Effectiveness of interventions for adults with psychological or emotional impairment after stroke: an evidence-based review

Occupational Therapy for Poststroke Anxiety and Depressive Symptoms in Inpatient Rehabilitation

Poststroke anxiety and depressive symptoms (P-SADS) affect one in three people and are associated with decreased participation in activities of daily living. This study sought to characterize occupational therapy (OT) P-SADS care practices and identify factors influencing P-SADS care provision in one U.S. inpatient rehabilitation (IRF) facility. An explanatory sequential mixed-methods study design was used by gathering data from electronic health records (from January 1, 2019 to December 31, 2019) as well as semi-structured interviews with OT practitioners in the IRF. No objective P-SADS screens were documented nor were any P-SADS-focused goals written. Minimal evidence-based P-SADS interventions were identified. Practitioners reported multi-level barriers to OT P-SADS care including limited time, pressure to prioritize physical recovery, and inadequate resources to guide practice. OT practitioner P-SADS care was inconsistent with established evidence-based practice. This research identifies gaps in comprehensive stroke recovery and informs implementation efforts to support evidence-based P-SADS care in IRFs.

Study protocol for a non-randomised controlled trial: Community-based occupational therapy intervention on mental health for people with acquired brain injury (COT-MHABI)

INTRODUCTION

The sequelae of moderate-severe acquired brain injury (ABI) encompass motor, cognitive, sensory, emotional and behavioural areas that affect meaningful occupational participation and quality of life, with a high prevalence of associated mental disorders. When the patient returns to community life after discharge from the hospital, specialised care is generally insufficient due to the lack of consideration of the dual condition of mental disorder and ABI. Since there is a negative impact on competence and thus on occupational participation, occupational therapy represents a convenient way of intervention. On these assumptions, a community-based occupational therapy protocol on mental health for people with moderate/severe acquired brain injury (COT-MHABI) is presented. It is focused on meaningful occupational participation and looks for improvement in the quality of life.

METHODS AND ANALYSIS

This study aims: (i) to design a protocol to evaluate the effectiveness of a community occupational therapy intervention based on MOHO for patients with a dual (mental health/ABI) for improving quality of life and self-perceived occupational performance; (ii) to analyse the outcomes of occupational and social variables (occupational balance, participation level, satisfaction with occupation and performed roles and community integration) after the COT-MHABI process; (iii) to analyse the impact of quality of life on satisfaction with occupations performed by this population. A non-randomised controlled clinical trial will be performed. Patients assigned to the experimental group will receive over one year of on-site and telematic occupational therapy sessions, 16 sessions on average. Variables such as quality of life, community integration or satisfaction with occupational performance will be collected at baseline, 6, and 12 months.

DISCUSSION

The needs for the dual mental/ABI population in their reintegration into the community are related to the associated deficits and to the absence of specialised services for the complexity of this patient profile. Few studies consider the coexistence of mental health and ABI issues. The COT-MHABI protocol is proposed to provide continuity to the community needs of this population, conceptualised from occupational participation, person-centred and focused on meaningful activities.

CLINICAL TRIAL REGISTRATION

Trial identifier and registry name ClinicalTrials.gov ID: NCT04586842 https://clinicaltrials.gov/ct2/show/NCT04586842?term=252136&draw=2&rank=1; Pre-results; Community-based Occupational Therapy Intervention on Mental Health for People With Acquired Brain Injury (COT-MHABI).

Occupational Therapy Interventions to Address Depressive and Anxiety Symptoms in the Physical Disability Inpatient Rehabilitation Setting: A Systematic Review

IMPORTANCE

Depressive and anxiety symptoms across physical disability inpatient rehabilitation (IPR) patient groups are well documented and negatively affect functional recovery. The strategies within the occupational therapy scope of practice to address these symptoms in IPR are unclear.

OBJECTIVE

To determine what interventions within the occupational therapy scope of practice have been used to address depressive and anxiety symptoms in IPR and to determine intervention efficacy.

DATA SOURCES

Nine databases for all publication years were searched (PubMed, Scopus, Embase, Web of Science, PsycINFO, Cochrane Library, AgeLine, OTseeker, and CINAHL). Study Selection and Data Collection: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for abstracting data and assessing quality. Included articles were peer reviewed, based in the United States, in English, controlled clinical trials or randomized controlled trials, in the IPR setting, and within the occupational therapy scope of practice. Two reviewers independently screened articles, with disagreements resolved by consensus.

FINDINGS

Five of 8,082 articles met inclusion criteria. Diagnoses included stroke (n = 1), traumatic brain injury (n = 1), spinal cord injury (n = 1), and musculoskeletal conditions (n = 2). Results are discussed among four categories: study design and outcome variables, intervention type, intervention intensity, and intervention efficacy.

CONCLUSIONS AND RELEVANCE

Limited, moderate-quality evidence exists within the occupational therapy scope of practice for addressing depressive and anxiety symptoms in the physical disability IPR setting. Interventions primarily included cognitive and behavioral strategies. Further research among diverse patient populations is needed to support occupational therapy practitioners in facilitating client participation and functioning. What This Article Adds: This systematic review provides an evaluation of the evidence within the occupational therapy scope of practice to address depressive and anxiety symptoms within the physical disability IPR setting. This research can support occupational therapy practitioners to comprehensively address physical and mental health for participation in IPR.

A Meta-analysis of the Effect of Motivational Interviewing on Depression, Anxiety, and Quality of Life in Stroke Patients

ABSTRACT

BACKGROUND: Motivational interviewing has become a popular approach for relieving mood disturbances. We aimed to investigate whether motivational interviewing can effectively improve depression, anxiety, and quality of life among stroke patients. METHODS: Seven electronic databases were searched from inception to March 15, 2021. Other potentially related studies were identified through manually searching the reference lists of empirical articles and relevant review articles. Randomized controlled trials that investigated the effects of motivational interviewing on stroke patients with mood disturbances were deemed eligible. The Cochrane Handbook 5.1.0 was used to assess the risk of bias. Meta-analyses were conducted using the Review Manager Version 5.3. RESULTS: Six articles with 1419 participants were included. The subgroup analysis revealed that motivational interviewing was associated with improvement of depression (P < .00001) and quality of life (P = .0007) among patients having stroke at less than 12 months of follow-up. No significant differences were detected for improving depression (P = .40) and quality of life (P = .38) at 12 months of follow-up. Furthermore, the meta-analysis showed that motivational interviewing was not associated with alleviation of anxiety (P = .81) among stroke patients. CONCLUSION: This meta-analysis indicated that motivational interviewing might have beneficial effects on depression and quality of life in stroke patients at less than 12 months of follow-up. However, large and well-designed randomized controlled trials are needed to confirm these findings.

Speech-Language Pathologists' Practice Patterns When Designing Home Practice Programs for Persons With Aphasia: A Survey

Purpose We aimed to describe the current practices of speech-language pathologists regarding the creation and implementation of home practice programs for persons with poststroke aphasia. Method Survey participants were American Speech-Language-Hearing Association-certified speech-language pathologists, had 30% of their caseload include persons with aphasia, and had recently created at least two home programs for persons with aphasia. Respondents completed a web-based survey on home program creation, training, technology, and methods for tracking adherence with closed and open-ended questions. Results We analyzed 80 complete surveys. Most of the participants (n = 56) created home programs for greater than 75% of their caseload. Common interventions in home programs addressed functional practice and spoken expression. Participants describe instructional techniques including building skill practice in daily routines and guided practice. Applications of technology and formal mechanisms to monitor adherence were less frequently reported. Various factors were identified as facilitators and barriers to home program creation with environmental support from others and client factors (i.e., motivation, impairments) most evident. Conclusions This study provides insight into speech-language pathologists' home program creation and implementation. Results can be used to consider mechanisms to improve use of and adherence to home programs to further support recovery. Supplemental Material https://doi.org/10.23641/asha.16840204.

What works in managing complex conditions in older people in primary and community care? A state-of-the-art review

The number of older people living with complex health conditions is increasing, with the majority of these managed in primary and community settings. Many models of care have been developed to support them, however, there is mixed evidence on their value and they include multiple overlapping components. We aimed to synthesise the evidence to learn what works for managing complex conditions in older people in primary and community care. We carried out a state-of-the-art review of systematic reviews. We searched three databases (January 2009 to July 2019) for models of primary and community care for long-term conditions, frailty, multimorbidity and complex neurological conditions common to older people such as dementia. We narratively synthesised review findings to summarise the evidence for each model type and identify components which influenced effectiveness. Out of 2,129 unique titles and abstracts, 178 full texts were reviewed and 54 systematic reviews were included. We found that the models of care were more likely to improve depressive symptoms and mental health outcomes than physical health or service use outcomes. Interventions including self-management, patient education, assessment with follow-up care procedures, and structured care processes or pathways had greater evidence of effectiveness. The level of healthcare service integration appeared to be more important than inclusion of specific professional types within a team. However, more experienced and qualified nurses were associated with better outcomes. These conclusions are limited by the overlap between reviews, reliance on vote counting within some included reviews and the quality of study reports. In conclusion, primary and community care interventions for complex conditions in older people should include: (a) clear intervention targets; (b) explicit theoretical underpinnings; and (c) elements of self-management and patient education, structured collaboration between healthcare professionals and professional support. Further work needs to determine the optimal intensity, length, team composition and role of technology in interventions.

Effectiveness of Motivational Interviewing on adult behaviour change in health and social care settings: A systematic review of reviews

BACKGROUND

The challenge of addressing unhealthy lifestyle choice is of global concern. Motivational Interviewing has been widely implemented to help people change their behaviour, but it is unclear for whom it is most beneficial. This overview aims to appraise and synthesise the review evidence for the effectiveness of Motivational Interviewing on health behaviour of adults in health and social care settings.

METHODS

A systematic review of reviews. Methods were pre-specified and documented in a protocol (PROSPERO-CRD42016049278). We systematically searched 7 electronic databases: CDSR; DARE; PROSPERO; MEDLINE; CINAHL; AMED and PsycINFO from 2000 to May 2018. Two reviewers applied pre-defined selection criteria, extracted data using TIDIER guidelines and assessed methodological quality using the ROBIS tool. We used GRADE criteria to rate the strength of the evidence for reviews including meta-analyses.

FINDINGS

Searches identified 5222 records. One hundred and four reviews, including 39 meta-analyses met the inclusion criteria. Most meta-analysis evidence was graded as low or very low (128/155). Moderate quality evidence for mainly short term (<6 months) statistically significant small beneficial effects of Motivational Interviewing were found in 11 of 155 (7%) of meta-analysis comparisons. These outcomes include reducing binge drinking, frequency and quantity of alcohol consumption, substance abuse in people with dependency or addiction, and increasing physical activity participation.

CONCLUSIONS

We have created a comprehensive map of reviews relating to Motivational Interviewing to signpost stakeholders to the best available evidence. More high quality research is needed to be confident about the effectiveness of Motivational Interviewing. We identified a large volume of low quality evidence and many areas of overlapping research. To avoid research waste, it is vital for researchers to be aware of existing research, and the implications arising from that research. In the case of Motivational Interviewing issues relating to monitoring and reporting fidelity of interventions need to be addressed.

Occupational Therapy Practitioners' Perspectives of Mental Health Practices With Clients in Stroke Rehabilitation

Following a stroke, depression and anxiety may negatively affect recovery and decrease quality of life. Occupational therapy (OT) practitioners are distinctly qualified to address both the physical and psychosocial sequelae of a stroke, including clients' mental and emotional health. This study explored the ways in which OT practitioners address the mental health needs of clients post stroke. A sequential explanatory mixed-methods design was used to collect both survey and focus group data. In all, 754 OT practitioners across the United States completed an online survey, and 10 practitioners participated in focus groups. Practitioners considered their clients' mental health needs to be a priority (68.17%); however, only 56.64% were satisfied with the care they provided related to mental and emotional health. They identified barriers that included limited time, increased productivity standards, expectations related to physical recovery, and poor educational preparation. Practitioners are motivated to improve their provision of mental health services to clients post stroke. To address the conflict between practice realities and professional values, education programs should better integrate curricular components that focus on physical and mental health.

Promoting Physical Activity and Nutrition in People With Stroke

The prevalence of cardiovascular disease, diabetes, and obesity is high in people with stroke. Risk factors for these conditions include hypertension, high cholesterol, and physical inactivity. These risk factors are common in people with stroke and often go unmanaged. Engagement in healthy behaviors is important for managing and preventing these risk factors and comorbid conditions. More specifically, physical activity and nutrition are key health behaviors for the management and maintenance of health in people with stroke. These health behaviors, by their very nature, are also occupations; thus, they are influenced by client factors, performance skills and patterns, and environments and contexts. This article discusses physical activity and nutrition within the context of the Occupational Therapy Practice Framework: Domain and Process and proposes potential roles for occupational therapy practitioners and researchers in developing, testing, and providing physical activity and nutrition interventions for people with stroke.

Cost effectiveness of the occupation-based approach for subacute stroke patients: result of a randomized controlled trial

BACKGROUND AND PURPOSE

The cost effectiveness of occupational therapy for subacute stroke patients is unclear in the extant literature. Consequently, this study determined the cost effectiveness of the occupation-based approach using Aid for Decision-Making in Occupation Choice (ADOC) for subacute stroke patients compared with an impairment-based approach.

METHODS

We conducted an economic evaluation from a societal perspective alongside a pilot randomized controlled trial, with a single blind assessor for participants in 10 subacute rehabilitation units in Japan. The intervention group received occupation-based goal setting using ADOC, with interventions focused on meaningful occupations. The control group received an impairment-based approach focused on restoring capacities. For both groups, occupational-therapy intervention was administered more than five times per week, for over 40 min each time, and they received physical and speech therapy prior to discharge. The main outcomes were quality-adjusted life years (QALYs) and total costs. Further, sensitivity analyses were performed to examine the influence of parameter uncertainty on the base case results.

RESULTS

The final number of participants was 24 in each of the two groups. In terms of QALYs, the intervention group is significantly higher than the control group (p = 0.001, difference 95% CI: 0.002-0.008) and total costs are not statistically significant. Applying a willingness-to-pay threshold of JPY 5 million/QALY, the probability of the occupation-based approach using ADOC being cost effective was estimated to be 65.3%.

CONCLUSIONS

The results show that the occupation-based approach is associated with significantly improved QALYs and has potential cost effectiveness, compared with the impairment-based approach.

State of the Journal, 2015

The American Journal of Occupational Therapy (AJOT) had a successful 2015. From September 2014 to September 2015, the number of manuscripts submitted had increased by 35%. Manuscripts were received from 23 countries, compared with 17 countries in 2014. AJOT continues to have the highest impact factor and to be the highest ranked of the occupational therapy journals listed in Journal Citation Reports. AJOT continues to focus on publishing research articles on aspects of occupational therapy among varied populations with diverse acute and chronic conditions. Additional changes for 2015 include new associate editors, a significantly enlarged pool of reviewers from across the globe, continuous publishing, pay-per-view, updated author guidelines, and the adoption of clinical trial registration requirements effective January 1, 2016.

Method for the Evidence-Based Reviews on Occupational Therapy and Stroke

Evidence-based reviews of the literature relevant to adults with stroke are important to the practice of occupational therapy. We describe the four questions that served as the focus for the evidence-based reviews of the effectiveness of occupational therapy interventions for adults with stroke. The questions include occupation- and activity-based interventions to improve occupational performance and social participation after stroke, as well as interventions for motor, cognitive, and psychological and emotional impairments after stroke. We include the background for the reviews; the process followed for addressing each question, including search terms and search strategy; the databases searched; and the methods used to summarize and critically appraise the literature. The final number of articles included in each evidence-based review; a summary of the themes of the results; the strengths and limitations of the findings; and implications for practice, education, and research are presented.