Parkinson’s disease (PD) is a multifaceted condition with individualized symptoms that progress at variable rates. Complex interactions between motor symptoms and psychological difficulties contribute to people with PD living with increasing disability over their lifespans, creating a variety of treatment challenges. While treatments often target specific symptoms, there's a need for approaches that address the whole person and their daily life. This study explored one such approach called Cognitive Orientation to daily Occupational Performance (CO-OP).  CO-OP is an approach that helps people learn new skills by solving problems and practicing them in real-life situations [1]. It focuses on both physical and psychological performance, aiming to improve how people manage their daily lives. While it has been successful in helping people with other brain conditions, this study was the first to test CO-OP for people with PD. We aimed to investigate the preliminary efficacy and feasibility of the CO-OP approach for improving goal attainment, skill transfer and functional outcomes for people with PD, and explored participant experiences of the CO-OP approach. 

We conducted a parallel-group assessor-masked randomized controlled feasibility trial (RCT) in Brisbane, Australia. The trial involved 20 participants, who were on average age 67.25 years old and were approximately 5.65 years post-diagnosis [2]. At baseline participants each chose four goals, three of which were targeted in the CO-OP intervention. The fourth goal was an untrained goal to evaluate whether transfer of skills learned in CO-OP had occurred. Goal setting was facilitated by the Canadian Occupational Performance Measure (COPM), and goal performance was comprehensively assessed using the COPM, the Goal Attainment Scale (GAS – rated by the masked-assessor) and the Performance Quality Rating Scale (PQRS).  Secondary functional outcome measures included the Nottingham Extended Activities of Daily Living scale, the Perceived Deficits Questionnaire, the Parkinson’s Disease Questionnaire (PDQ-8) and the General Self-efficacy Scale. A feasibility framework was used to evaluate aspects of feasibility including acceptability, demand, and implementation [3].

Following baseline assessment and goal setting, participants were randomly assigned to either receive CO-OP twice weekly at home for 10 weeks or a 10-week waitlist control (WLC), which was then followed by a lower-dose of CO-OP (once weekly for 10 weeks). A secondary aim of the trial was to explore the effect of CO-OP treatment intensity, so the WLC group received a lower intensity CO-OP intervention following their WLC period. Participants were interviewed about their experiences of CO-OP during the final intervention appointment. The trial also involved a follow-up appointment where outcomes were reassessed three months after the intervention phase had finished. The RCT employed descriptive statistics, inferential statistics, and multiple regression analysis. Reflexive thematic analysis was used to interpret the interview data.

The RCT results suggest that CO-OP was feasible at both intervention intensities, based on acceptability (effort M=3.16/5 and enjoyment M=3.35/5); demand (homework completion M=90.26%; protocol adherence M=89.25%); and implementation (CO-OP fidelity M=5/5) findings. Higher intensity CO-OP was superior to the WLC for self-perceived goal performance and performance quality COPM performance: p=<0.001; COPM satisfaction: p=<0.001; and PQRS: p=<0.001 for trained goals. Results were significant (COPM satisfaction: p=0.035; and PQRS p=<0.001) for untrained goals, with clinically meaningful results maintained at the follow-up timepoint. Whilst cognitive (p=0.69) and functional (p=0.44) status, quality of life (p=0.16) and self-efficacy (p=0.32) results were not statistically significant; clinically important increases in general self-efficacy were recorded (M = 1.86). Comparison of CO-OP intervention intensity did not demonstrate significant differences in goal attainment with comparable maintenance at follow-up. However, higher intensity CO-OP appeared superior for skill transfer to untrained goals. Overall, the feasibility RCT showed that CO-OP at both intensities was feasible and potentially beneficial for people with PD.  

The qualitative findings revealed four interrelated themes representing participants’ experiences of CO-OP: 1) key aspects of CO-OP that were important, 2) impacts on awareness, 3) benefits in a range of ways, and 4) sustained use for continued benefits. The themes illuminated participant views on the most important elements of CO-OP: the metacognitive strategies, the home context where CO-OP occurred, and the specific qualities and actions of the therapist. They described how these elements helped them better understand their own abilities in the context of PD. This newfound self-awareness was described as leading to increased confidence and a more positive outlook on their condition. As a result, participants described improvements in daily activities, social interactions, and overall well-being. Participants described how these positive changes then motivated them to continue using the strategies learned in CO-OP to maintain and enhance their quality of life beyond the program.

In conclusion, this research has contributed new evidence regarding the feasibility of the CO-OP approach for people with PD. Results indicate that CO-OP is a feasible, implementable, and a potentially beneficial approach for community dwelling people with PD. We found that CO-OP addressed PD consequences holistically [4] and enabled attainment of individualised goals. It was valued by people with PD, with reports of continued strategy use and generalisation following the intervention. Future research should be conducted to further establish efficacy of CO-OP for people with PD through a large-scale multi-national trial. Future work could explore the potential for flexible delivery modes, such as telehealth, to enhance access to essential holistic rehabilitation for people with PD.  

Implications
The potential long-term impact of this work is an implementable intervention approach that comprehensively addresses the daily living challenges experienced by people with PD, ultimately leading to improved performance and participation.

Takeaway
As we continue to unravel the complexities of PD, research initiatives like this highlight the remarkable resilience of individuals living with this condition. By prioritizing research into approaches that target daily living problems, we can develop individualized approaches that empower people with PD to navigate their unique challenges with greater confidence and support.

Acknowledgement
The authors would like to thank the 20 people with PD who participated in the study. The authors gratefully acknowledge this support. This research was supported by an Australian Government Research Training Program (RTP) Scholarship and by Parkinson’s Queensland Incorporated through a PhD Award. 

References

1.  Polatajko, H., Mandich, A., Miller, L., & Macnab, J. (2001). Cognitive Orientation to Daily Occupational Performance (CO-OP). Physical & Occupational Therapy In Pediatrics, 20(2), 83-106. https://doi.org/10.1300/J006v20n02_06

2.  Davies, S. J., Gullo, H. L., & Doig, E. (2023). Efficacy and Feasibility of the CO-OP Approach in Parkinson's Disease: RCT Study Protocol. Canadian Journal of Occupational Therapy. Revue Canadienne D'Ergothérapie, 90(4), 363-373. https://doi.org/10.1177/00084174231156287

3.  Bowen, D. J., Kreuter, M., Spring, B., Cofta-Woerpel, L., Linnan, L., Weiner, D., Bakken, S., Kaplan, C. P., Squiers, L., Fabrizio, C., & Fernandez, M. (2009). How we design feasibility studies. American Journal of Preventive Medicine, 36(5), 452-457. https://doi.org/10.1016/j.amepre.2009.02.002

4.   Davies, S. J., Gullo, H. L., & Doig, E. (2024). The Priority Goals and Underlying Impairments Contributing to Goal-Related Problems of People with Parkinson's Disease Receiving a Community-Based Rehabilitation Program. Parkinsons Dis, 2024, 9465326. https://doi.org/10.1155/2024/9465326

Sarah Davies attended the WPC 2023 and presented her work as part of the poster tours. Together with Dr. Hannah Gullo and Dr. Emmah Doig are from the School of Health and Rehabilitation Sciences, University of Queensland, Brisbane Australia. 

Ideas and opinions expressed in this post reflect that of the author(s) solely. They do not reflect the opinions or positions of the World Parkinson Coalition®