20 therapy sessions, the global
cognitive strategy of Goal, Plan, Do, Check and were guided to discover Domain Specific
Strategies appropriate for their goals. A key finding across these studies was the importance of
caregiver or significant other participation in the therapy process. Another significant finding
was the importance of client selected goals - which resulted in a greater sense of autonomy as
reported by both McEwen et al. (2010) and Polatajko et al. (2012).
The overall outcomes reported by these studies were improvements in performance and
satisfaction (Dawson et al., 2009), development of new skills, and generalization of strategies
(McEwen et al., 2010; Rodger & Vishram, 2010). Rodger and Vishram (2010) reported that in
their study with two children with Aspergers syndrome, the children improved in their social
and organizational goals for therapy and also experienced improvement in performance at home
and at school. Adults with chronic stroke showed increased decision making abilities following
intervention (McEwen et al., 2010) and individuals with TBI noted improvement in tasks that
were not addressed in therapy (Dawson et al., 2009). Additionally, McEwen et al. (2010)

USING CO-OP WITH INDIVIDUALS WITH PARKINSONS DISEASE AND MILD COGNITIVE
IMPAIRMENT

reported that at a three month follow-up, those improvements had been maintained. These
studies support the outcomes reported by Sangster et al. (2005) in their study with children with
DCD. These studies also support CO-OP as an appropriate and effective intervention for
individuals with many diagnoses that affect motor control and executive functioning deficits.
As discussed, a fair amount of research exists to support the use of CO-OP with
individuals across the lifespan and with a variety of motor-based and cognitive-based deficits.
There are, however, no research studies which address the use of the CO-OP model with
individuals with PD and MCI. This dual diagnosis (PD and MCI) affects both cognition and
motor control and greatly affects occupational performance and satisfaction. This study will
further the existing research supporting CO-OP by showing the effects of CO-OP with this
population. The aim of this study is to expand on current evidence that CO-OP is an effective
and versatile intervention, which can affect positive change across many diagnoses and across
the lifespan. This opens up the opportunity and cause for future research applying the CO-OP
model to additional populations which are not currently treated using CO-OP but could greatly
benefit from it.
In addition to the need to expand the areas of application for CO-OP, research is needed
to find evidence-based interventions to address the motor and cognitive deficits which are
present in individuals with PD and MCI. There is an increasing demand for interventions to
address the impact of PD and MCI on activities of daily living and other occupations. This
ground-breaking study will provide a foundation from which future research can build to further
investigate the efficacy of CO-OP and other cognitive interventions in improving function and
occupational performance for individuals with PD and MCI. This study aims to show that,
through the use of CO-OP strategies, individuals affected by PD with MCI can gain new skills,

USING CO-OP WITH INDIVIDUALS WITH PARKINSONS DISEASE AND MILD COGNITIVE
IMPAIRMENT

relearn skills, and generalize skills across activities and contexts to increase participation in
activities of daily living, social interactions, and other areas of occupation in which they want,
need, or are expected to participate.
Since this study is designed to build off of the previous studies which have been
conducted with a variety of clients across the lifespan, it will play an important role in furthering
such research and providing additional support for the use of CO-OP as an evidence-based
intervention. The study will also further the work of Occupational Therapy by offering a viable
intervention approach for the many patients seeking services because of the impact of PD and
MCI on activities of daily living and other occupations. Additionally, this study will directly
address many of the executive function deficits such as problem-solving, planning, initiation and
completion of tasks, organization, and memory. By directly addressing these areas through the
CO-OP method, the study aims to ultimately increase quality of life by increasing participation
and satisfaction with performance in activities of daily living and many other occupations.
Methods
As previously stated, the reason for this study is to determine if the CO-OP intervention
approach enhances performance of daily living skills for individuals with PD and MCI. To fulfill
this purpose, this study will aim to meet the following objectives. First, the CO-OP approach will
be taught to individuals with PD and MCI and the therapeutic interventions used will be video
recorded. Next, data will be collected regarding the success of using CO-OP with these
individuals to improve their performance of trained tasks. The generalizability and transferability
of the intervention strategies to non-trained tasks after intervention and at the 3-month follow-up
will also be studied.

USING CO-OP WITH INDIVIDUALS WITH PARKINSONS DISEASE AND MILD COGNITIVE
IMPAIRMENT

The design of this study is a descriptive case study. The study is modeled after the
qualitative study by Dawson et al. (2009). In this study, Dawson et al. looked at the effectiveness
of the CO-OP approach with three participants with acquired brain injury. The research question
that underlies this study, similar to the one Dawson et al., is: Can the CO-OP intervention
approach significantly improve performance of daily living activities for individuals with PD and
MCI?
Participants
The participants for this study will be chosen based on specific criterion. Each participant
must have a diagnosis of idiopathic PD. They must also exhibit MCI as indicated by a score of
21 25 on the Montreal Cognitive Assessment (MoCA). Each participant must be literate and
speak English. The intervention process requires the participant to be willing and able to
participate in biweekly Occupational Therapy sessions and complete out of therapy homework
for ten weeks. As the CO-OP method utilizes the support of a caregiver, an available significant
other, such as a friend or a family member, who can attend all sessions, learn the facilitation
techniques, and support the participant in practicing the trained tasks between sessions must be
available. Each participant will need to identify at least 5 difficult daily living tasks that can
appropriately be addressed through the CO-OP approach. At least three of these tasks must be
defined as instrumental activities of daily living (IADL) (American Occupational Therapy
Association, 2008).
Applicants will not be included in this study if they obtain a score of > 10 on the Short
Form Geriatric Depression scale (GDS) (Sheikh & Yesavage, 1986). They will be excluded from
the study if they do not meet the cut-off on the Pill Questionnaire (Dubois et al. 2007), which
could allude to cognitive impairment more severe than the mild level. Applicants will also be

USING CO-OP WITH INDIVIDUALS WITH PARKINSONS DISEASE AND MILD COGNITIVE
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excluded if they do not currently perform any of the problematic daily living tasks, or cannot
identify the major steps of the task.
To gather participants, the study was announced on the Utah Movement Disorders Clinic
Trials web page as well as the Utah American Parkinsons Disease Association newsletter. All of
the participants for this study will be individuals with PD currently being treated through the
University of Utah Outpatient Clinic and were notified about the study via letter. Patients who
are interested in the study will be able to gather more information about the study through a
phone conversation. During this phone conversation, a brief screening will be done which
consists of the MoCA, the GDS, and the Pill Questionnaire to make sure each participant meets
the inclusion criteria previously noted. If the patient meets all inclusion they will meet with the
Occupational Therapist to gather additional information, sign consent forms, and further discuss
the commitment for participating in the study. If the participant meets requirements criteria and
elects to participate in the study, a neurologist will verify that the client has PD and will obtain
the Hoehn and Yahr stage of the disease.
Instruments
All participants must be screened in order to participate in the study. The GDS
(Weintraub, Oehlberg, Katz, & Stem, 2006) will be used to screen for depression. The MoCA
(Nakas et. al, 2010) will be used to screen for cognitive impairment. The Pill Questionnaire
(Dubois et al. 2007) will be used to screen for severity of cognitive impairment. If the applicant
meets all screening requirements the following tests will be administered before intervention,
post intervention, and at a three month follow up visit.
The Canadian Occupational Performance Measure (COPM), will administered by an
Occupational Therapist and will be used to identify client reported problems in occupational

USING CO-OP WITH INDIVIDUALS WITH PARKINSONS DISEASE AND MILD COGNITIVE
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performance. The participant will identify concern in the following areas: self-care, productivity,
and leisure. The participant will then rate his or her level of performance in the top five areas of
concern and their satisfaction with performance. This information will be used to set treatment
goals and to measure progress after intervention. The COPM is a widely used assessment for all
ages to identify areas of concern. This test has a test-retest reliability of .75-.80 (Law et al.,
2005).
The Executive Function Performance Test (EFPT) will be administered to examine the
executive functioning of the participants. This test has been shown to have adequate to excellent
reliability and validity when used to examine executive functioning with other populations such
as individuals post-stroke (Baum, et al. 2008).
Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) is an
assessment used to identify neurocognitive deficits in a variety of disorders. It specifically
measures language, attention, delayed memory, and visual spatial skills. These areas of cognition
will be assessed pre and post intervention. This test has been used with individuals with PD and
has been shown to be sensitive in identifying neurocognitive impairment with this population
(Beatty et al. 2003).
Premorbid IQ testing will also be administered to determine the cognitive level of the
participations before and after intervention to monitor any changes.
Parkinsons Disease Questionnaire - 39 (PDQ-39) is a questionnaire designed to measure
well-being and certain aspects of function such as: activities of daily living, mobility,
communication, and cognition. During clinical testing of the PDQ-39 it was found that responses
produced produce valid information about health related quality of life for individuals with PD
(Peto, Jenkinson, & Fitzpatrick 1998).

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USING CO-OP WITH INDIVIDUALS WITH PARKINSONS DISEASE AND MILD COGNITIVE
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Procedures/Steps
The first step of the study is to complete the screening as mentioned above to verify that
the applicants qualify for the study based on the inclusion criteria. Next, pre-tests will be given
such as the COPM, EFPT, and neuropsychological assessments. The neuropsychological tests
including; RBANS, Trail Making Test Parts A and B, Stroop Color Word Test Phonemic
Fluence, and the Wide Range Achievement Test-4 will be given by research assistants
supervised by Dr. Duff.
Intervention focusing on increasing the occupational performance for 3 identified tasks
will then take place. The training schedule will be patterned after the Dawson et al. (2009) study
where participants received a one-hour intervention 2x/week for 10 weeks by an Occupational
Therapist trained in the CO-OP model. One intervention session will take place in the Life Skills
Clinic at the University of Utah while the other session will take place at the participants home
or in a community setting. Observation baseline task performance for the three identified tasks
will take place in the first two intervention sessions using the Performance Quality Rating Scale
(Polatajko, & Mandich, 2004). During the next few intervention sessions, the participant will be
taught the CO-OP Global Cognitive Strategy, Goal-Plan-Do-Check. In the final therapy
sessions the participant will use the CO-OP method to participate in the identified tasks and
establish appropriate domain specific learning strategies.
Following intervention, post-tests will be administered and compared with pre-test
scores. Data will also be collected 3 months post-intervention to gather follow-up information
concerning maintenance of improved task performance. Increase in function with the 3 identified
tasks will be measured along with improvement in unidentified non-trained tasks to examine the
transferability of the CO-OP strategies. By comparing pre, post, and follow-up data, the study

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USING CO-OP WITH INDIVIDUALS WITH PARKINSONS DISEASE AND MILD COGNITIVE
IMPAIRMENT

will determine if CO-OP is a viable intervention for individuals with PD and MCI and whether
further investigation is warranted either with a larger sample or with different subgroups of this
population.
Data Analysis
All of the pre- and post-test results will be gathered by a licensed Occupational Therapist
trained by Dr. Mcnulty. This pre- and post-data will be compared to identify significant
improvements. Significant improvement is defined as > 2 point change for the COPM and > .5
logits changed on the AMPS for each participant. COPM results for performance tasks identified
as problematic, but not established as the 3 identified tasks, will be looked at to determine if
there is a > 2 point change representing the generalizability and transferability of CO-OP
strategies. Although intervention is not expected to affect these results, Neuropsychological test
results will be compared to identify any significant change for each participant.
At least one intervention session per week with each participant will be video recorded.
Dr. Dunn, who is trained in the CO-OP method, will observe 25% of the recorded intervention
session to ensure fidelity to the treatment principles of CO-OP. Trained research assistants will
then manually code the domain-specific strategies (Polatajko & Mandich, 2004) used in
videotaped sessions. The assistants will identify which strategies are used most often and if there
are any new strategies used which are specific to individuals with PD.

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USING CO-OP WITH INDIVIDUALS WITH PARKINSONS DISEASE AND MILD COGNITIVE
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