Introduction

Spinal cord injury (SCI) can result in impairments of motor, sensory or autonomic functions.1 In general, individuals with SCI have permanent neurological deficits and disability, and are often exposed to undesirable consequences such as dependence, low quality of life and self-esteem, and social isolation.2, 3 In Ubolratana District, Khon Kaen Province, Thailand, the database of Ubolratana community hospital in January 2012 reported that there were ~400 persons with disabilities, and ~4% of them were individuals with SCI. To restore maximal functional independence to individuals with SCI, physical therapists of the hospital made great efforts with physical therapy knowledge and skills. However, most of the individuals with SCI were still dependent and had low self-esteem and community involvement, although there were improvements in their muscle strength, flexibility and some activities. It was thus necessary to find out an effective strategy to help these individuals.

At present, the task-oriented client-centered training (TOCCT) has been suggested as an alternative approach for individuals with SCI.4 The task-oriented training has focused on specific activities that are important to the patient.5 The client-centered care has aimed to incorporate the patient’s own needs and wishes in the rehabilitation process.6 In this strategy, the patient and the therapist work together to design a goal and plan of treatment that is motivating and engaging to the client.4 An advantage of the TOCCT in upper extremity functions of individuals with tetraplegia was reported in a previous study.7 Therefore, the authors were interested in applying the TOCCT to individuals with SCI in Ubolratana community and evaluating its effects on physical function, self-esteem and other aspects of this group of clients. To the best of our knowledge, this was the first study of this issue in Thailand. The two outcomes of this study, physical function and self-esteem, were published before.8 In this report, we presented three outcomes, physical function, perception of performance, as well as satisfaction with the activities, and achievement of training goals. The physical function was mentioned again because it was the main outcome measure of the study. However, its details were different between the previous and the current reports. Therefore, the underlying objective of the current report was to evaluate the impact of an 8-week TOCCT on physical function, perception of performance and satisfaction with the activities and achievement of training goals of individuals with SCI.

Materials and methods

This quasi-experimental community study was conducted during September 2012 to August 2013. We certified that all applicable institutional and governmental regulations concerning the ethical use of human volunteers were followed during the course of this research. The study was approved by The Khon Kaen University Ethics Committee for Human Research (HE552133).

Participants

A group of 12 participants in this report (Table 1) was the same group as published before.8 In brief, they were individuals with SCI living in Ubolratana District and were recruited with the following inclusion criteria: requiring partial help to perform daily life and/or outdoor activities, being able to verbally communicate and willing to participate, and cooperating with the study procedures. Volunteers were excluded if they were determined by a practitioner that they had significant psychiatric or general medical morbidity precluding their understanding of the nature of the intervention or undertaking the exercises. The participants consisted of 1 woman and 11 men. Their average age was 39.0±13.0 years (range 23–64 years). The average length of time since injury was 10.7±11.5 years. Nine and three of the participants were paraplegic and tetraplegic, respectively. All participants were injured by trauma. Co-morbidity (pressure sore at the buttocks) was found only in two participants (M5 and M11). The main caregivers of the participants were their family members.

Table 1 Demographic characteristics of participants (n=12)
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Outcome measures

A research assistant administered the pre- and post assessments to each of the participants with the following outcome measures.

Physical function

Independence in primary daily activities relevant for individuals with SCI was assessed by using the Spinal Cord Independence Measure version III (SCIM III).9, 10 The total score runs from 0 to 100 points (100 being the greatest physical function). A change of 4 points or more on the total SCIM III score is considered a clinically significant change.11 A detailed description of the SCIM III was given in a previous study by the authors.8

Perception of performance and satisfaction with the activities

This variable was assessed by using the Canadian Occupational Performance Measure (COPM).12 The COPM is a client-centered, individualized outcome measure to allow the clients to identify their difficulties in the areas of self-care, productivity and leisure, and rate their current perception of performance and satisfaction of the individual tasks.

Following problem identification (see details in the Procedures section), the participants were asked to rate their current perception of performance and satisfaction with that level of performance for each of their most problematic activities. Both performance and satisfaction were rated on a 1–10 numeric rating scale (1=great difficulty, not able to perform at all or not satisfied at all, and 10=no difficulty, able to perform extremely well or extremely satisfied). Total scores were calculated by adding together the performance or satisfaction scores for all problems and dividing by the number of problems.

The COPM has been shown to provide test–retest reliability and validity.12, 13, 14 In respect of the achievement of performance goals, a change of 2 points or more on the COPM is considered a clinically significant change.15

Achievement of training goals

The Goal Attainment Scale16 was used to objectively measure the effect of the training program on individual treatment goals. After identifying 2–3 personally most problematic activities of each participant (see details in the Procedures section), the participant and the authors were cooperatively specified treatment goals to be achieved within a particular time frame of 8 weeks. Possible outcomes in each of the treatment goals were identified and expressed as a behavioral statement that was observable. The most likely outcome was what the participant would reasonably expect to occur within 8 weeks. This was recorded as zero (0). Outcomes that would be better than expected (+1), much better than expected (+2), less than expected (−1) and much less than expected (current level of performance, −2) were also described. The validity, reliability and responsiveness to change of the Goal Attainment Scale were demonstrated in previous studies.16, 17, 18

Procedures

To follow the TOCCT concept, the study was processed into three phases as published before.8 Each phase is summarized as follows:

Client-centered phase

This phase aimed to explore each participant’s most problematic activities. The participants were asked to identify daily activities that they wanted to do, needed to do or expected to do. After that, they were asked to rate the importance of each issue using a scale from 1 to 10 (10 being the most important) and to choose at least 2 personally most problematic activities. These activities were used for setting individual treatment goals and training program. Specific, measurable, achievable and realistic goals to be achieved within 8 weeks, or the Goal Attainment Scale, were set jointly between each participant and the authors.

Task-oriented phase

Information gathered from the first phase was analyzed by the authors. Factors that limited or facilitated for the chosen tasks and were trainable were determined for each participant. This task-oriented analysis was based on a concept that skill acquisition was the result of a proper interaction between different factors of the person, the task and the environment.4 Then, an individually tailored training program was designed by using principles of training physiology, motor learning and, if needed, the use of assistive devices.4 Recommendations for the home-based training program was 30 min per set, 2 sets per day and at least 3 days per week. The participants were facilitated to perform the programs by themselves with the help of caregivers, if necessary.

Implementation and evaluation phase

Before and after implementing the TOCCT programs, pre- and post-implementation assessments for the three outcome measures were established by a research assistant. The individual training program was conducted for 8 weeks. During this time, the authors visited each participant at his/her residence with a frequency of 1–2 times per week. These home visits aimed to monitor the compliance of the program and offer advice.

Data analysis

Descriptive statistic analysis was used for demographic data of the participants. Paired t-tests were applied for comparing the pre- and post-implementation data of the SCIM III and COPM. The 95% confidence intervals were determined. The Shapiro–Wilk test was used to verify normality of distribution. Statistical analysis was performed using the SPSS version 17.0 (Statistical Package for the Social Sciences, SPSS Inc., Chicago, IL, USA); alpha was set at a value of P<0.05.

Results

The results of each phase of the TOCCT are presented as follows. Tables 2 and 3 were the same tables as published before.8 However, they were presented again in this report as they were baseline information, which could provide more understanding of the study results to the readers.

Table 2 The most problematic activities, current level of performance and expected goals to be achieved within 8 weeks of participants (n=12)
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Table 3 An example of the task-oriented analysis of a participant (M1)
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Client-centered phase

The most problematic activities, current level of performance and expected goals to be achieved within 8 weeks of each participant were summarized in Table 2. There were 28 problematic activities identified by the participants. Ten of them (35.7%) were wheelchair transferring and skills. Walking and toileting were the second (25%) and third (14.3%) ranks of most problematic activities, respectively.

Task-oriented phase

In this phase, an individually tailored training program was designed for each participant. Table 3 shows an example of the task-oriented analysis of a participant (M1). An 8-week, home-based training program of this participant consisted of strengthening, endurance and stretching exercises 4 days per week, training by a physical therapist twice a week, training at a local rehabilitation center every 2 weeks and group meeting with other participants once a month. Adaptation of a toilet was arranged for this participant during weeks 4–6 of the program.

Implementation and evaluation phase

At the end of the study, it was revealed that the 8-week TOCCT significantly improved physical function of the participants (P=0.001, 95% confidence interval 3.22–7.12) and the perception of performance and satisfaction with the activities (P=0.001, 95% confidence interval 1.31–3.49 and 1.68–3.67, respectively; Table 4). The mean changes in total scores of the SCIM III and COPM were 5.2, 2.4 and 2.7, respectively. Nine (75.0%) participants showed a clinically significant change in the SCIM III score. The clinical changes in the COPM, both perceived levels of performance and satisfaction with the activities, were found in 8 (66.7%) participants.

Table 4 Number (%) of participants who had a clinically meaningful change in scores of the SCIM III and the COPM, and mean±s.d. of the scores at pre- and post-implementation assessments and comparisons within groups (n=12; P-values obtained through paired t-tests)
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Furthermore, half of the participants (M4, M5, M6, F7, M8 and M10) could reach their expected or better than expected goals of all of the most problematic activities (Table 5). Three participants (M1, M3 and M11) reached their expected goals in some activities. No achievement of the expected goals of most problematic activities was seen in 3 participants (M2, M9 and M12).

Table 5 Scores of the Goal Attainment Scale of the most problematic activities at pre- and post-implementation assessments of participants (n=12)
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Discussion

This study demonstrated that an 8-week TOCCT program could significantly improve physical function of individuals with SCI. Nine participants had a clinically significant change in the SCIM III score (i.e. at least 4 points).11 In addition, at the end of the study, 8 participants demonstrated clinically meaningful improvements in perceived levels of performance and satisfaction with their identified goals assessed by the COPM. This finding added support to the positive effect of the TOCCT in individuals with SCI reported in a previous study.7 Furthermore, the changes in the COPM performance and satisfaction in this study could achieve the clinically significant improvements as the mean changes were greater than 2 points.15 This outcome was likely associated with the reported improvements in the physical function of the participants.

After termination of the program, six (50.0%) of the participants could reach their expected training goals. All of them were paraplegic with the time since injury between 0.5 and 15 years. Two of them were diagnosed with complete injury (The American Spinal Injury Association Impairment Scale (AIS) A) and four were incompletely injured (AIS B, C or D). The ranges of age and body mass index of the six participants were 25–45 years and 16–24 kg m−2, respectively. On the basis of this information, therefore, the authors presumed that the beneficial effects of the TOCCT to individuals with paraplegia did not depend on length of time since injury, completeness of injury, age and body mass index of the individuals. This probably indicated an unlimited use of the TOCCT for individuals with paraplegia in various demographic characteristics.

Three participants did not achieve the expected training goals. This was seen in the ones whose self-selected most problematic activities were standing and/or walking. Improvements in these activities could not occur immediately after training on each day.19 When no significant changes in the activities were shown after daily training programs, the participants may have felt disappointed and did not regularly perform their training programs, resulting in non-success in reaching the expected goals. Furthermore, it should be noted that a participant, M2, met an unexpected event during the study period, that is, his mother passed away at week 7 of the training. This may have made him exhausted and discontinue his training program, thereby failing to achieve his expected training goals.

In the study procedures, the client-centered phase was slightly complicated. In this phase, the authors had to pay attention specifically to ensure that the participants would be greatly involved in the procedure, that is, selecting their most problematic daily activities and specifying expected goals to be achieved within 8 weeks. Various strategies were applied to deal with the participants in this phase. Half of the participants with long length of time since injury, that is, >5 years, often showed some depression about their illness, felt hopeless and rarely expressed ideas regarding their most problematic activities and training goals. Hence, the authors had to visit them quite often to motivate them by using video clips of other cases who had similar severity of disability to them and could progress the ability. Their caregivers were also asked to cooperate with this procedure. These strategies could motivate this type of participants to actively involve themselves in the client-centered phase. Actually, the key success for completing the client-centered phase was building familiarity with the participants, being a good listener, expressing deep sincerity to solve problems and respecting wishes, rights and customs of the participants.

Two limitations of the study were presented. The first one was that there were only 12 individuals with SCI participating in the study because the study area was limited to a small district with 6 villages. However, this sample size was sufficient for presenting normal distribution and statistical significance of the data. The second limitation of the study was the lack of a control group because of a small study area. Thus, a quasi-experimental trial was established. A randomized controlled trial design should be considered for future studies. Moreover, to determine the long-term effects of the training program, a longitudinal study design should be conducted.

Despite some limitations, this study demonstrated beneficial effects of the TOCCT on individuals with SCI in community. The client-centered procedure could help in more in-depth understanding of health needs and daily life activities of the individuals, and give them a state of owning the intervention programs. The reality information obtained from the client-centered phase could be helpful for the task-oriented procedure for designing a training program tailored to specific activities of interest to the person. Specific rehabilitation goals rather than general ones were targeted. A study in individuals with neurological disorder reported that a home-based client-centered program was more suitable than a therapist-centered program because of its relevance for the individual patient.20 In addition, the lack of the participation of clients in rehabilitation teams resulted in the incontinuity of rehabilitation services.20

In conclusion, an 8-week TOCCT could significantly improve physical function and perception of performance and satisfaction with the activities of individuals with SCI in Ubolratana District, when compared with the pre-training period. Furthermore, the training could help most of the participants achieve their training goals. The TOCCT may be applied by physical therapists as an alternative rehabilitation approach for improving quality of life and independence of individuals with SCI in the community.

Data archiving

There were no data to deposit.