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Background An intervention that contains several interacting components can be defined as a complex intervention. This intervention was developed in accordance with the Medical Research Council (MRC) guidance for complex interventions. Aim To describe the development, theoretical framework, and content of a client-centred activities in daily living intervention (CADL) for people with stroke. Material and methods Different steps were used; identifying the evidence base, identifying/developing theory and the modelling process and outcomes in the development of the CADL. The remodelling of the process and content of the intervention that emerged are defined. Results Findings from a series of qualitative studies of people with stroke demonstrated the need to develop an ADL intervention based on the clients’ lived experiences. The theoretical framework is based on empirical research, theories about human occupation and client-centredness. The CADL is applying an occupational and phenomenological perspective in order to enable agency in daily activities and participation in everyday life among persons with stroke. Conclusions and significance The article can be used as an example of how to present the development and theoretical framework of a new complex intervention in occupational therapy.

Background Globally, there is a growing use of Information and Communication Technology (ICT), including mobile phones, tablets and computers, which are being integrated into people’s daily activities. An ICT-based intervention called F@ce was developed in order to provide a structure for the process in stroke rehabilitation and facilitate change by integrating a global problem-solving strategy using SMS alerts. The aim of the study was to evaluate the feasibility of i) F@ce within in-patient and primary care rehabilitation after stroke, ii) the study design and outcome measures used, and iii) the fidelity, adherence and acceptability of the intervention. Methods Three teams comprising occupational therapists and physiotherapists who work in neurological rehabilitation participated in a preparatory workshop on F@ce and then enrolled 10 persons with stroke to participate in the intervention. Goals were set using the Canadian Occupational Performance Measure (COPM) and the participants with stroke rated their performance and satisfaction with the activities associated with the three goals every day for 8 weeks. Data were collected at inclusion, at four and 8 weeks, using the COPM, Stroke Impact Scale, Frenchay Activities Index, Life Satisfaction Checklist, Self-Efficacy Scale, Hospital Anxiety and Depression Scale, Fatigue Severity Scale, follow-up survey, daily ratings on the web platform and logbooks. Results All of the participants showed increased scores in the primary outcome (COPM) and a clinically meaningful improvement of ≥2 points was found in four participants regarding performance and in six participants regarding satisfaction. Overall fidelity to the components of F@ce was good. The response rates to the F@ce web platform were 44–100% (mean 78%). All of the participants stated that F@ce had supported their rehabilitation. Conclusion The results indicate that the most beneficial part of F@ce was the person-centred, goal-setting process and SMS alerts. All participants were satisfied with F@ce and highlighted the benefits of receiving daily alerts about their goals. This encouraged them to be more active. The only downside mentioned was that they felt under an obligation to practice, although this was described as “a positive obligation”. Funding: Financial support was provided by the Doctoral School in Health Care Sciences (FiV) at Karolinska Institutet, the Swedish Research Council (VR), the Swedish Research Council for Health, Working Life and Welfare (FORTE) [2014-4656] and the Swedish Stroke Association. The funders had no role in study design, data collection and analysis, or in preparation of the manuscript. Open Access funding provided by Karolinska Institute.

Background: This qualitative study was conducted in the context of a client-centred activities of daily living (CADL) intervention aiming to enable agency in daily activities and participation in everyday life after stroke. The intervention was based on the principles of client-centred occupational therapy and then further developed based on empirical research findings. Objective: To identify what from the clients’ perspective characterises the lived experience and meaning of participating in a CADL intervention after stroke. Methods: The study included 10 persons with stroke who received the intervention and who were able to communicate their experience of participating. Data were collected through two interviews, after the initiation and after the end of the intervention. The analysis was performed using an empirical phenomenological psychological method. Results: The overall characteristic of the meaning of participating in the intervention was transparency, which was expressed in the participants’ experiences of being able to see and follow their own rehabilitation process. An awareness and understanding of their own situation enabled the participants to be actively involved in their rehabilitation. Conclusion: The intervention contributed to transparency, which appeared to enable and support the client’s sense of ownership of daily activities and rehabilitation after stroke. Implications for rehabiliation A client-centred activities of daily living intervention seems to contribute to transparency, where persons with stroke can discover and understand their new ability and situation after stroke. A client-centred rehabilitation situation seems to enable clients to actively engage in their own rehabilitation process. Inviting clients to participate in goal-setting seems to be important in order to create the experience of transparency. Creating continuity in the therapeutic alliance seems to be important in order for the clients to feel trust and experience agency in everyday life.

To follow up an original research project of persons 11-13 years after stroke, in order to describe and understand the impact of stroke on everyday life experienced during these years. Eleven persons who had had a stroke were interviewed 11-13 years after the original research project. Data were collected and analysed using the empirical phenomenological psychological method. Three main characteristics were identified from analysis of participants' experiences during the years after stroke: () going through the loss of the previous life; () struggling to reclaim the former existence; () finding meaning in a "new" and different world. This study provides an understanding of the complexity of the lost connection between body and world occurring for a long time after stroke. This understanding provides support for the need for long-term and intermittent support and guidance to enable the re-creation of meaning and participation in everyday life in order to find a "new" self-identity after stroke, especially among persons with residual cognitive impairment.

Objective: The aim of the present study was to compare client-centeredness as it was documented by the occupational therapists in the units randomized to the intervention clusters with documentation by occupational therapists in the control clusters. Design: Comparison of medical records. Setting: The study is conducted in a context of a randomized controlled trial in Sweden, with 16 post-stroke rehabilitation units cluster randomized to intervention or control group. Subjects: Occupational therapist documentation in medical records of 279 clients with stroke. Main measures: The medical records were reviewed for their level of client-centeredness using a protocol developed from the Stewart et al model. The occupational therapists in the intervention groups participated in a workshop training to enhance their client-centeredness. Results: Occupational therapists with training in client-centeredness documented significantly more on goal setting (OR = 4.1; 95% CI, 1.87-8.81), on client participation in goal setting (OR=11.34; 95% CI, 5.97-21.57), on how the goals could be reached (OR=2.8; 95% CI, 1.7-4.62), on client participation in how goals could be reached (OR=4.56; 95% CI, 2.73-7.64), on the follow-up on goals (OR=5.77; 95% CI, 2.78-11-98) and on client participation in follow-up on goals (OR=7.44, 95% CI, 4.33-12.8). This association remained after adjustment for healthcare setting, client socio-demographic variables, and stroke severity. Conclusion: Documentation of goal setting and client participation in goal setting can be influenced by training.

Client-centredness is a prominent contemporary concept in rehabilitation. However, there is a lack of knowledge on if and how a client-centred rehabilitation approach is incorporated in the everyday life of significant others of people who receive such rehabilitation.Explore and describe if and how a client-centred ADL intervention (CADL) was integrated in the everyday lives of significant others of people with stroke.Qualitative longitudinal design, with a grounded theory approach. Seven significant others, who cohabited with persons receiving a CADL intervention, were interviewed during the first year.One core category was identified: "Taking responsibility and achieving balance with respect to self-esteem in order to get on with everyday life". The integration of the CADL was a process. A key aspect was that as the person with stroke acted upon his/her own desired activity goals the significant others were encouraged to act on their own needs.Enablement is important also for the significant others of people with stroke. One way of enabling significant others to maintain an active lifestyle and find respite in everyday life might be to enable people with stroke to formulate and act upon their desired activity goals.

OBJECTIVE: To compare changes regarding perceived participation, independence in activities of daily living (ADL) and life satisfaction between 3, 6 and 12 months after inclusion in a study of a client-centred ADL intervention and usual ADL intervention after stroke.DESIGN: A multicentre randomized controlled trial.METHODS: Sixteen rehabilitation units were randomly assigned to provide client-centred ADL intervention or usual ADL intervention. Eligible participants were persons ≤ 3 months after stroke who had been treated in a stroke unit, were dependent in two ADL domains, had not been diagnosed with dementia, and were able to understand instructions. Data collection was performed by blinded assessors. The primary outcome, perceived participation, was assessed with the Stroke Impact Scale 3.0, domain 8. The secondary outcomes, participation, independence in ADL, and life satisfaction, were assessed with validated instruments. For statistical power, 280 participants were required. Statistical analyses were performed on an intention-to-treat basis.RESULTS: There were no differences between the groups regarding changes in perceived participation, independence in ADL, or life satisfaction during the first 12 months. There was a trend towards a clinically meaningful positive change in perceived participation that favoured client-centred ADL intervention.CONCLUSION: Further research is required to understand the benefits of client-centred interventions.

Objective The aim was to study a client-centred activities of daily living (ADL) intervention (CADL) compared with the usual ADL intervention (UADL) in people with stroke regarding: independence in ADL, perceived participation, life satisfaction, use of home-help service, and satisfaction with training and, in their significant others, regarding: caregiver burden, life satisfaction, and informal care. Methods In this multicentre study, 16 rehabilitation units were randomly assigned to deliver CADL or UADL. The occupational therapists who provided the CADL were specifically trained. Eligible for inclusion were people with stroke treated in a stroke unit ≤3 months after stroke, dependent in ≥two ADL, not diagnosed with dementia, and able to understand instructions. Data were collected at inclusion and three months thereafter. To detect a significant difference between the groups in the Stroke Impact Scale (SIS) domain “participation”, 280 participants were required. Intention-to-treat analysis was applied. Results At three months, there was no difference in the outcomes between the CADL group (n = 129) and the UADL group (n = 151), or their significant others (n = 87/n = 93) except in the SIS domain “emotion” in favour of CADL (p = 0.04). Conclusion The CADL does not appear to bring about short-term differences in outcomes and longer follow-ups are required.

Purpose: The purpose of this study was to identify how people 6–12 months after stroke were using and integrating information and communication technology (ICT) in their everyday lives. Method: To capture the participants’ experiences, one focus group and 14 individual interviews were carried out in Sweden and Denmark regarding the use of ICT in everyday life. The participants comprised 11 men and seven women aged 41–79 years. A grounded theory approach was used throughout the study and a constant comparative method was used in the analysis. Results: Five categories were identified from the analysis of the interviews with the participants: 1) Using the mobile phone to feel safe, 2) Staying connected with others, 3) Recreating everyday life, 4) A tool for managing everyday life, and 5) Overcoming obstacles for using ICT. From these categories one core category emerged: The drive to integrate ICT in everyday life after stroke. Conclusions: People with stroke had a strong drive to integrate ICT in order to manage and bring meaning to their everyday lives, although sometimes they needed support and adaptations. It is not only possible but also necessary to start using ICT in rehabilitation in order to support people’s recovery and promote participation in everyday life after stroke. Implications for rehabilitation People with stroke have a strong drive for using information and communication technology in their everyday lives, although support and adaptations are needed.The recovery process of people with stroke could benefit from the use of ICT in the rehabilitation and ICT could possibly contribute to independence and promote participation in everyday life.Knowledge from this study can be used in the development of an ICT-based stroke rehabilitation model.

Objective: To describe and understand the lived experience and to identify what characterizes the phenomenon of participation in everyday occupations after stroke, in Tehran, Iran. Methods: Eight individuals with stroke, who had previously been admitted to a neurological hospital ward in Tehran, were interviewed in-depth on one occasion. Data were collected and analysed using the Empirical, Phenomenological, Psychological method. Results: The findings identified 3 main characteristics of the phenomenon of participation in everyday occupations as being: (i) I cannot do activities as before; (ii) I am not the same person – discovery of a different self; (iii) I am not living my life. Conclusion: Enabling participation after stroke within a client-centred paradigm in this socio-cultural context requires consideration of the essential meaning of this concept as characterized by the dynamic process between the characteristics of “doing”, “identity”, and “living life”. The study highlights how the provision of efficient rehabilitation services in this Eastern context requires attention to both “doing” and to “identity” in rehabilitation interventions, in order to enable individuals to adapt to their new lives after stroke and to “live their lives”.

Aim The aim of this study was to describe the experiences and meaning of using mobile phones in everyday life after stroke, among persons with stroke and their family members. Methods Qualitative semi-structured interviews were conducted among 11 persons with stroke and 9 family members 2 months to 2 years after the stroke. The interviews were analysed by using constant comparative grounded theory (GT) approach. Results Seven categories were identified from the analysis of the participants' experiences. The mobile phone: (1) as an enabler of communication and connections with other people, (2) a source of inspiration for agency, (3) structuring routine and activities in daily life, (4) as a facilitator of social and economic wellbeing of an individual or family, (5) promoter of belonging and participation in social relationships, (6) facilitator of reintegration to community living and (7) enabler of family members to feel secure. From these categories, a core category emerged: The mobile phone as a "life line" and an extension of the body enabling connection, belonging and agency to act in a complex everyday life situation. Conclusion The study gives support for the possibility of using mobile phones to facilitate change and community integration in the rehabilitation process after stroke. Implications for Rehabilitation Stroke leads to decreased functioning in everyday life due to impairments, activity limitations and participation restrictions as well caregiver burden. Mobile phones seem to be an accessible and affordable technology used in daily life of persons with stroke and family members and connects them to the needed services and social relationships. The mobile phone technology reduces resource and infrastructural challenges and increases accessibility to rehabilitation interventions. The mobile phone was an important instrument that facilitated the quality of life of persons with stroke and their family members and could increase their participation in rehabilitation interventions.

The objective of this study was to psychometrically evaluate the Persian version of the Occupational Gaps Questionnaire (OGQ-P) and LiSat-11 checklist, and to describe occupational gaps after stroke and their relation to aspects of functioning and perceived life satisfaction. A total of 102 individuals who had experienced a stroke were assessed for their occupational gaps, aspects of functioning, and life satisfaction. Psychometric analyses of the Persian versions of the OGQ and LiSat-11 were completed and the measures were applied for using univariate and multivariate analyses. The results provided evidence of internal scale validity, person response validity, and sensitivity for the instruments. The participants perceived the most common occupational gaps in “helping and supporting others.” Furthermore, perceived physical function including activities of daily living ability, motor function, and perceived life satisfaction were the most influential variables for the prediction of occupational gaps. It is essential to address the occupations such as “helping and supporting others” that are important from an individual perspective but overlooked in rehabilitation. A combination of physical function, motor function, and life satisfaction can predict occupational gaps after stroke.

THE study's rationale: Eating difficulties are common after stroke. However, to better meet individuals' needs, in terms of care, support and rehabilitation after stroke, it was considered importan ...

Actions link meaning to particular places over time. This study examined how familiar places, in turn, inspired or influenced actions in the rehabilitation process for individuals who had experienced stroke. The aim of this study was to describe the meanings of actions in different places during 1 year of rehabilitation after stroke. The interview data were longitudinal and collected on four occasions during the first year after stroke (e.g., at 1, 3, 6, and 12 months). Seven categories emerged from the data analysis using a constant comparative method: (1) workplace in mind, (2) experiences at home enabling reflection, (3) rehabilitation setting creates uncertainty, (4) retrieving inspiration from familiar places, (5) matching the complexity of tasks across places, (6) understanding the reality by confrontation, and (7) on the way to place integration. From these themes, a core or overarching theme emerged: the desire for place integration inspires engagement in rehabilitation. The central finding in this study revealed a strong relationship between the desire to be reintegrated into familiar places, such as work and home, and motivation to engage in rehabilitation. Further, this desire for place integration was a constant driving force over the year that motivated the participants to find activities on their own that matched the task demands at their workplaces.

The aim of the study was to evaluate the effect of client-centred, self-care intervention (CCSCI) on (i) activities of daily living (ADL) and life satisfaction in persons with stroke, (ii) caregiver burden, use of informal care and home-help services, and (iii) the feasibility of the study design.Randomized controlled trial, a pilot study of an intervention group (IG) receiving CCSCI or a control group (CG) receiving ordinary training.Forty persons with stroke (IG n = 19, CG n = 21) were included: non-demented, able to follow instructions, dependent regarding self-care and referred for rehabilitation, and their significant others (IG n = 8, CG n = 8).Data were collected at baseline and three months later using established instruments regarding ADL, life satisfaction, caregiver burden, and use of health services from medical records, the county register, and by interviews.There were no differences in ADL, life satisfaction, caregiver burden, or use of services at three months. Both groups improved significantly and clinically important improvements were achieved by 86% in IG and 63% in CG.The CCSCI appears promising for the recapturing of self-care after stroke and a large randomized controlled trial is warranted, in which the present design and methods with some modification will be feasible.

To explore the experience and management of eating situations among persons affected by stroke, 6 months after stroke onset.A qualitative constant comparative approach, influenced by principles of grounded theory, was used to analyse the interviews. Thirteen participants were interviewed in the home setting 6 months after the stroke.Experiences and desire to master eating situations varied, and was related to values and previous habits. Eating difficulties were experienced as disgusting, uncomfortable, strenuous, or unproblematic and not implying shame. Getting help from others could be experienced as embarrassing and undesirable. In particular, eating could be more difficult when eating in company of unfamiliar people. The participants found new ways of mastering eating situations. Some had regained former routines.Old values and habits and/or involvement of other people were the basis of mastering eating situations. New ways of mastering were found, some accepted, and got used to the new situation. Some regained former routines. This knowledge could contribute to health care personnel's awareness of each patient's individual values and previous habits during the rehabilitation process. A dialogue is needed with the person suffering from eating difficulties after stroke, to help create the best possible individual conditions for mastering eating situations.

This study identifies the meaning of context in recapturing self-care after a stroke or spinal cord injury (SCI). Recapturing denotes the process of engaging in self-care to regain the ability to participate in self-care activities. Five people who had had a stroke and 6 people with SCI were interviewed 1–3 months after onset. The interviews were open ended and transcribed verbatim. They were analyzed by using the empirical, phenomenological, psychological method, which identified 6 main characteristics describing the role of context in recapturing self-care: (1) support from others, (2) an air of expectation, (3) extended time, (4) new daily structure, (5) therapeutic relationship as enabling possibility, and (6) gradual change in challenge. These findings showed that rehabilitation professionals play an important role in creating a context that contributes to recapturing self-care by allowing extended time, enabling patients to see possibilities, and creating expectations for them to do things on their own.

This study sought to identify the characteristics of the lived experience of recapturing self-care after a stroke or a spinal cord injury (SCI). Five people who had had a stroke and six with SCI who were in the midst of recapturing self-care (1–3 months after onset) were interviewed. All interviews were analyzed using the Empirical, Phenomenological, and Psychological method. Four main characteristics were present among all of the participants’ lived experiences: (a) becoming familiar with the new body, (b) recapturing self-care through trying, (c) reclaiming control, and (d) feeling uncertainty in the continued recapturing process. The findings indicate that a prerequisite for recapturing self-care was to get experience from doing to become familiar with the new body, which makes explicit the importance of enabling self-care in the rehabilitation process after stroke or SCI. The findings can be used in clinical practice to improve the understanding of how to better plan individualized self-care intervention.

Objective: Compare caregiver burden, provision of informal care, participation in everyday occupations and life satisfaction of caregivers to people with stroke, who either had received a client-centred, activities of daily living intervention or usual activities of daily living interventions. Design: A multicentre cluster randomized controlled trial in which 16 rehabilitation units were randomly assigned to deliver a client-centred, activities of daily living intervention or usual activities of daily living interventions. Caregiver outcomes were compared cross-sectionally at 12 months and changes in outcomes between three and 12 months after people with stroke were included in the study. Setting: Inpatient and outpatient rehabilitation. Participants: Caregivers of people with stroke enrolled in the trial. Intervention: A client-centred, activities of daily living intervention aiming to increase agency in daily activities and participation in everyday life for people after stroke. Main measures: Caregiver Burden Scale, Occupational Gaps Questionnaire, LiSat-11. Results: There were no differences in outcomes between caregivers in the client-centred, activities of daily living ( n = 88) and the usual activities of daily living ( n = 95) group at 12 months. The caregiver burden score was 42.7 vs. 41.8, p = 0.75, mean occupational gaps were 3.5 vs. 4.0, p = 0.52 and satisfaction with life was 53% vs. 50%, p = 0.87. There were no differences in changes between three and 12 months. However, within groups there were significant differences in caregiver burden, factor general strain, for caregivers in the client-centred, activities of daily living group, and in provision of informal care for the usual activities of daily living group. Conclusion: The client-centred intervention did not bring about any difference between caregiver-groups, but within groups some difference was found for caregiver burden and informal care.

Background Long-term disability following stroke can lead to participation restrictions in complex and social everyday activities, yet information is lacking on to what extent stroke survivors return to their pre-stroke levels of participation. Objectives The objectives of this study were to investigate the level of participation in complex and social everyday activities 6 years after stroke, to compare this with pre-stroke participation and to identify predictors of returning to pre-stroke levels of participation. Method All patients admitted to Karolinska University Hospital's stroke units during a 1-year period were eligible to participate and 349 patients were recruited. Assessments were made at base-line, 3 months and 6 years using self-reported outcome measures. Participation was assessed using the Frenchay Activities Index (FAI). The 6-year score for each participant was compared to the pre-stroke score, both for the total score and for each domain (domestic chores, leisure/work and outdoor activities). Predictors of having the same or better level of participation at 6 years were identified using logistic regression. Results At 6 years, 121 participants were followed up, 166 were deceased, 44 declined to take part and 18 could not be traced. At 6 years 84% could be described as active (FAI≥15). The same level of participation or better than pre-stroke was found in 35% of participants, in 65% the level was lower. Similar predictors were identified for achieving the same or better level of participation at 6 years for FAI total and the three domains; ability to walk without aids and a lower age at stroke onset, and perceived mobility, participation and recovery at 3 months. Conclusion Six years after stroke, 35% of participants had the same or better level of participation as pre-stroke. Rehabilitation after stroke to improve walking ability and participation might improve long-term participation in complex and social everyday activities.

PURPOSE. Research in the field of brain injury rehabilitation has tended to regard return to work as a measure of outcome. Researchers have not paid particular attention to the experiences of people living with a brain injury. The aim of the phenomenological study reported here was to identify and describe what characterizes the meaning of work to those with acquired brain injury. METHODS. Ten participants of working age were interviewed about the meaning of work 1–5 years after being inflicted with a brain injury. Data were analyzed and interpreted using the Empirical Phenomenological Psychological method. RESULTS. The findings revealed a meaning structure consisting of four main characteristics. Work was no longer experienced as the primary event in life and the social dimension had become more important. The perceived competence and work identity were threatened after the injury. A common theme across all interviews was the struggle to return to a state of normality, and working was considered to be evidence of success. CONCLUSION. The findings described the altered meaning of work 1–5 years after brain injury. This knowledge should lead to an increased understanding among occupational therapists engaged in work rehabilitation after brain injury and can serve as a basis for individualized intervention strategies.

The objective of this survey was to identify couples' joint perception of their satisfaction with life as a whole when one of the persons in the couple had acquired brain injury between one and five years earlier. The focus was on the influence that functioning and disability in everyday life have on the couple's joint life satisfaction after brain injury. The sample consisted of 55 couples, and the mean age of the brain-injured persons was 51 years. Both persons in the couple answered a mailed questionnaire encompassing questions concerning perceived impairments, activity limitations, participation restrictions, and life satisfaction. The results showed that in 16 of the 55 couples both partners were satisfied with life as a whole. The joint experience of life satisfaction was significantly related to the couple's functioning in everyday life, and specifically to perceived participation in leisure time and in their social life, and in their ability to wash clothes. Important implications from this study, showing that only one-third of the couples were satisfied, are that the partners should be included to a greater extent in the rehabilitation process and the couple's perspective of what they find difficult to deal with should serve as a guide during rehabilitation.

Objective: The Baking Tray Task is a comprehensible, simple-to-perform test for use in assessing unilateral neglect. The aim of this study was to validate further its use with stroke patients. Methods: The Baking Tray Task was compared with 2 versions of the Behaviour Inattention Test and a test for personal neglect. A total of 270 patients were subjected to a 3-item version of the Behaviour Inattention Test and 40 patients were subjected to an 8-item version of the Behaviour Inattention Test, besides the Baking Tray Task and the personal neglect test. Results: The Baking Tray Task was more sensitive than the 3-item Behaviour Inattention Test, but the 8-item Behaviour Inattention Test was more sensitive than the Baking Tray Task. The best combination of any 3 tests was Baking Tray Task, Reading an article, and Figure copying; the 2 lastmentioned being a part of the 8-item Behaviour Inattention Test. Conclusion: Multi-item tests detect more cases of neglect than do single tests. However, it is tiresome for the patient to undergo a larger test battery than necessary. It is also time-consuming for the staff. Behavioural tests seem more appropriate when assessing neglect. The Baking Tray Task seems to be one of the most sensitive single tests, but its sensitivity can be further enhanced when it is used in combination with other tests.

The purpose was to explore, describe and compare the characteristics of physiotherapy sessions with patients after stroke from two perspectives: the patients' and the physiotherapists', in relation to observed behaviour.A qualitative, descriptive, comparative approach was used. Nine patients and 10 physiotherapists participated. Data from observations and semi-structured interviews were used.Six themes were identified: setting and attaining goals, focusing on motor activity, finding the optimal training strategy, facilitating active patient involvement, making use of environmental factors and adjusting to the structural reorganization of the rehabilitation services. The physiotherapists and the patients made similar descriptions in some of the themes but differed in some. The physiotherapists expressed what they perceived to be their lack of scientific knowledge, while the patients trusted their physiotherapists' competence. The physiotherapists wanted to take the patients' personal experiences into account in the sessions, which was not obvious to the patients.Differences in physiotherapists' and patients' descriptions of characteristics of physiotherapy sessions have to be taken into consideration in the rehabilitation of stroke patients. In order to empower the patient to take a more active part in the rehabilitation process, there is a need to explore how to incorporate the patients' personal experiences and knowledge into the rehabilitation process.

This study examines how persons with visuospatial agnosia following stroke experience their interaction with the physical environment in everyday occupations. Eight clients with cerebrovascular les...

OBJECTIVE. The purpose of this study was to gain an understanding of social environmental influences on occupational experience and performance over the course of rehabilitation of four persons with unilateral neglect. METHODS. The Phenomenological Psychological Method (Karlsson, 1993) was used to gather and analyze qualitative data on four women over a 4-month period. Four women were interviewed five to seven times each and observed during their rehabilitation process. Analysis focused on how these persons with unilateral neglect experienced and responded to their interactions with others in their everyday lives. FINDINGS. As perceived by the study participants, rehabilitation professionals and relatives demonstrated a sequence of strategies for dealing with and helping the women perform despite their unilateral neglect. The sequence of strategies reflects the changing experience of neglect over time. The strategies used by professionals and family members during the rehabilitation process enabled these women to reclaim and occupy the neglected half of the world. Moreover, the women with neglect learned to incorporate others as extensions of their bodies in order to compensate for their ongoing inability to directly experience the left half of the world. CONCLUSION. The results suggest that it is important for others (e.g., therapists, nurses, or relatives) to understand the client’s changing experience of neglect and adjust their support and collaboration accordingly. Occupational therapy intervention for persons with neglect could potentially become more effective by systematically incorporating the kinds of strategies identified in this study. Moreover, therapists could consult with others to increase their understanding and effectiveness in interacting with persons who have unilateral neglect.

This study examined the phenomenon ?what are occupational therapists doing when they feel competent?. Data were provided by eleven occupational therapists who narrated clinical cases in which they had felt themselves to be competent. The empirical phenomenological psychological (EPP) method was used to analyse and interpret the data. The result revealed that on a general level the experience of feeling competent as an occupational therapist derived from achieving results in the rehabilitation project that were satisfying for both participants (the therapist and the client). The strategies for accomplishing this were related to the empathic competence of the therapists. This competence involved interpreting clinical situations as well as understanding the relationship between motive, meaning, decision and time. Further it involved bringing objects, in the form of adaptations, technical aids, structures, simplifications or compensations, into the clinical situation. These abilities together had a great impa...

To compare the effects of a video procedure and a conventional verbal procedure in giving patients feedback on their neglect behavior in a practical task.Subjects in group A were trained with a video feedback procedure and subjects in group B with a conventional, verbal procedure. Three hours after the procedures, the subjects were tested with four different neglect tests to evaluate the effects of training.A consecutive series of 14 right-brain-damaged patients with moderate to severe unilateral neglect (UN): 7 patients in group A and 7 in group B.Subjects in group A were given the opportunity to see their performances on video, directly after the performance of the "Baking Tray Task" (BTT). They could see their neglected left side on the right side of the TV monitor. Subjects in group B were given verbal and visual guidance to see their results in the BTT.Line Cancellation Task, Figure Copying Task, Line Bisection, and BTT before and after procedures.The video feedback group improved significantly in the BTT, as tested 3 hours after training (p.02). Conventional training had no effect on the BTT or on the other neglect measures. In the video feedback group, no generalization effects from the videotaped BTT on other neglect tests were observed.Video feedback seems to be a useful technique in the rehabilitation of patients with unilateral neglect.

A goal for rehabilitation after stroke is to regain the ability to manage activities of daily living (ADL). The Swedish health care legislation recognizes that individuals bring unique sets of needs and preferences to encounters with the health care system, which should impact the services delivered. Consequently rehabilitation needs to be designed to meet each individual’s concern i.e., be client-centered. This implies interventions tailored to the client’s ability and perceived needs, services that take the client’s unique life-world experiences as the point of departure for goals and collaboration during the rehabilitation. However, studies on such services are scarce. Thus the aim was to compare a client-centered ADL intervention (CADL) to usual ADL training (UADL) regarding perceived participation, independence in ADL and life satisfaction at 3 months after inclusion. Methods: Sixteen rehabilitation units in Stockholm, Uppsala and Gävleborg, Sweden were randomly assigned to deliver either CADL or UADL to people in need of ADL rehabilitation after stroke. The occupational therapists (OT) who delivered the CADL were specifically trained. At 3 months perceived participation was assessed with the Stroke impact scale (SIS) and the Occupational Gaps questionnaire (OGQ), self-reported dependence in ADL with the Barthel Index (BI) and the Katz Extended ADL Index (KE), and life satisfaction with the LiSat-11. Number of contacts with an OT was collected in the clients’ medical records. Intention-to-treat analysis was applied. The significance level was set to 0.05. ClinicalTrials.gov identifier: NCT01417585 . Results: Two hundred and eighty persons with stroke were included (CADL n=126, UADL n=154). The mean number of OT sessions in the CADL was 19 and 14 in the UADL group. There were no differences regarding SIS (p=0.64), OGQ (p=0.15), BI (p=0.06), KE (p=0.78) or in LiSat-11 (p=0.77). Conclusion: Albeit people with stroke who receive CADL tend to be more independent in ADL at 3 months it is likely that differences in perceived participation and life satisfaction will not be present until later. Thus there is a need to evaluate such services in the long term, their impact on significant others and qualitative studies of the clients’ experiences.

BACKGROUND AND OBJECTIVE: To a large extent, people who have suffered a stroke report unmet needs for rehabilitation. The purpose of this study was to explore aspects of rehabilitation provision that potentially contribute to self-reported met needs for rehabilitation 12 months after stroke with consideration also to severity of stroke.METHODS: The participants (n = 173) received care at the stroke units at the Karolinska University Hospital, Sweden. Using a questionnaire, the dependent variable, self-reported met needs for rehabilitation, was collected at 12 months after stroke. The independent variables were four aspects of rehabilitation provision based on data retrieved from registers and structured according to four aspects: amount of rehabilitation, service level (day care rehabilitation, primary care rehabilitation and home-based rehabilitation), operator level (physiotherapist, occupational therapist, speech therapist) and time after stroke onset. Multivariate logistic regression analyses regarding the aspects of rehabilitation were performed for the participants who were divided into three groups based on stroke severity at onset.RESULTS: Participants with moderate/severe stroke who had seen a physiotherapist at least once during each of the 1st, 2nd and 3rd-4th quarters of the first year (OR 8.36, CI 1.40-49.88 P = 0.020) were more likely to report met rehabilitation needs.CONCLUSION: For people with moderate/severe stroke, continuity in rehabilitation (preferably physiotherapy) during the first year after stroke seems to be associated with self-reported met needs for rehabilitation.

This paper describes a new neglect test, where patients are asked to spread out 16 cubes as evenly as possible over a 75 × 100 cm board "as if they were buns on a baking tray". A consecutive series of 52 brain-damaged patients and 30 control subjects were examined with the new test as well as with several commonly used neglect tests. The baking tray task proved to be a quick and yet sensitive test, suitable for screening purposes and longitudinal studies.

The aim of this study was to validate the Occupational Gaps Questionnaire (OGQ) when used in samples of people with acquired brain injuries (ABI), stroke, stress-related disorders, concussion, and persons receiving rehabilitation after ABI to investigate whether the OGQ could be used as a generic scale. A total of 601 individuals answered the OGQ at various time points after illness/injury. A Rasch analysis was performed on the data to evaluate evidence of internal scale validity and person response validity, and the capability of the OGQ to separate people into different levels of participation in everyday occupations. The results provided evidence that the OGQ is a valid measure across different diagnostic groups. A generic version of the OGQ can separate at least two levels of perceived occupational gaps and is therefore recommended as a screening tool to be used by occupational therapists working with different diagnostic groups.

Objective: To explore and describe factors associated with occupational gaps and to identify factors at 3 months that predict occupational gaps one year post-stroke. A gap, a restriction in participation, is considered to be present when there is a discrepancy between what the individual wants to do and what they actually do in everyday life. Design: Prospective longitudinal study. Subjects: Two hundred persons with stroke. Methods: Data from the Occupational Gaps Questionnaire, one year post-stroke, was used as the dependent variable in 3- and 12-month regression analyses. Domains of the Stroke Impact Scale, global life satisfaction, demographic and medical factors were used as independent variables. Results: At 3 months, activities of daily living abilities, social participation and not being born in Sweden predicted occupational gaps at 12 months. Stroke severity and not being born in Sweden and 3 factors at 12 months: social participation, self-rated recovery, and global life satisfaction were associated with occupational gaps. Conclusion: Activities of daily living ability at 3 months predicted occupational gaps after stroke. Thus, it is possible to identify early on, and provide interventions for, those that risk participation restrictions. Not being born in the country might be an indicator of a risk for participation restrictions.

To describe and compare how occupational gaps were reported in everyday occupations in a rehabilitation group of people with musculoskeletal pain or stress-related ill health and in a reference group from the Swedish population.Seventy-two persons with musculoskeletal pain or stress-related ill health and 261 people from the Swedish population were included. The Occupational Gaps Questionnaire, measuring to what extent individuals perceive a discrepancy between what they want to do and what they actually do, was completed by the participants. Descriptive statistics were used to analyse the data.Occupational gaps were reported more often in the rehabilitation group. Leisure activities were the gaps reported most often. The occupational repertoire seemed to decrease over time as the number of activities was decreasing, particularly leisure and work-related activities. Instrumental ADL were more desirable as the length of sick leave extended.Being on sick leave appears to start a process towards occupational deprivation where the areas that remain in the occupational repertoire become more important. Our study highlights the need to emphasize the whole occupational repertoire in rehabilitation and to facilitate engagement in valued activities to create a sound base for the process of returning to work.

Objective To describe perceived participation and autonomy among a sample of persons with stroke in Iran and to identify different aspects of functioning and contextual factors predicting participation after stroke. Design A cross-sectional study. Subjects A total of 102 persons, between 27 and 75 years of age, diagnosed with first-ever stroke. Methods Participants were assessed for different aspects of functioning, contextual factors and health conditions. Participation was assessed using the Persian version of the Impact on Participation and Autonomy questionnaire. Results This study demonstrated that the majority of the study population perceived their participation and autonomy to be good to fair in the different domains of their participation, but not with respect to the autonomy outdoors domain. In addition, physical function was found to be the most important variable predicting performance-based participation, whereas mood state was the most important variable predicting social-based participation. Conclusion The results emphasize the importance of physical function, mood state and access to caregiving services as predictors of participation in everyday life after stroke. Whilst there are two dimensions of participation in this Persian sample of persons with stroke, the factors explaining participation seem to be the same across the cultures.

Objective To investigate the meaning of acting with others, in different places over the course of 1 year post-stroke. Methods Qualitative interviews with 9 persons, age range 42-61 years (7 persons with cerebrovascular accident and 2 with subarachnoidal haemorrhage) over the course of a year (i.e. 3, 6, 9 and 12 months) were analysed using a grounded theory approach. Results Four categories were identified from the analysis of the participants' experiences during the year of rehabilitation: (i) not recognized as the person I am; (ii) the burden of burden; (iii) inspiration and belonging through acting with others; (iv) reality adjustment through acting with others. From these categories a core category emerged: a process of belonging for integration. Conclusion The 4 categories identified suggest that belonging is integral to participation, which is viewed as the goal of rehabilitation.

The purposes of this study was to examine the possibilities of a home-based electronic memory aid with sensors for persons with memory impairments, as support to carry out everyday activities in their own home environments.The method involved a single-subject study with a multiple baseline AB design. Five participants identified three activities each that they usually forget to carry out. An electronic memory aid with individually spoken reminders was installed in the participant's home. There were automatic computer registrations of completed activities during the study phase of 12 weeks. Assessments of functioning and quality of life (QoL) were conducted before and after the intervention and at follow-up after 2 months.Four participants improved in completing most of the self-chosen activities when the electronic memory aid was used. Performance and satisfaction with performance and QoL improved, but there was no memory function improvement. There were technical problems with the aid, which had a negative effect for users.Electronic memory aids have a large potential for supporting persons with cognitive impairments. It is important to conduct follow-up afterwards, because the use of an aid and the need of support change over time and put high demands on technical reliability of the electronic memory aid.

The aim of the study was to identify and describe two couples' approaches to changes in everyday life during the first year after a stroke. An additional aim was to describe how the couples viewed rehabilitation as well as their own personal training relative to changes in everyday life during the first year at home after stroke.The study design was a prospective longitudinal case study based on two couples where one of the spouses in each couple had experienced a stroke. Data collection consisted of interviews and a questionnaire and took place in the participants' homes. Data analysis utilized a constant comparative method.The findings showed a divergence in the couples' approaches to changes in their everyday life at home and were described through the following categorizations: engaging in occupations, getting experience and thereby feedback from doing, changing one's occupational needs and demands, contributing to a picture of a possible future and, integrating training in everyday life. Getting experience and feedback from doing was found to be a key category or "driver" in the change process.The couples' experiences of changes in everyday life after stroke illustrated two very divergent approaches, which is discussed in the paper. The approaches in turn had consequences for how daily life was spent after stroke which is also discussed.

The aim was to describe how former clients with stress-related disorders and rehabilitation team members experience the rehabilitation process, and to describe how experiences from the rehabilitation have been integrated into the former clients' everyday lives. A qualitative grounded theory approach was used. The sample consisted of seven team members working at a vocational rehabilitation clinic and eight former clients who were interviewed. The participants were involved in four different rehabilitation programmes, all of which used cognitive approaches. In addition, two of the programmes offered activities in a therapeutic garden. The result highlighted experiences that might have contributed to changes in the former clients' self-image, development of conscious strategies for handling stressful situations, and changes in values attached to everyday occupations. In addition, two different modes of integrating experiences from rehabilitation into the former clients' everyday lives were identified: changing approaches to handling stressful situations in everyday life and changing occupational repertoire in everyday life. Important implications might be that activities which promote relaxation and enjoyment should be included in the rehabilitation of people with stress-related disorders since experiences from these activities seemed to facilitate occupational balance in everyday life.

Objective: To explore the relationship between occupational gaps, depressive mood and life satisfaction in persons who have acquired a brain injury during the past 1–4 years and to test the Occupational Gaps Questionnaire. Design: A cross-sectional study. Subject: A total of 116 persons with traumatic brain injury or subarachnoid haemorrhage acquired 1-4 years previously. Methods: A postal survey with questions on occupational gaps, focusing on the domains instrumental activities of daily living, social life, leisure and work (Occupational Gaps Questionnaire), life satisfaction (LiSat-11 checklist) and depressive mood (Hospital Anxiety and Depression Scale). Rasch analyses and principal component analyses were performed to ensure that data from the LiSat-11 and Occupational Gaps Questionnaire could be used subsequently as valid unidimensional measures in regression and correlational analyses. Results: Calibration of the Occupational Gaps Questionnaire and the LiSat-11 revealed that the items and persons demonstrated acceptable goodness-of-fit to the Rasch models respectively, supporting internal scale validity and person-response validity. In addition, principal component analyses revealed that the measures could be used as valid uni-dimensional estimations of occupational gaps and life satisfaction. There was a strong relationship between the extent of occupational gaps and perceived life satisfaction, a weaker relationship with depressive mood and a non-significant relationship with the aetiological diagnoses and life satisfaction. The factors explained 32% (occupational gaps), 6% (depressive mood), and 2% (diagnosis), respectively, of the total explained variance (40%). Conclusion: There was a strong correlation between participation in desired everyday occupations and life satisfaction 1–4 years after an acquired brain injury. This indicates that individually perceived occupational gaps, as recorded by the Occupational Gaps Questionnaire, could be relevant targets for tailored interventions in order to improve life satisfaction among clients with acquired brain injuries.

This study describes and expands our understanding of the lived-experience of driving ability after stroke in the context of being under a driving evaluation.Four men with stroke were interviewed on three occasions. The interviews were open-ended, taped and transcribed verbatim, and analysed using Karlsson's Empirical, Phenomenological and Psychological method.The findings revealed five main characteristics expressed in the participants' lived experiences: (1) the meaning of driving remained throughout life; (2) being questioned and advised not to drive--an untenable situation; (3) being out of control and violated by the driving evaluation; (4) driving safely (as usual) during the on-road test; and (5) perceiving consequences in everyday living.The findings indicate that driving is important and taken for granted even after stroke. To lose the ability to drive was unexpected and aroused strong feelings and reactions. The present study contributes to a deeper understanding of how people with stroke experience their driving ability and the evaluation process, which can be integrated in clinical procedures to help improve information, emotional support and clinical procedures.

OBJECTIVES. This study examined the relationship between awareness of disability and occupational performance in a group of elderly persons during the year after stroke. METHOD. Data on awareness of disability and occupational performance (i.e., activities of daily living [ADL] motor and process ability) were collected 1, 3, 6, and 12 months after stroke. A mixed-linear-effects model was implemented to examine the relationship between awareness of disability and ADL motor and process ability over time. RESULTS. Increased awareness of disability was related to improvements in occupational performance (ADL motor and process ability). The 2 relationships were different, with a positive linear relationship between awareness of disability and ADL motor ability, and a stronger, positive, nonlinear relationship between awareness of disability and ADL process ability. CONCLUSION. Clients’ awareness of disability and their ability to perform occupations should be assessed several times during a rehabilitation process so that interventions can be adjusted to match each client's potential to benefit from them.

Background and Purpose Intervention programs for home-based rehabilitation are not fully described in the literature, and rehabilitation team members' experiences and tacit understanding of working with patients after stroke in the home environment need to be further understood. The aim of this study was to identify the meaning of rehabilitation in the home environment after stroke from the perspective of members of a multiprofessional team. Subjects Thirteen members of a multiprofessional outreach team (physical therapists, occupational therapists, speech and language therapists, and a social worker) working at a geriatric hospital in Stockholm, Sweden, participated in the study. Methods A qualitative method (the Empirical Phenomenological Psychological method) was used, with data being obtained from retrospective interviews of the team members after completing home-based rehabilitation of patients after acute stroke. Results One main theme (“supporting continuity”) and 4 subthemes (“making a journey together from hospital to home,” “enabling experiences of functioning,” “refraining from interventions—encouraging patient problem-solving skills,” and “looking for a new phase—uncertain endings”) were revealed. Discussion and Conclusion The findings suggest that contextual factors, both environmental and personal, were considered to be of great importance by the members of the multiprofessional team and were accounted for when they were working in the home environment in the rehabilitation of patients after stroke. Contextual factors detected in the home environment gave valuable information to the team members, who used the information in their strategies to assist the patients in finding continuity in their daily life and to link the past to the present and the “new body” to the “old body.”

OBJECTIVE: To investigate aspects of validity and stability of Performance Analysis of Driving Ability (P-Drive), for people with stroke when used in a driving simulator. DESIGN: A cross-sectional observational study. SUBJECTS: The study included a consecutive series of 101 participants with stroke referred for evaluation or selected from a stroke registry. METHODS: P-Drive was used to observe driving performance in order to assess driving ability. P-Drive comprises 20 items assessing the quality of the participant's driving performance. Aspects of validity and reliability in P-Drive were evaluated using Rasch statistics. RESULTS: The items (95%) and participants (97%) demonstrated acceptable goodness-of-fit and met statistical expectations according to the Rasch model. The results support internal scale validity and person response validity. P-Drive could separate the participants with different driving abilities and the standard errors were within reasonable criteria for drivers with a moderate-to-low ability to drive. CONCLUSION: The findings from this study indicated that P-Drive is an assessment tool with properties of internal scale validity, person response validity, and which also contains aspects of reliability in relation to precision of the estimates and separation. P-Drive seems to be a valid and stable assessment tool for assessing the driving ability in a simulator of people with stroke. Language: en

To explore adaptation, by examining the occupational gaps occurring between what individuals want to do and what they actually do in terms of their everyday activities before and after brain injury. In addition, the relationships between occupational gaps and impairment/activity limitations and the time lapse since the brain injury were explored.A cross-sectional study.A total of 187 persons, affected by traumatic brain injury or subarachnoid haemorrhage 1-4 years previously.A postal questionnaire encompassing questions concerning gaps in the performance of activities in everyday life before and after the brain injury and perceived impairment/activity limitations.The numbers of occupational gaps increased after the injury, with the number of gaps having increased from 46% to 71%. The number of occupational gaps was significantly related to executive impairment/activity limitations, and motor impairment/activity limitations and other somatic impairments, such as headache, also had an impact. The time lapse since the brain injury had no significant effect on the number of occupational gaps.The results suggests that there is a need for adaptation in everyday activities, even several years after a brain injury, which indicates that follow-up and access to individualized rehabilitation interventions in the long-term are required.

OBJECTIVE. The objective of this study was to investigate how persons with acquired brain damage experienced their 1-week stay in an apartment fitted with electronic aids to daily living (EADL). The study focused on how the individuals adapted to this artificial environment in their performance of daily activities and how their occupational experiences influenced their view of the future. METHODS. The 11 participants were interviewed on the last day of their rehabilitation period in an EADL-equipped training apartment. The data were collected and analyzed using the Empirical Phenomenological Psychological (EPP) method. FINDINGS. The findings revealed four main characteristics that described an adaptation process that occurred during the week in the EADL-equipped training apartment: plunging into an EADL-equipped environment, “landing” and feeling comfortable with the new environment, incorporating the “new” in daily activities, and “taking-off” for the future. CONCLUSION. In a short time, the combination of the EADL and the aesthetically attractive environment gave the participants experiences that contributed to a “taking off” for their future life. Findings from this study suggest that, in clinical practice, clients may need initial guidance from the therapists to “land” and feel comfortable in a new environment, like a training apartment, before they can learn how to incorporate new electronic aids in their every day activities.

OBJECTIVE. The objective of this phenomenological study was to understand the meanings of the lived experiences of persons with long-term mental illness at a social working cooperative. METHOD. Eighteen participants were interviewed either two or three times while participating in a working cooperative in a community psychosocial rehabilitation program. Data were analyzed and interpreted using the Empirical, Phenomenological, Psychological (EPP) method (Karlsson, 1993). RESULTS. The findings revealed a meaning-structure consisting of one main constituent that characterized the cooperative as a normalizing life-world. Three phases contributed to the normalization process. In the first phase the participants experienced a shift from an unsatisfying occupational context to an enriching occupational life-world. In the second phase participants had the possibility to satisfy some of their occupational and social needs. During this phase, experiences of being productive and needed, commitment to others, development of their skills, and competence in work tasks and social activities were expressed, all of which contributed to personal growth and a more positive view of self. In the third phase, the meaning of the cooperative changed for some participants, who expressed this through their readiness to leave and take a further step into the life-world outside the cooperative. CONCLUSION. The study emphasizes that the cooperative is an important alternative to employment for participants with severe mental illness who do not have the capacity to be employed in the community or who do not want to leave the life-world of the cooperative that gives them pride, joy, and satisfaction.

Objective. Awareness of disabilities is known to be a central problem of rehabilitation among clients with large right cerebrovascular lesions and unilateral neglect. The aim of this study was to evaluate the effect of an intervention program focused on improving the awareness of disabilities in four participants with unilateral neglect. The intervention program developed for this study was based on the assumption that awareness of disabilities is a prerequisite for being able to learn and use compensatory techniques in the performance of activities of daily living (ADL). Method. The study followed a single-case experimental ABA design. The Assessment of Awareness of Disability was used to measure awareness of disabilities; the Assessment of Motor and Process Skills was used to measure ADL ability; and neuropsychological tests were used to assess unilateral neglect and sustained attention. The intervention program used meaningful and purposeful occupations as therapeutic change agents to improve awareness of disabilities. Results. Awareness of disabilities and ADL ability improved in all four participants; unilateral neglect decreased in three participants; and sustained attention improved in two participants. Conclusion. The preliminary findings indicate that training to improve awareness of disabilities might improve the ability to learn the use of compensatory techniques in the performance of ADL in clients with unilateral neglect. The effects of the intervention strategy need to be evaluated further in future research.

Many studies have shown a co-variation of unilateral neglect with nonlateralised attentional functions. Recently, Posner has argued that there are two separate neural systems that influence the posterior attentional system which is presumed to be impaired in unilateral neglect, namely, the posterior system itself (located partly in the inferior parietal lobules) as well as a secondary modulatory sustained attention or vigilance system. This latter system is linked to the nor-epinephrine system, which is known to be more strongly represented in the right compared to the left hemisphere of the brain. If this hypothesis is true, then unilateral neglect should be improved by increasing activation of the sustained attention system. Eight patients suffering from chronic left unilateral neglect were trained to sustain their attention by a self-alerting procedure partially derived from Meichenbaum's self-instructional methods. Using a multiple-baseline-by-function design, as well as multiple-baseline-by-subject designs, statistically significant improvements in unilateral neglect as well in sustained attention were found following onset of sustained attention training, without corresponding improvements in control measures. Theoretical implications for the attentional underpinnings of unilateral neglect are discussed, as well as the rehabilitation implications of this training procedure.