National survey of Canadian occupational therapists' assessment and treatment of cognitive impairment post-stroke

Stroke rehabilitation: from diagnosis to therapy

Stroke remains a significant global health burden, necessitating comprehensive and innovative approaches in rehabilitation to optimize recovery outcomes. This paper provides a thorough exploration of rehabilitation strategies in stroke management, focusing on diagnostic methods, acute management, and diverse modalities encompassing physical, occupational, speech, and cognitive therapies. Emphasizing the importance of early identification of rehabilitation needs and leveraging technological advancements, including neurostimulation techniques and assistive technologies, this manuscript highlights the challenges and opportunities in stroke rehabilitation. Additionally, it discusses future directions, such as personalized rehabilitation approaches, neuroplasticity concepts, and advancements in assistive technologies, which hold promise in reshaping the landscape of stroke rehabilitation. By delineating these multifaceted aspects, this manuscript aims to provide insights and directions for optimizing stroke rehabilitation practices and enhancing the quality of life for stroke survivors.

Understanding Occupational Therapists' Knowledge and Confidence When Assessing for Spatial Neglect: A Special Issue Review

IMPORTANCE

Spatial neglect (SN)-failure to respond to stimuli on the side of the body contralateral to a poststroke lesion-is one of the most disabling impairments for stroke survivors, and 80% of stroke survivors may have undetected SN. Occupational therapists' evaluations should include determining the impact of poststroke SN.

OBJECTIVE

To investigate occupational therapists' confidence, knowledge, current practices, barriers, and facilitators when assessing for SN in adult stroke survivors.

DESIGN

A 30-item survey was created with guidance from stroke rehabilitation occupational therapists who reviewed the survey for face and content validity.

SETTING

Online survey.

PARTICIPANTS

Occupational therapist survey responders (N = 76).

OUTCOMES AND MEASURES

Self-report assessments were used to measure occupational therapists' confidence in identifying SN, SN assessment practices, and barriers to and facilitators of SN assessment. Knowledge of SN signs and symptoms, neuroanatomy, and clinical presentation were measured with a three-question quiz.

RESULTS

Eighty-one percent of the respondents reported a high level of confidence in identifying SN, and 70% reported routinely assessing for SN, with 81% using clinical observation rather than standardized tools as the primary assessment method. Barriers to SN assessment included time and resources.

CONCLUSIONS AND RELEVANCE

Most respondents, despite reporting high levels of confidence with routine SN assessments, did not use standardized SN measures and demonstrated suboptimal knowledge of SN. These results emphasize the need to increase clinical education about SN and its assessments. Plain-Language Summary: This study gathered baseline information on an underinvestigated topic-occupational therapists' education, confidence, current practices, barriers, and facilitators when assessing for spatial neglect in adult stroke survivors. The study results also contribute to future research on occupational therapists' current confidence and knowledge when assessing for spatial neglect.

Capacity building for providers of cognitive rehabilitation in Queensland: a needs analysis survey

Background Cognitive rehabilitation of people with traumatic brain injury is a complex and challenging area of practice. Practitioners working in cognitive rehabilitation require ongoing training to stay abreast of new research and best practice interventions. A needs analysis was conducted to inform the development of a capacity building program for cognitive rehabilitation providers. Methods A cross-sectional online survey of providers of cognitive rehabilitation services in Queensland collected data on demographic information, perceptions of knowledge, skills and confidence in cognitive rehabilitation, previously completed training, desired training opportunities and delivery methods, and barriers and facilitators to engaging in training. Results The 103 respondents included 67 occupational therapists, 17 speech pathologists, 12 psychologists and seven social workers with a broad range of practice experience. Participants perceived a need for further training, with executive function and functional cognition the most desired topics. The number of topics previously trained on was significantly correlated with levels of knowledge, skills and confidence (P   Conclusion Cognitive rehabilitation providers in Queensland reported a need for further training, delivered flexibly, with a focus on managing complex cognitive impairments.

Addressing ADL ability in people with poststroke cognitive impairments: A Danish survey of clinical practice

BACKGROUND

In Denmark, stroke represents a leading disability cause. While people with difficulties in performing activities of daily living (ADL) due to poststroke cognitive impairments are often referred to occupational therapy, limited knowledge is available on the nature of these services.

AIM/OBJECTIVE

To explore how Danish occupational therapists describe their practice when addressing decreased ADL ability in people with poststroke cognitive impairments in hospital and municipality settings.

MATERIAL AND METHODS

National, cross-sectorial, web-based public survey.

RESULTS

244 occupational therapists accessed the survey; 172 were included in the analysis. Most respondents could indicate the theory guiding their reasoning; half used standardised assessments. Regarding intervention, restorative and acquisitional models were preferred; specific strategies were identified. Intensity: 30-45 min 3-4 times/week in hospitals; 30-60 min 1-2 times/week in municipalities.

CONCLUSIONS

Therapists report to be guided by theory in their reasoning. Standardised assessments are used to a higher extend than previously reported. Still, the results invite critical reflections on correct use of assessment instruments, content and intensity of interventions, and how therapists keep themselves updated.

SIGNIFICANCE

The results document the need for practice improvements and may inform the definition of standard care in future trials.

Using Serial Trichotomization to Determine Fitness to Drive in Medically At-Risk Drivers

IMPORTANCE

Clinical tests that identify fit and unfit drivers with 100% sensitivity and specificity would reduce uncertainty and improve efficiency of occupational therapists performing comprehensive driving evaluations (CDEs).

OBJECTIVE

To examine whether serial trichotomization of clinical tests predicts pass-fail outcomes with 100% sensitivity and specificity in a sample of medically at-risk drivers and in drivers with and without cognitive impairment (CI) referred for a CDE.

DESIGN

Retrospective data collection and analysis of scores on the Montreal Cognitive Assessment; Trail Making Test, Part A and Part B; and the Useful Field of View® Subtests 1 to 3 and outcomes on the CDE (pass-fail or indeterminate requiring lessons and retesting). Receiver operating characteristic curves of clinical tests were performed to determine 100% sensitivity and specificity cut points in predicting CDE outcomes. Clinical tests were arranged in order from most to least predictive to identify pass-fail and indeterminate outcomes.

SETTING

A driving assessment clinic.

PARTICIPANTS

Among 142 medically at-risk drivers (M age = 69.2 yr, SD = 14.1), 66 with CI, 46 passed and 39 failed the CDE; 57 were indeterminate.

OUTCOMES AND MEASURES

On-road pass-fail outcomes.

RESULTS

Together, the six clinical tests predicted 62 pass and 49 fail outcomes in the total sample; 21 pass and 34 fail outcomes in participants with CI; and 58 pass and 14 fail outcomes in participants without CI.

CONCLUSIONS AND RELEVANCE

Serial trichotomization of clinical tests increases the accuracy of making informed decisions and reduces the number of drivers undergoing unnecessary on-road assessments. Plain-Language Summary: Clinical tests and their cut points that identify fit and unfit drivers vary substantially across settings and research studies. Serial trichotomization is one method that could help control for this variation by combining clinical test scores showing 100% sensitivity and specificity to identify pass (fit drivers) and fail outcomes (unfit drivers) and to reduce the number of drivers undergoing unnecessary on-road assessments.

Feasibility of the Perceive, Recall, Plan and Perform system of intervention for persons with brain injury in community-based rehabilitation: a pilot for a multiple-baseline design study

OBJECTIVES

This paper describes a pilot study investigating the feasibility of the Perceive, Recall, Plan and Perform (PRPP) system for persons with cognitive impairments after acquired brain injury in the context of community-based rehabilitation for older individuals.

DESIGN

The feasibility, acceptability and practicability of the research procedures were evaluated by exploring the effectiveness of the PRPP intervention with non-concurrent multiple baseline designs.

SETTING AND PARTICIPANTS

Three participants (63+years of age) from two health centres were included.

INTERVENTION

In the PRPP intervention, the occupational therapist (OT) supports the participant in applying cognitive strategies in everyday activities to enhance task mastery, with nine sessions of 45-60 min over 3 weeks.

PRIMARY AND SECONDARY OUTCOME MEASURES

The participants completed measurements of five everyday tasks in each phase as dependent variables. PRPP assessment stages 1 and 2 served as the primary and secondary outcome measures, respectively. The percentage of mastery of the tasks and the participants' application of cognitive strategies at baseline acted as a control and was therefore compared with the other phases within the participant. The Goal Attainment Scale and Barthel Index served as generalisation measures. The uncertainties and acceptability of the procedures were also investigated with a procedural checklist and qualitative statements reported in the procedures or noted in dialogue meetings with the conducting OTs.

RESULTS

The procedures were acceptable for the OT and the participants and were feasible if the steps in the research procedure were clearly understood. The target behaviour should be changed to the use of one task with five measurement points instead of measuring five tasks. This can enable the application of recommended analysis methods.

CONCLUSIONS

The outcomes of this study led to a change in the target behaviour and clarification of the research procedure for the planned PRPP intervention study.

TRIAL REGISTRATION NUMBER

NCT05148247.

A Survey of Canadian Physiotherapists' and Physiotherapy Students' Knowledge and Use of Executive Functioning Assessments in Clinical Practice

Purpose

This study examined what physiotherapists and physiotherapy students understand and know about executive functioning (EF), what EF outcome measures they use clinically, and whether their primary area of practice influences their assessment practices.

Method

An open online survey was distributed to registered members of the Canadian Physiotherapy Association, its various divisions, and colleges of physiotherapy within Canada that took approximately 15 minutes to complete and was available for 13 months. Pearson correlation was used to assess the relationship between subjective and objective understanding and knowledge of EF (UKEF) and a one-way multivariate analysis of variance was used to analyze differences in survey responses based on respondents' primary area of practice.

Results

A total of 335 respondents consented to participate (completion rate = 78.4%). There was a significant moderate positive correlation between subjective and objective UKEF (r = 0.43; 95% CI: 0.32, 0.54; n = 260; p < 0.001). Significant differences in survey responses were related to physiotherapists' primary areas of practice (i.e., musculoskeletal, neurological, cardiorespiratory, or multi-systems; F12,555.89 = 2.29, p = 0.008; Wilks Λ = 0.880; partial η2 = 0.042).

Conclusions

Respondents reported that they had good subjective UKEF, but this was only moderately correlated with objective UKEF.

Effectiveness of the Perceive, Recall, Plan and Perform intervention for persons with brain injury in community-based rehabilitation: protocol for a single-case experimental design with multiple baselines

INTRODUCTION

There is a need for standardised interventions in community-based rehabilitation to improve everyday performance for older adults with cognitive challenges due to acquired brain injury (ABI). The Perceive, Recall, Plan and Perform System (PRPP) of intervention has a growing research base. The intervention is suitable for any client with decreased performance in everyday tasks due to ineffective cognitive strategy application to enhance mastery in performance of needed or desired activities. There is no current evidence on the effectiveness of the PRPP intervention for this population.

PURPOSE

To describe a protocol for a clinical trial that investigates the effectiveness of the PRPP intervention in the context of community-based rehabilitation for persons (65+ years) with difficulties in task performance due to cognitive challenges after ABI.

METHODS AND ANALYSIS

A non-concurrent multiple baseline design across participants with systematic replications (n=6) will be used. Nine sessions of PRPP intervention will be applied by trained occupational therapists in two community-based rehabilitation units. The participants will complete five repeated measurements of everyday tasks as target behaviours. PRPP Assessment stages 1 and 2 serve as outcome measures at baseline, in the intervention period, in the postintervention period and in the follow-up phase. Mastery percentage of the tasks and the participants' application of cognitive strategies at baseline acts as a control and will be compared with the following phases within the participant. Delayed intervention phases act as a control between participants. Goal Attainment Scaling and the Barthel Index will serve as generalisation measures. Data will be analysed using systematic visual inspection of graphical data, descriptions of clinical significance and descriptive statistical analysis.

ETHICS AND DISSEMINATION

This trial, including the data management plan, is approved by The Norwegian Regional Ethics Committee (215391). Results will be published in congresses and scientific journals.

TRIAL REGISTRATION NUMBER

NCT05148247.

Identification and Use of Assessment Tools in Spanish Occupational Therapists: An Exploratory Study

The use of standardized assessment tools is essential for the occupational therapy intervention process to ensure clinical practice is appropriate and of high quality. This study aimed to explore which assessment tools Spanish occupational therapists use in their clinical practice. An ad hoc online questionnaire of 19 open and closed questions was used to collect information on assessment tools, socio-demographics, and academic background. The assessment tools were classified according to the main domains of occupational therapy using the last edition of the American Occupational Therapy Association framework. The survey was completed by 73 Spanish occupational therapists, of whom 86.3% were women; the median age was 31 years, and more than 60% treated people suffering from neurological and neurodegenerative disorders or worked in geriatric medicine. Of 147 assessment tools identified, those designed to assess activities of daily living, body functions, process skills, and motor skills were the instruments most frequently used. Specifically, the Barthel Index, Lawton Instrumental ADL Scale, Functional Independence Measure, Sensory Profile 2, and Mini-Examen Cognoscitivo were the tools most employed by Spanish occupational therapists. However, more than one third of the participants used assessment tools without knowing whether they were validated in the Spanish context and/or a specific target population. To our knowledge, this is the first time a study has examined the use and type of assessment tools in Spanish occupational therapists. Our results may constitute a positive step forward for developing strategies for enhancing evidence-based assessment in occupational therapy practice.

Occupational therapy for cognitive impairment in stroke patients

BACKGROUND

Cognitive impairment is a frequent consequence of stroke and can impact on a person's ability to perform everyday activities. Occupational therapists use a range of interventions when working with people who have cognitive impairment poststroke. This is an update of a Cochrane Review published in 2010.

OBJECTIVES

To assess the impact of occupational therapy on activities of daily living (ADL), both basic and instrumental, global cognitive function, and specific cognitive abilities in people who have cognitive impairment following a stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, four other databases (all last searched September 2020), trial registries, and reference lists.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that evaluated an intervention for adults with clinically defined stroke and confirmed cognitive impairment. The intervention needed either to be provided by an occupational therapist or considered within the scope of occupational therapy practice as defined in the review. We excluded studies focusing on apraxia or perceptual impairments or virtual reality interventions as these are covered by other Cochrane Reviews. The primary outcome was basic activities of daily living (BADL) such as dressing, feeding, and bathing. Secondary outcomes were instrumental ADL (IADL) (e.g. shopping and meal preparation), community integration and participation, global cognitive function and specific cognitive abilities (including attention, memory, executive function, or a combination of these), and subdomains of these abilities. We included both observed and self-reported outcome measures.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies that met the inclusion criteria, extracted data, and assessed the certainty of the evidence. A third review author moderated disagreements if consensus was not reached. We contacted trial authors for additional information and data, where available. We assessed the certainty of key outcomes using GRADE.  MAIN RESULTS: We included 24 trials from 11 countries involving 1142 (analysed) participants (two weeks to eight years since stroke onset). This update includes 23 new trials in addition to the one study included in the previous version. Most were parallel randomised controlled trials except for one cross-over trial and one with a two-by-two factorial design. Most studies had sample sizes under 50 participants. Twenty studies involved a remediation approach to cognitive rehabilitation, particularly using computer-based interventions. The other four involved a compensatory and adaptive approach. The length of interventions ranged from 10 days to 18 weeks, with a mean total length of 19 hours. Control groups mostly received usual rehabilitation or occupational therapy care, with a few receiving an attention control that was comparable to usual care; two had no intervention (i.e. a waiting list). Apart from high risk of performance bias for all but one of the studies, the risk of bias for other aspects was mostly low or unclear.  For the primary outcome of BADL, meta-analysis found a small effect on completion of the intervention with a mean difference (MD) of 2.26 on the Functional Independence Measure (FIM) (95% confidence interval (CI) 0.17 to 4.22; P = 0.03, I2 = 0%; 6 studies, 336 participants; low-certainty evidence). Therefore, on average, BADL improved by 2.26 points on the FIM that ranges from 18 (total assist) to 126 (complete independence). On follow-up, there was insufficient evidence of an effect at three months (MD 10.00, 95% CI -0.54 to 20.55; P = 0.06, I2 = 53%; 2 studies, 73 participants; low-certainty evidence), but evidence of an effect at six months (MD 11.38, 95% CI 1.62 to 21.14, I2 = 12%; 2 studies, 73 participants; low-certainty evidence). These differences are below 22 points which is the established minimal clinically important difference (MCID) for the FIM for people with stroke. For IADL, the evidence is very uncertain about an effect (standardised mean difference (SMD) 0.94, 95% CI 0.41 to 1.47; P = 0.0005, I2 = 98%; 2 studies, 88 participants). For community integration, we found insufficient evidence of an effect (SMD 0.09, 95% CI -0.35 to 0.54; P = 0.68, I2 = 0%; 2 studies, 78 participants). There was an improvement of clinical importance in global cognitive functional performance after the intervention (SMD 0.35, 95% CI 0.16 to 0.54; P = 0.0004, I2 = 0%; 9 studies, 432 participants; low-certainty evidence), equating to 1.63 points on the Montreal Cognitive Assessment (MoCA) (95% CI 0.75 to 2.52), which exceeds the anchor-based MCID of the MoCA for stroke rehabilitation patients of 1.22. We found some effect for attention overall (SMD -0.31, 95% CI -0.47 to -0.15; P = 0.0002, I2 = 20%; 13 studies, 620 participants; low-certainty evidence), equating to a difference of 17.31 seconds (95% CI 8.38 to 26.24), and for executive functional performance overall (SMD 0.49, 95% CI 0.31 to 0.66; P < 0.00001, I2 = 74%; 11 studies, 550 participants; very low-certainty evidence), equating to 1.41 points on the Frontal Assessment Battery (range: 0-18). Of the cognitive subdomains, we found evidence of effect of possible clinical importance, immediately after intervention, for sustained visual attention (moderate certainty) equating to 15.63 seconds, for working memory (low certainty) equating to 59.9 seconds, and thinking flexibly (low certainty), compared to control.

AUTHORS' CONCLUSIONS

The effectiveness of occupational therapy for cognitive impairment poststroke remains unclear. Occupational therapy may result in little to no clinical difference in BADL immediately after intervention and at three and six months' follow-up. Occupational therapy may slightly improve global cognitive performance of a clinically important difference immediately after intervention, likely improves sustained visual attention slightly, and may slightly increase working memory and flexible thinking after intervention. There is evidence of low or very low certainty or insufficient evidence for effect on other cognitive domains, IADL, and community integration and participation.  Given the low certainty of much of the evidence in our review, more research is needed to support or refute the effectiveness of occupational therapy for cognitive impairment after stroke. Future trials need improved methodology to address issues including risk of bias and to better report the outcome measures and interventions used.

A Nationwide Multi-Center Questionnaire Survey on the Real-World State and Clinical Management of Poststroke Dementia in Japan

Background:

Poststroke dementia (PSD) is a serious problem for stroke survivors. However, there is still limited data on the real-world state and clinical management of PSD worldwide, and several countries already have a super-aged society.

Objective:

We conducted a nationwide questionnaire survey to examine the real-world state and management of PSD in Japan.

Methods:

A survey was conducted in the top 500 Japanese hospitals regarding the number of stroke patients treated between July 2018 and August 2019. Thirteen questions regarding PSD were mailed to doctors responsible for stroke management.

Results:

Responses were obtained from 251 hospitals (50.2%). The chief doctors responsible for stroke management answered the questionnaires. The median numbers of patients admitted annually with stroke in the departments of neurology and neurosurgery in the hospitals were 281.0 (interquartile range [IQR], 231.8–385.3) and 253.5 (IQR, 210.0–335.3), respectively, and most hospitals were acute care hospitals. Executive dysfunction was the most common cognitive dysfunction (10.9%), followed by amnesia (9.5%) and apathy (4.1%). Surprisingly, many stroke survivors lived alone at home (23.7%). Montreal Cognitive Assessment was significantly uncommon compared to Mini-Mental State Examination (p < 0.01). Furthermore, objective evaluation tests for behavioral and psychological symptoms of dementia were not often performed. Cognitive rehabilitation treatments were performed more often and earlier than drug treatments. The first drug of choice for PSD was predominantly donepezil (79.1%), followed by galantamine (6.1%), cilostazol (4.9%), memantine (2.5%), and rivastigmine (1.8%).

Conclusion:

Our study provides real-world evidence for the state of clinical practice related to PSD in Japan.

Current practice of physical therapists in outpatient stroke rehabilitation: a cross-sectional survey in Baden-Württemberg and Thuringia / Arbeitsweise von Physiotherapeut*innen in der ambulanten Schlaganfallrehabilitation: eine Querschnittsumfrage in Baden-Württemberg und Thüringen

Objective

Guidelines recommend task-oriented training and the use of standardized assessments to improve stroke-related mobility deficits. However, the German outpatient physical therapy prescription catalogue does not include these recommendations resulting in a possible gap between guideline recommendations and clinical practice. Therefore, the purpose of this study was to describe physical therapy practice patterns of stroke-related mobility deficits in the outpatient setting exemplified by the states Baden-Württemberg and Thuringia.

Methods

Using an online survey, physical therapists treating people with stroke in outpatient settings in Baden-Württemberg and Thuringia were recruited. The questionnaire was developed using a multi-step procedure. Using a case vignette and open-ended questions, preferred evaluation and treatment methods were assessed. Data were analyzed using content analysis and descriptive statistics.

Results

Data from 63 physical therapists were included in the analysis. Answers to the open questions showed a wide range of different citations. Of 186 citations on evaluation methods, 28 (15,1 %) were classified as “standardized assessments”, while 158 citations (84,9 %) were classified as “basic physical therapy evaluation (non-standardized)”. Standardized assessments were cited by 25% of participants. Of 182 citations on treatment methods, 69 (35,2%) were classified as “traditional therapies”. These traditional therapies were cited by 81 % of participants. Task-oriented training was not cited.

Discussion

Despite the small sample size our data confirm the insufficient guideline use in German physical therapy and contribute results on practice patterns in outpatient stroke settings. These results will be used to initiate theory-based implementation strategies aiming to optimize physical therapy for people with stroke.

Results of a UK-wide vignette study with occupational therapists to explore cognitive screening post stroke

Background/Aims

There is a paucity of evidence in the UK regarding cognitive screening performed by occupational therapists and whether, and how, cognitive impairments are identified and assessed. The aim of this study was to identify current occupational therapy practice for the assessment of cognitive problems in patients following stroke.

Methods

Occupational therapists were invited to complete an online vignette study. Participants were asked to: identify any presenting cognitive problems; decide whether to complete cognitive assessments; and list any assessments they would use. Data were analysed using descriptive analysis.

Results

A total of 53 occupational therapists from across the UK participated. Participants identified key cognitive issues, but some problems, such as apraxia and attention, were overlooked. A large number of potential assessments were suggested, the most common being the Montreal Cognitive Assessment and Oxford Cognitive Screen.

Conclusions

The variation found in occupational therapists' recognition and assessment of cognitive problems has the potential to impact on management and rehabilitation in stroke services, survivor outcomes, education and research.

Behaviour Change Domains Likely to Influence Occupational Therapist Use of the Canadian Occupational Performance Measure

INTRODUCTION

Occupational therapists have shown low adoption rates for many evidence-based practices. One such practice is the limited uptake of standardized outcome measures such as the Canadian Occupational Performance Measure. Use of this measure has not consistently translated into practice despite decades of encouragement. Theory-based approaches to understanding healthcare provider behaviour change are needed if we are to realize the goal of attaining practice that is in keeping with evidence. This study utilized the Theoretical Domains Framework, a theory-based approach for understanding barriers to evidence-based practice, in order to increase our understanding of the limited uptake of the Canadian Occupational Performance Measure in occupational therapy practice.

METHODS

Theoretical Domains Framework methods were followed. First, primary data was collected from occupational therapists through semistructured interviews that focused on key behaviour change domains as they related to the use of the Canadian Occupational Performance Measure. Two independent researchers coded interview data into domains, derived belief statements from the data, and used belief strength, conflict, and frequency to determine the more and less influential domains for using the Canadian Occupational Performance Measure.

RESULTS

Interviews with 15 practicing occupational therapists across a range of practice areas yielded six key behaviour change domains for increasing the use of the Canadian Occupational Performance Measure. The more relevant domains were Social influences, Social professional role and identity, Beliefs about consequences, Beliefs about capabilities, Skills, and Behavioural regulation). The other eight domains were found to be less relevant.

CONCLUSION

We identified important domains and beliefs that influence the use of the Canadian Occupational Performance Measure by occupational therapists. Results inform our understanding of the use of this measure in practice and identify potential targets for behaviour change interventions.

Identifying clinicians' priorities for the implementation of best practices in cognitive rehabilitation post-acquired brain injury

PURPOSE

To identify clinicians' perceptions of current levels of implementation of cognitive rehabilitation best practices, as well as individual and consensual group priorities for implementing cognitive rehabilitation interventions as part of a multi-site integrated knowledge translation initiative.

METHOD

A two-step consensus-building methodology was used, that is the Technique for Research of Information by Animation of a Group of Experts (TRIAGE), including a cross-sectional electronic survey followed by consensual in-person group discussions to identify implementation priorities from a list of evidence-based practices for cognitive rehabilitation following traumatic brain injury and stroke. Thirty-eight professionals from three rehabilitation teams (n = 9, 13 and 16) participated, including neuropsychologists, occupational therapists, speech-language pathologists, educators, clinical coordinators and program managers. Descriptive statistics were used to document the perceived levels of implementation as well as individual and consensual group priorities.

RESULTS

Most of the best practices (81-100%) were perceived as at least partially implemented by a minimum of 50% of the participants but only 20-25% of the practices were considered fully implemented. Findings suggest that current practices are mostly consistent with general cognitive rehabilitation principles suggested in guidelines but that further efforts are needed to support the application of specific cognitive rehabilitation strategies and interventions. Executive function and self-awareness retraining, as well as interventions promoting the generalization of skills, were among the highest implementation priorities. Consensual in-person group discussions, included as part of the TRIAGE process, also helped to define and operationalize these best practices into more specific intervention components according to the teams' needs and priorities.

CONCLUSIONS

TRIAGE consensus-building methodology can be used to engage stakeholders and support clinicians' decision-making regarding the identification of implementation priorities in cognitive rehabilitation post-ABI in order to tailor the implementation process to local needs.IMPLICATIONS FOR REHABILITATIONThe Technique for Research of Information by Animation of a Group of Experts (TRIAGE) can be used to support clinicians' decision-making regarding the identification of implementation priorities in cognitive rehabilitation post-ABI.The combination of individual consultations followed by consensual in-person group discussions, as part of the TRIAGE process, may help clinicians in defining and operationalizing best practices into more specific intervention components to implement.Effective implementation strategies are needed to support the use of specific cognitive rehabilitation interventions in prioritized areas, such as executive function and self-awareness retraining, as well as generalization of skills.Some differences in clinicians' perceived priorities point up the importance of tailoring implementation to local needs and contexts from the early stages in the process.

Evidence based practice and knowledge translation: A survey of Australian occupational therapy practice with clients experiencing neurocognitive impairments

INTRODUCTION

The clinical practice patterns and use of research evidence by Australian occupational therapists working with clients experiencing neurocognitive impairments has not been surveyed for nearly 10 years. This survey aimed to evaluate the current status of occupational therapy practice and evidence use and provide recommendations for ongoing evidence translation.

METHODS

An online survey of occupational therapists working in Australia was conducted over four months targeting registered clinicians working with adults experiencing neurocognitive impairments.

RESULTS

191 occupational therapists from a wide range of clinical practice areas, with a significant level of experience completed the survey. Functional retraining (n = 180, 94%), compensatory training (n = 173, 91%) and task/environmental modifications (n = 161, 84%) were the most commonly reported intervention techniques, while more targeted interventions such as context-sensitive training (n = 54, 28%), positive behaviour supports (n = 42, 22%) and metacognitive strategy training (n = 37, 19%) were used less frequently. Half the respondents were aware of current research evidence and suggested a wide range of strategies supporting evidence translation. Traditional barriers of limited time, access and skills to interpret research were also reported.

CONCLUSION

Consistent with earlier surveys most occupational therapists continue to use a functional/compensatory approach to cognitive rehabilitation, with an increasing number of therapists using specialist cognitive interventions. The current challenge for occupational therapists is embedding specialist techniques into occupation-based intervention. Knowledge translation and implementation strategies will be a critical component to achieving this.

[Overview of the assessment practices of occupational therapists working in Quebec]

BACKGROUND.

In occupational therapy practice, client assessments are essential for establishing treatment priorities and determining the effectiveness of interventions. However, occupational therapists' assessment practices are not well documented.

PURPOSE.

This work aimed to provide an overview of the assessment practices of Quebec occupational therapists based on the person-environment-occupation components and clienteles.

METHOD.

A cross-sectional survey was conducted using an online survey that was sent to occupational therapists in Quebec.

FINDINGS.

In paediatrics, occupational therapists tend to use standardized tools to assess physical and neurological abilities. Adult assessment focuses mainly on physical abilities and productivity. For seniors, assessment focuses mainly on functional aspects (physical abilities, personal care, and home safety) and screening for cognitive difficulties.

IMPLICATIONS.

Occupational therapy assessment mostly focuses on physicial abilities. To ensure a holistic approach, more occupational and environmental components should be included in the assessment practices.

Attributes of evidence-based occupational therapists in stroke rehabilitation

BACKGROUND.

A better understanding of the features characterizing expert evidence-based occupational therapists in stroke rehabilitation is needed to inform the design of educational and knowledge translation interventions aimed at addressing research-practice gaps.

PURPOSE.

The study aimed to identify the attributes of evidence-based occupational therapy stroke rehabilitation experts from the perspective of their peers.

METHOD.

Forty-six occupational therapy clinicians and managers completed an online questionnaire asking them to nominate "outstanding" and "expert evidence-based" occupational therapists in stroke rehabilitation and to explain their choices. A thematic analysis of respondents' statements was conducted.

FINDINGS.

Both outstanding and expert evidence-based occupational therapists were perceived to be motivated self-learners; to have extensive knowledge, skills, and experience; to act as scholarly practitioners; to achieve superior client outcomes; and to work in specialized settings.

IMPLICATIONS.

The development of future strategies supporting occupational therapy students and clinicians to become lifelong learners should take into account key attributes of expertise, such as motivation for continuous learning and professional development.

The conflicted practice: Municipal occupational therapists' experiences with assessment of clients with cognitive impairments

BACKGROUND

The practice of Norwegian occupational therapists (OTs) in municipal practice is a little explored area and with the Coordination Reform Act from 2012, Norwegian OTs in municipal practice have received responsibilities concerning clients with cognitive impairments. The aim of this study was to explore municipal OTs experiences with assessment of clients with cognitive impairments.

METHOD

Fourteen individual interviews with OTs who worked with clients with cognitive impairments, were conducted. An inductive thematic analysis, using text condensation and coding, was performed.

RESULTS

The results revealed three themes; power of occupation, advantages and disadvantages of assessments used and the need for competencies within municipal services. The participants emphasized using observation in the assessment process and reflected on pros and cons of the standardized assessment tools they used. They expressed a need for competence development, although it was difficult to prioritize to do so.

CONCLUSION

This study illustrated a conflicted practice related to choices OTs make in their practices. They valued the importance of working occupation based, however, they chose to use impairment based standardized assessments. They expressed a need to engage in professional development, but due to heavy workloads, the limited power they experienced and lack of knowledge, this was difficult.

Development and Pilot Testing of a Measure of Potential Barriers and Facilitators to the Use of a Standardized Assessment Tool

INTRODUCTION

Standardized assessment tools (SATs) are essential to evidence-based assessment practices. Identifying what impedes clinicians' use of a SAT can help tailor strategies promoting its use in clinical practice. This article presents the development of the "Measure of potential barriers and facilitators to the Use of a Standardized assessment Tool (MUST)" questionnaire. Preliminary findings are also reported from pilot testing in which the MUST was used to investigate occupational therapists' (OTs) perceptions of potential barriers and facilitators to the use of the Activities of Daily Living Profile (ADL Profile), a SAT evaluating independence in everyday activities of cognitively impaired adults.

METHODS

The MUST was administered to 41 OTs attending continuing education workshops on the ADL Profile. Internal consistency was explored using Chronbach alpha. Descriptive statistics were used to analyze scores for each statement.

RESULTS

Internal consistency for subscales related to clinicians' characteristics (α = 0.7) and to the SAT's characteristics (α = 0.8) were adequate but lower for the subscale related to the clinical setting (α = 0.6). OTs' perceptions of potential barriers were associated with: OTs' perceived self-efficacy; ADL Profile's applicability to OTs' clienteles; ADL Profile's compatibility with values promoted in the work setting and with clients' preferences; limited peer support; time to implement the ADL Profile.

DISCUSSION

The MUST, a theory-informed questionnaire, may prove useful in identifying potential barriers needing to be addressed in continuing education training promoting the use of SATs by clinicians. The MUST is quick to administer and initial testing provides support for its internal consistency.

Assessment of clients with cognitive impairments: A survey of Norwegian occupational therapists in municipal practice

BACKGROUND

With the Coordination Reform Act initiated in 2012, Norwegian occupational therapists in municipal practice have been given responsibilities concerning clients with cognitive impairments. With emphasis on supporting best practice, the aim was to investigate the practice of Norwegian municipal occupational therapists (OTs) in their assessment of clients with cognitive impairments.

METHOD

An online questionnaire was used to collect data from 497 of 1367 OTs in Norwegian municipalities (RR = 36%) Results: The most frequently used methods were informal interviews (91%), observations (91%) and standardized assessments (73%). The most frequently used standardized assessments were the Clock Drawing test (60%) and the Mini Mental State Examination (MMSE 59%). The most common reasons for using standardized assessments were to get a better foundation for initiating interventions (74%), to get more reliable results (64%) and to measure the effect of interventions (47%). The most common reasons for not using standardized assessments were that they did not have competence (49%) or that they did not have access to the materials (40%).

CONCLUSION

The results indicate that there are challenges when it comes to the methods and standardized assessments used. These findings invite further research on enabling municipal OTs to move further towards evidence-based practice.

Cognitive Assessment Trends in Home Health Care for Adults With Mild Stroke

OBJECTIVE

This article describes current trends in cognitive assessment use for adults with mild stroke by home health practitioners in the United States.

METHOD

Participants were 56 home health occupational therapists and occupational therapy assistants. A self-administered survey about use of cognitive assessment tools in home health care and influences on their use was conducted.

RESULTS

Ninety-six percent of participants assessed cognition in adults with mild stroke. Nonstandardized assessments were the most widely used method for evaluating cognition in the home health setting. Influences such as specialized training in specific assessments, confidence, and productivity requirements may have affected the practitioners' cognitive assessment decisions in home health care.

CONCLUSION

Although cognitive assessments are widely used in home health care, occupational therapy practitioners are selecting nonstandardized assessments most frequently to assess cognition.

Survey of cognitive rehabilitation practices in the state of Kuwait

Background Rehabilitation professionals must be astute at recognizing, assessing, and treating individuals with cognitive deficits. No research is available to examine cognitive rehabilitation practices applied to individuals with neurological conditions in Kuwait.

OBJECTIVES

To identify the use of cognitive assessments, the availability of resources, and the barriers to cognitive rehabilitation practices in Kuwait. Methods Face-to-face interviews were conducted with health care professionals working with adult individuals with neurological conditions. These professionals included occupational therapists, speech-language pathologists, psychiatrists, and neurologists. Results The most commonly used cognitive based assessments are MMSE (41%), and MoCA and LOTCA (15.2%). The only clinical assessment used is the Line-Bisection Test (2.2%). The most used occupation-based assessments are FIM (6.5%), COPM (4.3%), the Interest Checklist (2.2%), and the Barthel Index (2.2%). Resources related to cognitive rehabilitation in Kuwait that are unavailable to practitioners include journal clubs (91%), special interest groups (89%), and continuing education programmes (82.6%). Barriers to cognitive rehabilitation practice included lack of sufficient funds for continuing education, lack of time, lack of standardized assessments, and lack of inter-professional teamwork. Conclusion Many adults in Kuwait live with cognitive impairment. There is a need to develop appropriate evidence-based cognitive rehabilitation clinical guidelines in Kuwait.

Identifying the components of clinical vignettes describing Alzheimer's disease or other dementias: a scoping review

Background

Clinical vignettes are often used to elicit information about health conditions in research studies. This review summarizes the components of clinical vignettes describing Alzheimer’s disease (AD) or other dementias. The purpose is to provide recommendations for the development of standardized vignettes that may be used in future studies.

Methods

MEDLINE, EMBASE, PsycINFO, ASSIA, CINAHL were searched from their inception to June 2014. Primary English-language studies employing vignettes to describe AD or similar disorders (including other dementias and Parkinson’s disease) were included in the review. Included studies had to describe the content of the vignettes in the published manuscripts. The characteristics of the included studies and the vignettes were extracted in tabular form and summarized qualitatively.

Results

Forty-two studies were included in the review. Twenty-four of the studies contained at least one AD vignette, 11 had vignettes focusing on non-AD dementias, and seven contained vignettes describing conditions other than dementia. In total, 58 vignettes were obtained from the 42 included studies.

Conclusions

Key aspects to consider when constructing vignettes for AD or other dementias include writing the vignettes from a third-person perspective and presenting hypothetical patients as being at least 65 years of age. Researchers should develop standardized vignettes for use across studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-015-0179-x) contains supplementary material, which is available to authorized users.

Identification and assessment of functional performance in mild cognitive impairment: a survey of occupational therapy practices

BACKGROUND/AIM

Despite the amount of research evidence pointing to functional changes experienced by individuals with mild cognitive impairment (MCI), we still do not understand how occupational therapists are currently addressing these concerns. Thus, we designed a national study to investigate Canadian occupational therapists practices with this clientele.

METHODS

We conducted a Canada-wide online survey to investigate occupational therapists' practices with clients with potential MCI. Clinicians were prompted by a case vignette that described two clients: one vignette included cues associated with amnestic MCI (aMCI), the other non-amnestic MCI (naMCI). Specifically, clinicians were asked to identify potential concerns and to indicate the screening and assessment tools they would use in clinical practice.

RESULTS

Two hundred and eighty-five participants met the inclusion criteria and were included in the final analysis. The average clinician age was 38.6 (SD = 10.3), 92% were female and 71.2% worked full-time. Almost all clinicians identified a concern in both vignettes, with cognitive concerns being identified more frequently than functional concerns [i.e. Instrumental Activities of Daily Living (IADL) concerns]. In terms of assessment practices, 18 standardised IADL assessments and 10 standardised cognitive assessments have been reported.

CONCLUSION

Encouragingly, almost all clinicians identified a concern. However, some are still missing the IADL cues. Moreover, the lack of consensus in terms of which assessment practices to employ indicates that clinicians might benefit from guidelines in this area of practice.

Assessment practices of Canadian occupational therapists working with adults with mental disorders

Background.

Little is known about assessment practices of occupational therapists working with adults with mental disorders.

Purpose.

This study investigates the assessment practices of occupational therapists working with clients experiencing symptoms of schizophrenia or major depressive disorder.

Method.

We conducted a national survey of assessment practices using case vignettes of hypothetical clients.

Findings.

From 343 vignettes completed by 286 respondents, 68.4% included the use of one or more standardized measures during treatment. Measures were rarely repeated. Results showed that the Canadian Occupational Performance Measure was the most frequently used, suggesting a focus on assessing global functioning, while the Assessment of Motor and Process Skills was listed as the most desired assessment tool. Implementing nonstandardized assessments was common.

Implications.

Despite wide variations in occupational therapists’ assessment practices, the use of standardized assessments is prevalent. The low rate of repeated measures (0% to 25.9%) suggests a need to better monitor changes and treatment outcomes.

What is the evidence for the effectiveness of interventions to improve occupational performance after stroke?

Although rapid progress has been made in generating evidence to support occupational therapy interventions for clients who survive a stroke, the areas receiving research attention show a lack of balance that researchers should correct in order to better guide practice.

Executive functioning: a scoping review of the occupational therapy literature

BACKGROUND

Increasingly recognized as an important factor in the performance of complex, goal-directed tasks, executive functioning is understood in different ways across disciplines.

PURPOSE

The aim was to explore the ways in which executive functioning is conceptualized, discussed, described, and implied in the occupational therapy literature.

METHOD

A scoping review of the occupational therapy literature was conducted following Levac, Colquhoun, and O'Brien's (2010) recommended methodology.

RESULTS

Executive functioning is described both as a set of performance component skills or processes and as the executive occupational performance inherent in complex occupations. Executive functioning is implicit in occupational performance and engagement, and some health conditions seem to be commonly associated with impaired executive functioning. Assessing executive functioning requires dynamic occupation- and performance-based assessment. Interventions targeting executive functioning are grounded in metacognitive approaches.

CONCLUSION

Executive functioning is a complex construct that is conceptualized with considerable variance within the occupational therapy literature, creating barriers to effective service delivery.

Cognitive assessment across the continuum of care: the importance of occupational performance-based assessment for individuals post-stroke and traumatic brain injury

BACKGROUND/AIM

When working with individuals following stroke or traumatic brain injury, an important role of the occupational therapist is to assess the impact of cognitive impairment on their ability to engage in occupations and resume important life roles. The aim of this study was to survey therapists' reasons for selection of and challenges with using various cognitive assessment approaches, across the continuum of care, when working with individuals following stroke and traumatic brain injury.

METHODS

A cross-sectional survey, completed via post or online, with responses from 209 Australian occupational therapists was conducted. Participants included clinicians working in acute, inpatient rehabilitation and community settings.

RESULTS

Occupational performance-based assessments were ranked as the most important assessment method, with 69% of participants reporting using these assessments for more than 75% of their clients with cognitive impairment. Participants identified the lack of quantitative data provided by these assessments as a frequent challenge. The identification of cognitive deficits was the highest ranked reason for using cognitive screens and batteries. Challenges identified with using cognitive screens and batteries included difficulty linking assessment results to occupational performance, and difficulty using results to generate intervention strategies. The majority of participants reported using a combined approach to assessment, and used screens and batteries to support findings of occupational performance-based assessments.

CONCLUSIONS

Targeted efforts to further incorporate standardised occupational performance-based methods into clinical practice, research, and ongoing professional development is required to enhance occupational therapy services when working with individuals with cognitive impairment.

From What We Know to What We Do: Translating Stroke Rehabilitation Research into Practice

Despite the recent advances in stroke rehabilitation research, the translation of research evidence into practice remains a challenge. The purpose of this article is to communicate practical experience and describe research methodologies used to promote change and implementation of stroke rehabilitation research in three international settings. In England, the development of an evidence-based consensus document, combined with qualitative and quantitative methods, was used to promote practice change in community-based stroke services. The Canadian research program involved synthesis of evidence, creation of user friendly information, and development of multimodal knowledge transfer strategies to promote change at an individual clinician level. Australian researchers followed a multistep process, involving audit and feedback, identification of barriers, and tailored education to improve implementation of one clinical guideline recommendation. Reducing the evidence–practice gap requires the development of active management strategies. This article highlights the importance of close collaboration between stakeholders – both in terms of the transfer of evidence into clinical practice and for optimizing future Phase IV implementation research endeavours.