Evaluation of evidence within occupational therapy in stroke rehabilitation

Occupational therapy in rehabilitation of complex patients: protocol for a superiority randomized controlled trial

Patient-centered, interprofessional occupational therapy is feasible in complex patients in the early phase of rehabilitation, and it contributes to meet needs in the domains of self-care, productivity, and leisure, promoting social role. We planned this single-center single-blind two-arm parallel individual patient randomized controlled trial, to verify the superiority of interprofessional experimental occupational therapy (EOT) compared to standard rehabilitation (SR) in producing higher levels of patients' social participation assessed by the Reintegration to Normal Living Index. EOT is a patient-centered, hospital/home-based rehabilitation intervention based on the Canadian Model of Occupational Performance and Engagement. This appropriately powered study will provide evidence regarding the effectiveness of EOT on the recovery of social participation in the critical transition of complex patients from hospital to the home setting.

Implementing and Evaluating a Mobile Phone-Supported and Family-Centered Rehabilitation Program for People With Stroke in Uganda (F@ce 2.0): Protocol for a Randomized Controlled Trial

BACKGROUND

Stroke is a global societal challenge. Annually, 13 million people experience stroke, and the prevalence of stroke is increasing in low-income countries; hence, accessible rehabilitation needs to be developed. Information and communication technology can help by providing access to rehabilitation support through information, self-evaluation, and self-management of rehabilitation. The F@ce 2.0 rehabilitation program provides support in goal-setting and problem-solving strategies through phone calls from the interventionist twice a week and daily SMS text message reminders over 8 weeks to improve performance in valued activities in everyday life. Our hypothesis is that F@ce 2.0 will increase functioning in daily activities and participation in everyday life as well as improve performance and satisfaction in valued daily activities and self-efficacy (ie, confidence in own ability to perform activities) among people living with the consequences of stroke.

OBJECTIVE

This study aims to implement F@ce 2.0, a mobile phone-supported and family-centered rehabilitation program, and evaluate its effects on performance in daily activities and participation in everyday life in comparison to ordinary rehabilitation among persons with stroke and their family members in Uganda. An additional aim is to explore experiences of participating in F@ce 2.0 and plausible mechanisms of impact that might explain the potential effects of F@ce 2.0.

METHODS

A randomized controlled trial will be conducted to compare the outcomes of the F@ce 2.0 group and a control group receiving ordinary rehabilitation. Health care professionals will recruit 90 clients from both urban and rural areas. The primary outcomes for persons with stroke are perceived performance in daily activities assessed using the Canadian Occupational Performance Measure and self-efficacy assessed using the Self-Efficacy Scale; for family members, the primary outcome is caregiver burden evaluated using the Caregiver Burden Scale. Descriptive statistics will be used to present characteristics and outcomes at 3 and 6 months. All statistical analyses comparing the outcomes at the different time points between the F@ce 2.0 and control groups will be performed using intention-to-treat analysis. Qualitative interviews will be used to explore the experiences of persons with stroke and their family members participating in F@ce 2.0, using a grounded theory approach to data collection and analysis. A process evaluation will be conducted using a single-case study design with mixed methods to explore the implementation process.

RESULTS

Recruitment and data collection in the randomized controlled trial were initiated in January 2022 and have been completed. The intervention has been provided to 51 participants in the intervention group. Interviews of persons with stroke, family members, and health care professionals have been conducted. Data analysis will be performed during autumn 2024 and spring 2025.

CONCLUSIONS

This study will provide evidence of the plausible effects of F@ce 2.0 and the process of implementing the program in low-income countries.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/60955.

Practice educators' emphasis on research in supervision of occupational therapy students

BACKGROUND

One approach to promote students' use of research in future practice involves integrating students' research use in supervision during practice placements. Studies examining this aspect of supervision in practice placements are lacking.

AIM

To explore how practice educators perceive and emphasise research in their supervision of occupational therapy students during practice placements.

MATERIALS AND METHODS

A qualitative study was conducted. A purposive sample was recruited, consisting of participants from community-based health services and hospitals in Norway. We conducted three focus groups and one individual interview with occupational therapists (n = 9). The qualitative data analysis was based on interpretive description.

RESULTS

We identified four themes: 'emphasis on research in supervision of students'; 'practice educators' research competence and awareness of research'; 'institutionalisation of research use in everyday practice'; and 'communication and cooperation between education and practice regarding research'. Despite highlighting several benefits of research use, the practice educators focused rarely on students' research use in practice placements. Conclusions and significance: Cooperation between practice educators and faculty members regarding students' training in research use seems essential. Practice educators may need additional training in how research should be emphasised in supervision.

An occupation-based intervention in patients with hand-related disorders grouped using the sense of coherence scale-A randomized controlled trial

STUDY DESIGN

A nonblinded randomized controlled trial.

INTRODUCTION

Occupation-based interventions are superior to physical exercise-based interventions in patients with activity limitations. However, only a few studies have examined the effect in patients with hand-related disorders. Patients recover heterogeneously, which could be due to personal factors, such as sense of coherence (SOC).

PURPOSE OF THE STUDY

To investigate the effectiveness of an occupation-based intervention for patients with hand-related disorders and whether SOC can give an indication of the expected effects.

METHODS

A total of 504 patients were stratified into three SOC groups and then randomized to either an occupation-based intervention, including physical exercises (OBI) or a physical exercise-based occupation-focused intervention. The primary outcome, functioning, was measured using the Disability of the Arm, Shoulder and Hand questionnaire. Primary endpoint was at three months. Patients were followed up for a year.

RESULTS

No significant difference was found in primary outcome analysis. Nevertheless, patients receiving OBI had a statistically significant and greater change in satisfaction with their occupational performance at one, two, and three months follow-up. Patients with a weak SOC had worse functioning and lower health-related quality of life than those in the other groups, at all times.

CONCLUSIONS

OBI as delivered in this study was not superior to physical exercise-based occupation-focused intervention in this patient group. However, in taking a client-centered approach, we recommend that OBI be based on individual needs, given that patients had a statistically greater change in score regarding satisfaction with their occupational performance. It is evident that patients with a weaker SOC have a lower level of functioning. This knowledge should inform clinical practice.

Activities in Daily Living: The development of a new client-centred ADL intervention for persons with stroke

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.

Work Potential and Work Performance during the First Try-Out of the Person-Centred Return to Work Rehabilitation Programme ReWork-Stroke: A Case Study

BACKGROUND

This case study explores changes in work potential and work performance for ten people who worked before their stroke while participating in the ReWork-Stroke programme. It describes measures performed by the occupational therapists to enhance work potential and work performance and the participants' level of work re-entry nine months after the start of their work trial.

METHODS

Ten people who had experienced a mild or moderate stroke participated. Changes were assessed using the Worker Role Interview and the Assessment of Work Performance. Logbooks relating to work potential and work performance were analysed using content analysis.

RESULTS

The participants' work potential was in general supportive to returning to work at baseline and remained so at the three-month follow-up. Most changes occurred in the environmental factors regarding the participants' belief that adaptations at the workplace would make re-entry possible. Changes concerning work performance were predominately in a positive direction. Seven of the participants returned to paid work.

CONCLUSION

The ReWork-Stroke programme seems promising for promoting changes in work potential, work performance, and return to paid work. However, further studies are needed to evaluate changes in work potential and work performance and the programme's effectiveness for increasing work re-entry for people who have had stroke.

Client-centred practice in Scandinavian contexts: A critical discourse analysis

Background: The concept of client-centred practice is an essential element of occupational therapy (OT), but there is a lack of a clear and shared definition of the concept in Scandinavia (Norway, Sweden and Denmark). This may complicate the articulation, discussion, development and implementation of client-centredness in OT practices.Aim: The purpose of this study was to investigate and discuss current understandings of client-centred practice in Scandinavian contexts.Material and method: The study was based on a social constructivist research approach in which Fairclough's critical discourse analysis was applied. The analysis was based on six documents published in Scandinavian OT journals and four documents published in Scandinavian Journal of OT.Results: In Scandinavian contexts, the concept of client-centred practice was articulated in three overall discourses: a client, collaborative and practice discourse. The practice discourse was the most prominent and the source of the other discourses.Conclusions and significance: Occupational therapists (OTs) in the Scandinavian countries have conceptual understandings of client-centred practice that potentially provide the basis for knowledge sharing and collaboration between OT communities. However, the study also found that client-centred practice may not yet be firmly established in all OT practices in Scandinavia.

Analysis of the occupational therapist's professional identity when working in acquired brain injury rehabilitation within a municipal service

Background

Changes in rehabilitation pathways are reducing the amount of time patients spend in hospital, resulting in an earlier return to municipal care. Studies show that occupational therapists find working with patients with acquired brain injury to be complex and that, in some situations, they fail to believe in their own professional expertise. This qualitative study aimed to explore how the professional expertise of occupational therapists working in acquired brain injury rehabilitation within a municipal service is understood.

Methods

One monoprofessional focus group interview with occupational therapists and five focus group interviews with professionals from municipal interprofessional rehabilitation coordinating units formed the basis for the study. Data were analysed using systematic text condensation.

Results

A holistic view and strategically selected areas of expertise were found to characterise the work of occupational therapists in the municipal setting. A composed base of knowledge enables occupational therapists to be rehabilitators while working in collaboration with multiple professional partners.

Conclusions

Expertise in the areas of adaptation, assistive devices and cognition are considered to be valuable in acquired brain injury rehabilitation in a municipal setting. A practical synthesis of knowledge, transprofessional collaboration and role release enable the occupational therapist to act as a multifarious rehabilitator.

Feasibility of increasing the dosage of inpatient occupational therapy and physiotherapy rehabilitation via independent tasks and exercises: 'My Therapy'

INTRODUCTION

The dosage of occupational therapy and physiotherapy positively correlates with rehabilitation patient and health service outcomes. Nevertheless, increasing the dosage during inpatient rehabilitation without additional resources can be challenging. This study aimed to determine feasibility of increasing the dosage of inpatient occupational therapy and physiotherapy rehabilitation with independent tasks and exercises outside of supervised sessions, the 'My Therapy' programme.

METHODS

A two-group, quasi-experimental, pre-post-design examined feasibility of delivering My Therapy in addition to usual care, compared to usual care alone, for hospitalised musculoskeletal and frail older rehabilitation patients. My Therapy was prescribed by the occupational therapist and physiotherapist. A booklet was provided with an individually tailored set of tasks and exercises that were a sub-set of routine therapy, to be practised safely, effectively and independently outside of supervised sessions. The primary outcome was feasibility of My Therapy implementation to achieve at least 70% adherence. Secondary outcomes were self-reported daily My Therapy participation (minutes), total daily rehabilitation participation (minutes), adverse events, length of stay, 10-metre walk speed, FIM scores and discharge destination.

RESULTS

Participation in My Therapy was achieved by 72% (83/116) of the My Therapy group, who averaged 14 min (SD 14) of daily practice outside of supervised sessions. Total daily rehabilitation participation was 177 min (SD 47) for My Therapy participants (n = 116) and 148 min (SD 88) for usual care participants (n = 89); mean difference 30 min (p = .00). A minimal clinically important difference in FIM was achieved for a significantly higher portion of the My Therapy group (22%, n = 26) compared to usual care (10%, n = 9; p = .02). There were no adverse events, safety concerns or group differences for other secondary outcomes.

CONCLUSION

My Therapy was a feasible and safe way to increase the dosage of inpatient occupational therapy and physiotherapy rehabilitation via independent practice. Clinical Trial Registry: ACTRN12616000691448.

Self-perceived occupational performance of community-dwelling adults living with stroke

Background.

Stroke has long-term consequences for functional performance of daily activities. Evaluating client-perceived occupational performance provides insight for designing stroke-specific programs supporting home and community participation.

Purpose.

This study describes the personal characteristics and self-perceived occupational performance in community-dwelling adults with stroke.

Method.

A retrospective chart review was undertaken of 25 stroke survivors who sought services at a community-based centre. The outcome measures were the Canadian Occupational Performance Measure (COPM) to evaluate self-perceived occupational performance and the Montreal Cognitive Assessment (MoCA) to screen for cognitive impairment. The analysis used descriptive statistics.

Findings.

Mean participant age was 64 years, and most participants were Caucasian males (72%). The mean cognitive function score was 22.1 on MoCA, and the mean COPM performance and satisfaction subscores were 4.1 and 3.9, respectively. The top three challenging daily activities were driving, seeking employment, and functional mobility.

Implications.

Stroke-specific community programs should emphasize the diverse performance concerns important to stroke survivors.

Five-year follow-up of a cluster-randomized controlled trial of a client-centred activities of daily living intervention for people with stroke

Objective:

To compare five-year outcomes and changes over time of a client-centred activities of daily living (ADL) intervention versus usual ADL interventions for people with stroke and their significant others.

Design:

Five-year follow-up of a cluster-randomized controlled trial where a client-centred ADL intervention (n = 129) or usual ADL interventions (n = 151) were delivered to people with stroke.

Setting:

Multicentre study including 16 inpatient or home-based rehabilitation units.

Participants:

People with stroke and significant others.

Intervention:

The client-centred ADL intervention aimed at enabling agency in daily activities and participation in everyday life and at reducing caregiver burden.

Main measures:

For people with stroke, perceived participation (Stroke Impact Scale), independence in ADL, life satisfaction, and use of formal/informal care were measured. For significant others, caregiver burden, life satisfaction, and mood (Hospital Anxiety and Depression Scale) were assessed.

Results:

Five years post-intervention, data were collected from 145 people with stroke (intervention group: n = 71/control group: n = 74) and 75 significant others (intervention group: n = 36/control group: n = 39). For those with stroke, the Participation domain of the Stroke Impact Scale showed no group differences at year five (68.9 vs 75.4, P = 0.062) or in changes over time. At year five, the control group had better outcomes regarding Other help/supervision. Significant others in the control group were more likely to show signs of depression at year five (odds ratio = 22.3; P < 0.001).

Conclusion:

The client-centred ADL intervention appears to render similar long-term effects as usual ADL interventions for people with stroke, but for significant others signs of depression might be reduced.

Interventions to Improve Movement and Functional Outcomes in Adult Stroke Rehabilitation: Review and Evidence Summary

Background

Patients who have had a stroke may not be familiar with the terminology nor have the resources to efficiently search for evidence-based rehabilitation therapies to restore movement and functional outcomes. Recognizing that a thorough systematic review on this topic is beyond the scope of this article, we conducted a rapid review evidence summary to determine the level of evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke.

Objective

The objective of this study was to find evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke.

Methods

Medline Complete, PubMed, CINAHL Complete, Cochrane Database, Rehabilitation and Sports Medicine Source, Dissertation Abstracts International, and National Guideline Clearinghouse, from 1996 to April of 2016, were searched. From 348 articles, 173 met the following inclusion criteria: (1) published systematic reviews or meta-analyses, (2) outcomes target functional movement or motor skills of the upper and lower limbs, (3) non-pharmacological interventions that are commonly delivered to post-stroke population (acute and chronic), (4) human studies, and (5) English. Evidence tables were created to analyze the findings of systematic reviews and meta-analyses by category of interventions and outcomes.

Results

This rapid review found that the following interventions possess credible evidence to improve functional movement of persons with stroke: cardiorespiratory training, therapeutic exercise (ie, strengthening), task-oriented training (task-specific training), constraint-induced movement therapy (CIMT), mental practice, and mirror therapy. Neuromuscular electrical stimulation (NMES) (ie, functional electrical stimulation) shows promise as an intervention for stroke survivors.

Conclusions

Most commonly delivered therapeutic interventions to improve motor recovery after a stroke possess moderate quality evidence and are effective. Future research recommendations, such as optimal timing and dosage, would help rehabilitation professionals tailor interventions to achieve the best outcomes for stroke survivors.

Virtual Activities of Daily Living for Recovery of Upper Extremity Motor Function

A study was conducted to investigate the effectiveness of virtual activities of daily living (ADL) practice using the SaeboVR software system for the recovery of upper extremity (UE) motor function following stroke. The system employs Kinect sensor-based tracking to translate human UE motion into the anatomical pose of the arm of the patient's avatar within a virtual environment, creating a virtual presence within a simulated task space. Patients gain mastery of 12 different integrated activities while traversing a metaphorical "road to recovery" that includes thematically linked levels and therapist-selected difficulty settings. Clinical trials were conducted under the study named Virtual Occupational Therapy Application. A total of 15 chronic phase stroke survivors completed a protocol involving three sessions per week over eight weeks, during which they engaged in repetitive task practice through performance of the virtual ADLs. Results show a clinically important improvement and statistically significant difference in Fugl-Meyer UE assessment scores in the study population of chronic stroke survivors over the eight-week interventional period compared with a non-interventional control period of equivalent duration. Statistically significant and clinically important improvements are also found in the wolf motor function test scores. These results provide new evidence for the use of virtual ADL practice as a tool for UE therapy for stroke patients. Limitations of the study include non-blinded assessments and the possibility of selection and/or attrition bias.

Outcomes of a multicomponent intervention on occupational performance in persons with unilateral acquired brain injury

Complications after unilateral acquired brain injury (ABI) can affect various areas of expertise causing (depending on the location of the lesion) impairment in occupational performance. The aim of this study was to analyze and compare the concepts of occupational performance and functional independence, both before and after a multicomponent intervention including occupational therapy, in persons with unilateral brain damage. This was a longitudinal quasi-experimental pretest post-test study in a sample of 58 patients with unilateral brain injury (28 with traumatic brain injury and 30 with ischemic stroke). The patients' level of independence was measured using the short version of the International Classification of Functioning, Disability and Health. We also measured quality of performance using the Assessment of Motor and Process Skills. The findings of this study showed that patients with injury in the right hemisphere improved more than those with left hemisphere damage (p<0.001). All the patients with ABI, especially those with right-sided injury, derived benefit from the multicomponent intervention, except in the area of motor skills. More research is needed on the specific techniques that might address such skills.

Attitudes of mental health occupational therapists toward evidence-based practice

Background.

Evidence-based practice is an important driver in modern health care and has become a priority in mental health occupational therapy in recent years.

Purpose.

The aim of this study was to measure the attitudes of a cohort of mental health occupational therapists toward evidence-based practice.

Method.

Forty-one mental health occupational therapists were surveyed using the Evidence-Based Practice Attitude Scale (EBPAS). Mann-Whitney U tests and Spearman’s rho were used to analyze the data.

Findings.

The occupational therapy respondents had generally positive attitudes toward evidence-based practices comparable to established norms. Respondents with further qualifications beyond their professional degree were significantly more likely to try new interventions ( p = .31). Significant negative correlations were found also for the subscales of Appeal and Openness in relation to years of occupational therapy practice (rho = –.354, p = .023; rho = –.344, p = 0.28) and mental health experience (rho = –.390, p = 0.12; rho = –.386, p = .013).

Implications.

Therapist factors can significantly impact attitudes toward evidence-based practice.

Behavioral intention to use a virtual instrumental activities of daily living system among people with stroke

OBJECTIVE

The purpose of this study was to investigate the behavioral intention to use (BIU) regarding a virtual system for practicing instrumental activities of daily living (IADLs) among people with stroke.

METHOD

Fourteen people who had sustained a stroke used a virtual world-based system over four sessions to participate in virtual occupations of preparing meals and putting away groceries. To investigate intention to use the technology, participants responded to a questionnaire based on the Technology Acceptance Model and were interviewed about the experience.

RESULTS

Analysis of questionnaire responses revealed favorable attitudes toward the technology and statistically significant correlations between these attitudes and positive BIU. Analysis of qualitative data revealed four themes to support system use: Use of the affected arm increased, the virtual practice was enjoyable, the technology was user-friendly, and the system reflected real-life activities.

CONCLUSION

This study shows that participants reported a positive BIU for the virtual system for practicing IADLs.

Development of a group-based self-management programme for individuals with chronic fatigue syndrome: a pilot study

OBJECTIVE

The aim of the study was to develop a group-based self-management programme for individuals with chronic fatigue syndrome (CFS) by using the participants' experiences with the initial version of the programme, which intends to promote coping with the illness in a primary healthcare setting.

METHODS

An initial programme was developed, based on self-efficacy theory and the concepts of client-centred practice and empowerment. Subsequently, the programme was tested and further developed by drawing on the participants' experiences with the programme. Focus-group interviews were applied. The interviews were analysed using thematic analysis.

RESULTS

The initial programme was found to be feasible, although several modifications regarding the content and practical organization of the programme were proposed.

CONCLUSION

In line with the participants' experiences, the final self-management programme was developed, which includes short presentations of eight topics, exchange of experiences among participants, goal-setting, construction of action plans, and relaxation exercises, in addition to a meeting for relatives. The programme will be provided in eight biweekly sessions and be led by juxtaposed peer counsellors and occupational therapists. The effects of the final programme will be evaluated in a randomized controlled trial.

[Potential analyses for research on occupational therapy-led training of activities of daily living in stroke patients]

HEALTH PROBLEM

Every year about 200,000 people in Germany suffer from a first stroke and 65,000 persons from a recurrent stroke. Stroke is one of the major causes of acquired life-long disability. It is associated with multiple limitations in functioning, activities of daily living and social participation. People with stroke must develop and apply considerable coping and adaptation strategies to manage the consequences of disabilities in daily life. Insufficient adaptations may result in social isolation, depressive disorders, need for medical and nursing care and subsequently lead to increasing costs for care. Thus occupational therapy-led treatment addressing social participation as well as skills training, adaptation strategies and assistive technology for activities of daily living is essential for stroke patients after hospital discharge.

CORPUS OF EVIDENCE

Based on nine randomised comparisons, a Cochrane review from 2006 revealed that occupational therapy-led training after stroke had positive effects on personal activities of daily living (8 studies; 961 participants; 0.18 SMD; 95 % CI [0.04 to 0.32]), on extended activities of daily living (6 studies; 847 participants; 0.21 SMD; 95 % CI [0.03 to 0.39]), and on poor outcome (7 studies; 1,065 participants; odds ratio 0.67; 95 % CI [0.51 to 0.87]). However, direct implementation into the German healthcare context is not recommendable due to (1) different settings and heterogeneity within the primary studies, (2) lack of manualisation of treatment programmes and (3) insufficient evaluation of client-oriented outcomes.

IMPLICATION FOR RESEARCH

It is recommended to manualise client-centred standardised modules of a stage-specific occupational therapy-led training of activities of daily living and to pilot-test this intervention programme in a feasibility study. If this trial results in a set of reliable and valid client-oriented outcome measurements applicable within the German care context and in a feasible treatment programme well accepted by stroke patients and their treating occupational therapists, a large-scaled randomised clinical trial in terms of comparative effectiveness research may follow.

Effect of neurofeedback and electromyographic-biofeedback therapy on improving hand function in stroke patients

PURPOSE

The aim of the present study was to evaluate the effect of applying electroencephalogram (EEG) biofeedback (neurobiofeedback) or electromyographic (EMG) biofeedback to conventional occupational therapy (OT) on improving hand function in stroke patients.

METHODS

This study was designed as a preliminary clinical trial. Thirty patients with stroke were entered the study. Hand function was evaluated by Jebsen Hand Function Test pre and post intervention. Patients were allocated to 3 intervention cohorts: (1) OT, (2) OT plus EMG-biofeedback therapy, and (3) OT plus neurofeedback therapy. All patients received 10 sessions of conventional OT. Patients in cohorts 2 and 3 also received EMG-biofeedback and neurofeedback therapy, respectively. EMG-biofeedback therapy was performed to strengthen the abductor pollicis brevis (APB) muscle. Neurofeedback training was aimed at enhancing sensorimotor rhythm after mental motor imagery.

RESULTS

Hand function was improved significantly in the 3 groups. The spectral power density of the sensorimotor rhythm band in the neurofeedback group increased after mental motor imagery. Maximum and mean contraction values of electrical activities of the APB muscle during voluntary contraction increased significantly after EMG-biofeedback training.

CONCLUSION

Patients in the neurofeedback and EMG-biofeedback groups showed hand improvement similar to conventional OT. Further studies are suggested to assign the best protocol for neurofeedback and EMG-biofeedback therapy.

Evaluating the Impact of Audits and Feedback as Methods for Implementation of Evidence in Stroke Rehabilitation

Introduction:

This paper evaluates audits and feedback as methods to increase implementation of evidence in stroke rehabilitation.

Method:

The study used an action research approach and theories of knowledge translation. A sample of 22 occupational therapists participated from two Danish hospitals that admitted stroke patients. Data collection methods included audits of occupational therapy medical records, documentations of daily practice, and collaborative discussions. Active feedback and discussions of the findings took place, at a group level in four local clinical audits. Data analysis of daily self-reported recordings and audits was descriptive. Audit data were analysed using descriptive statistics. A phenomenological hermeneutical interpretive methodology was used for analysing qualitative data.

Findings:

Audits and feedback were based on clear standards and contextual developing action plans. Daily practice in both settings adapted to the clinical guidelines. Implementations of the standardized assessment tools seemed to be the most successful.

Conclusion:

The effects of audit and feedback profited from the active participation of the therapists, as well as local gatekeepers having formal responsibilities for implementing change. The process was strengthened by providing the audits and feedback more than once. The effect of audits and feedback was positively influenced by being in line with current conceptual frameworks, local policies, and values.

Development of the Occupational Therapy Stroke Arm and Hand Record: An Upper Limb Treatment Schedule

Introduction:

This study aimed to develop a comprehensive occupational therapy treatment schedule of upper limb interventions for stroke survivors with reduced upper limb function.

Method:

In a three-phased qualitative consensus study, 12 occupational therapists from acute and community settings in North West England contributed to interviews and subsequently group discussions to design and pilot a treatment schedule. Interview data were analysed using thematic analysis; the themes were used to develop a framework for the schedule that was supported by and reflected the International Classification of Functioning, Disability and Health framework. A draft schedule was the subject of a focus group and the resultant schedule was piloted in clinical practice by eight local occupational therapists working in neurological rehabilitation.

Findings:

Consensus was reached on three themes summarizing aspects of function: interventions that address preparation for activity, functional skills (that is, an aspect of function), and function. Three additional themes summarized other aspects of therapy: advice and education, practice outside therapy sessions, and psychosocial interventions. These themes became the main headings of the treatment schedule. The Occupational Therapy Stroke Arm and Hand Record treatment schedule was piloted and found to be comprehensive and potentially beneficial to clinical practice.

Conclusion:

The Occupational Therapy Stroke Arm and Hand Record treatment schedule provides a tool for use in stroke research and clinical practice.

A client-centred ADL intervention: three-month follow-up of a randomized controlled trial

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.

Quality of life of elderly ischaemic stroke patients one year after thrombolytic therapy. A comparison between patients with and without thrombolytic therapy

Background

An observational study to examine whether thrombolytic therapy in stroke patients realizes better quality of life outcomes compared to patients without thrombolytic therapy one year after stroke. We also examined whether daily functioning, mental functioning and activities improved after thrombolytic treatment.

Methods

A total of 88 stroke patients were interviewed at home one year post-stroke. Health-related quality of life (HRQOL) was assessed using the RAND-36, disability with the Barthel Index, depression and anxiety with the Hospital Anxiety and Depression Scale, and a questionnaire about patient way of life was completed. People aged under 60, moving to a nursing home or with a haemorrhage were excluded.

Results

The thrombolysis group (TG) had more severe stroke (higher NIHSS) scores and were younger than the group without thrombolytic therapy (WTG). The primary outcome was HRQOL, which was high and nearly identical in both groups, however the TG had significantly better HRQOL for the ‘mental health’ and ‘vitality’ scales. Patients who stopped or reduced their hobbies because of stroke had a significantly worse HRQOL.

One year after stroke, more patients in the TG were totally or severely ADL dependent (12% TG and 0% WTG, p = 0.022). The level of dependence decreased in the TG (p = 0.042) and worsened in the WTG (p < 0.001) after one year. Being more dependent is related to diminishing daily occupations in both groups. In the TG the level of dependence had less impact on visiting family and friends and going on holiday. The prevalence of anxiety disorder and depression was low compared to other studies and there is no significant difference between the two groups.

Conclusion

No major differences in the primary outcome (HRQOL) could be found between the two groups. In addition, no essential difference could be found in mental functioning and participation. We expected that patients undergoing thrombolytic therapy would have worse quality of life because of the greater initial severity of their stroke. Therefore, thrombolytic therapy seems to be of great importance in achieving better quality of life in ischemic stroke patients who respond to this therapy.

The Relationship Between Client-Centered Goal-Setting and Treatment Outcomes

Shifting definitions of health and well-being, prompted by the World Health Organization's International Classification of Functioning (2001), have stimulated changes in traditional clinician-client relationships in rehabilitation. Among these changes, in keeping with the concept of client-centered care, is a trend toward more collaborative goal-setting and joint determination of intervention plans. Evidence suggests that supporting clients' autonomy in prioritizing personally meaningful goals leads to increased engagement in intervention, less emotional anxiety about the rehabilitation process, and improved treatment outcomes. Supporting people with aphasia in a process of collaborative goal formulation may also serve to alter treatment priorities so that they address more relevant communication challenges embedded in post-rehabilitation life.

Stroke patients' experiences with Wii Sports® during inpatient rehabilitation

INTRODUCTION

Commercial virtual reality games have been used as adjunct therapy for stroke rehabilitation, mainly after patients have been discharged. The aim of this study was to explore stroke patients' experiences with Wii Sports® as a supplement to conventional occupational therapy in a controlled hospital setting.

MATERIALS AND METHODS

The study had a qualitative triangulation design that included semi-structured interviews and field notes. Nine Danish stroke patients participated, receiving between one and nine interventions with Wii Sports® during a three-week period. Responses were coded by qualitative content analysis.

RESULTS

Analysis revealed one overarching category, "Connecting to past, present, and future occupations", and three categories that encompassed patients' experiences with Wii: (i) variety, (ii) engagement, and (iii) obstacles and challenges. Interview findings were confirmed by field notes that included observations of engagement and challenges.

DISCUSSION

Stroke patients in hospital settings may experience Wii Sports® as a beneficial and challenging occupation for both rehabilitation and leisure. Incorporation of Wii Sports® into conventional occupational therapy services may benefit patient rehabilitation directly or provide motivation for alternative leisure activities.