Effectiveness of occupation-based interventions to improve areas of occupation and social participation after stroke: an evidence-based review

The Internet-Based Intervention Strategies for Empowering Activities in Everyday Life: Qualitative Study of Experiences of Clients With Stroke

BACKGROUND

There is a need to enhance access to and support for self-management of activities in everyday life after a stroke. Internet-based solutions have the potential to contribute to this development. Consequently, an internet-based intervention called Strategies for Empowering Activities in Everyday Life (SEE) was developed. The intervention aims to assist clients in developing management strategies that promote a healthy distribution and balanced engagement in various activities performed in different places and with other people. To further support the development and feasibility of this intervention, more knowledge is needed about clients' experiences during the intervention process.

OBJECTIVE

This study aims to explore and describe how clients with stroke experienced the SEE intervention process and whether participation in SEE influenced their experience of everyday life.

METHODS

Overall, 9 clients with stroke who received SEE participated in the study-4 (44%) women and 5 (56%) men aged 37 to 73 years. Qualitative interviews about experiences with SEE were conducted twice during the intervention process with each participant. The data were analyzed using the constant comparative method of grounded theory.

RESULTS

The participants' experiences with the intervention process of SEE formed the core category, conceptualized as The relevance of and readiness for entering a change process in activities of everyday life differ among clients, constituting of two main categories: (1) an eye-opener providing agency for a change process and (2) never beginning a change process in activities in everyday life. The results showed that the relevance of and readiness for SEE differed between the participants. The experiences of 78% (7/9) of the participants reflected that the intervention process provided them with an agency to drive their own change process for activities in everyday life to promote health. Overall, 22% (2/9) of the participants refrained from entering a change process during SEE as they did not recognize any need for changes in their activities. When SEE was relevant and adopted as expected, the participants described it as an eye-opener for how they can alter their health based on how they distribute and spend their time on various activities.

CONCLUSIONS

SEE has the potential to support clients' development of self-management and to take an active role in influencing their engagement in activities in everyday life and health. This study identified necessary improvements in the educational program for professionals to enhance delivery and strengthen the therapeutic mechanisms of SEE for future research. To effectively implement internet-based interventions such as SEE, it is crucial to identify clients who express a need for self-management in activities and are ready to invest the effort required to adopt a change process. Furthermore, it is indicated that participants' self-analysis of their everyday activities empowers them to adopt new self-management strategies, which can also benefit other interventions.

Training to deal with distractions and conflicting situations in activities of daily living after traumatic brain injury (TBI): Preliminary evidence from a single-case experimental design study

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03958487.

Occupation-based interventions to improve occupational performance and participation in the hospital setting: a systematic review

PURPOSE

To critically review the evidence for occupation-based interventions in improving occupational performance and participation outcomes in the hospital setting.

METHODS

Five databases were searched from 2000-2022. Peer-reviewed studies of any design investigating the impact of occupation-based interventions in the hospital setting were included. Methodological quality was assessed using the appropriate tool for each study design. Following data extraction, a narrative synthesis was conducted.

RESULTS

Thirty-three studies comprising of 26 experimental, five non-experimental, and two mixed methods studies were included (n = 1646 participants). Results indicate good evidence to support occupation-based interventions to improve occupational performance and participation outcomes in inpatient rehabilitation; it is unclear whether they are more effective than any control/alternative intervention. Research in the acute and mental health hospital settings were scarcer. Understanding the benefits of occupation-based interventions was enhanced through qualitative results including improving independence and confidence to discharge home, increasing motivation for therapy, connecting with others, and peer-based learning.

CONCLUSIONS

Heterogeneity and methodological weaknesses across existing studies limits the conclusions that can be drawn on the impact of occupation-based interventions in the hospital setting. More rigorous research should be conducted with better reporting of intervention design and the use of robust measures of occupational performance.Implications For RehabilitationThe use of occupation-based interventions should be considered to improve occupational performance and participation outcomes in the hospital setting.There is good evidence to support the impact of occupation-based interventions on improving occupational performance and participation outcomes in the inpatient rehabilitation setting; evidence in the acute and mental health settings is scarcer.Occupation-based interventions are valued by both patients and clinicians for their impact on patient outcomes and the patient experience.

Occupational Therapy Practice: Time From Stroke Onset to Outpatient Upper Limb Rehabilitation

Upper limb stroke rehabilitation has been understudied in usual occupational therapy. The study's purpose was to describe the timing and amount of usual occupational therapy in the stroke population for hospital-based outpatient upper limb rehabilitation. A multi-site study of timing and amount of occupational therapy was calculated for mild and moderate upper limb stroke impairments using the Fugl-Meyer Assessment-Upper Extremity (FMA-UE). Mild stroke participants (n = 58) had a mean of 164.25 days, and the moderate stroke participants (n = 64) had a mean of 106.75 days from the date of stroke onset to first treatment which was significantly different (p = .047). There were no significant differences in the amount of therapy between mild or moderate stroke patients. Mild stroke patients experience a longer delay in receiving outpatient occupational therapy compared with moderate impairments which may be attributed to the subtlety of the impairments that impact participation in daily activities.

Feasibility and clinical applicability of a novel power wheelchair training approach

PURPOSE

To evaluate the feasibility and the clinical applicability of administering the COMET (cognition, occupation, mobility, evaluation and training) intervention.

MATERIALS AND METHODS

A pilot research was conducted with adults who were being considered for power wheelchair (PWC) provision, or who were recently provided a PWC, and who had been identified to benefit from a PWC training. The COMET intervention applies a goal directed, client-centred and occupation-based approach. Feasibility and applicability indicators were collected for: process, resources, management and treatment. Indicators were evaluated as "successful/unsuccessful". Clinical outcomes included the Goal Attainment Scale (GAS), the Canadian Occupational Performance Measure (COPM), the Power mobility Indoor Driving Assessment (PIDA) and the Wheelchair Skills Test (WST).

RESULTS

Four females (62.5 ± 3.5 years) with cognitive impairment participated in the study. Among the 13 indicators, 10 were successfully achieved. Indicators that did not meet the criteria for success were adherence rate, safety and treatment for the PIDA. Two adverse events were reported, with one minor injury. Participants demonstrated better than expected results on the GAS, the COPM scores and the WST. However, only two reported an improvement beyond 4% of the PIDA.

CONCLUSIONS

With few modifications, the COMET intervention and the study protocol will be feasible and applicable in clinical practice. Individuals with complex cognitive and mobility impairment demonstrated abilities to learn PWC use. Further investigation of the COMET intervention is required to evaluate its efficacy.Implications for rehabilitationA novel power wheelchair (PWC) training approach adapted to individual with complex mobility and cognitive impairments was developed: the COMET (cognition, occupation, mobility, evaluation and training) intervention.The COMET intervention applies a goal directed, client-centred and occupation-based approach.With minor modifications, the COMET intervention may be feasible and clinically applicable to train individuals with complex motor and cognitive impairments how to use a PWC.Further evaluation of the COMET intervention and lager control trialsare suggested.

Occupational therapists' experiences of using a new internet-based intervention - a focus group study

BACKGROUND

Research is limited about how the introduction of new ways of delivering and conducting occupational therapy, in accordance with expected changes in health care, is experienced by occupational therapists (OTs).

AIM

To explore how OTs experienced use of a new internet-based intervention, 'Strategies for Empowering activities in Everyday life' (SEE), focusing on supporting client resources to manage an active everyday life after stroke.

MATERIAL AND METHODS

A focus group study with periodical repeated discussion was designed. Four sessions during a period of 22 months were conducted with a total of four OTs.

RESULT

Overall, the results reflected that the OTs experienced that the use of SEE for persons with stroke was a valuable complement to existing rehabilitation. The process of introducing SEE included a multifaceted transition involving context, intervention process and delivery that renewed occupational therapy.

CONCLUSION

These results indicate how the use of new internet-based interventions such as SEE can influence and support renewal of occupational therapy that extends beyond the particular intervention. Continued research is needed to explore more aspects of SEE feasibility.

Feasibility of Increasing Occupation-Based Assessment Using the Knowledge to Action Framework

The Assessment of Motor and Process Skills (AMPS) is a standardized occupation-based measure; however, barriers often limit use in practice. The Knowledge to Action Framework (KTA) is one of the most widely used implementation approaches to induce practice change. The objective of the study is to examine the feasibility and acceptability of a KTA-informed intervention to increase the use of the AMPS. AMPS-trained occupational therapists were recruited through convenience sampling. Interventions included workshops, action planning, goal setting, peer support, and organizational resources. Recruitment and retention were tracked. Pre- and post-survey results of interventions' helpfulness, AMPS behaviors, and motivational changes informed acceptability. Participants (n = 5) rated 7/7 (100%) intervention strategies as helpful, reported decreased barriers and increased frequency of AMPS administration, increased resources for AMPS implementation, and improved compatibility with practice. Implementation of a KTA-informed intervention to increase AMPS practice was feasible and supported by environmental changes and peer support in a physical rehabilitation setting.

Exploring occupation-based practice among occupational therapists in hospitals and rehabilitation institutions

BACKGROUND

While occupational therapists value occupation-based practice, they appear to spend less time on this approach and more time on impairment-based practices. Several barriers are reported for the occupation-based approach.

AIM

To explore different aspects of occupation-based practice among occupational therapists working in hospitals and rehabilitation institutions, and to examine associations between sociodemographic factors, barriers, and occupation-based practice.

MATERIALS AND METHODS

A cross-sectional survey was conducted. Participants were occupational therapists working in hospitals and rehabilitation institutions in Norway. The data were analysed with descriptive statistics and logistic regression.

RESULTS

The therapists (n = 124) valued occupation-based practice and reported using it frequently and to a large extent. Relatively small proportions of their practice (26% assessments and 38% interventions) were classified as occupation-based. Lack of time, space and equipment were reported as large barriers. Lack of time and lack of equipment were associated with low self-reported level of occupation-based practice.

CONCLUSIONS

The participants valued occupation-based practice, while the reported assessment and intervention methods were mainly not occupation-based. Several barriers were reported, and some were associated with less use of occupation-based practice.

SIGNIFICANCE

The results can be used to raise awareness of occupational therapists' use of occupation-based practice and barriers to this approach.

Evaluation of improvement of functional independence in a multicentre cohort of rehabilitation outpatients with neurological conditions

PURPOSE

The objectives were to examine: (1) the changes in independence in basic activities of daily living (ADL) following an outpatient occupational therapy (OT) intervention in people with neurological conditions; (2) the factors associated with good relative functional gain (RFG) and with good OT efficiency; (3) and the effects on instrumental activities of daily living (IADL) and caregiver assistance.

MATERIALS AND METHODS

A prospective observational study examining changes in a multicentre cohort (three urban hospitals). Ninety-eight adults were assessed on admission and after intervention. Barthel Index was the primary outcome (ADL).

RESULTS

Acquired brain damage (ABI) was the most frequent diagnosis (84.7%). There was an improvement in ADL (p < 0.001); the effect size (r) was large (r = 0.59). RFG was good for 88.8% of participants. A good RFG was significantly associated with ABI, a lower number of hours of caregiver assistance, and a greater intensity of OT. The OT efficiency was good for 43.9% of participants. Factors significantly associated with good efficiency were being young and male patients, and receiving fewer hours of caregiver assistance. Secondary measures were improved: IADL (p < 0.001) and hours of caregiver assistance (p < 0.001).

CONCLUSIONS

This study suggests that the intervention is an effective approach to improve functional independence.Implications for rehabilitationLittle is known about the outcomes of outpatient occupational therapy intervention in neurorehabilitation services for the adult population with neurological diseases.In a multicentre cohort of neurorehabilitation outpatients, the occupational therapy intervention can lead to improvements in the level of independence in basic and instrumental daily activities, as well as reducing the hours of caregiver assistance.A good relative functional gain is associated with acquired brain injury, a lower number of hours of assistance, and a greater intensity of occupational therapy.The factors associated with good efficiency are being younger, male patients, and receiving fewer hours of assistance.

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).

Exploring Patient Outcomes After Participation in an Inpatient Occupation-Based Group: A Longitudinal Observational Cohort Study

IMPORTANCE

Occupation-based interventions are used during inpatient rehabilitation, and group models may enhance intervention delivery. However, little is known about the impact of occupation-based groups on patient outcomes.

OBJECTIVE

To examine the effect of an occupation-based group on patient outcome measures of instrumental activities of daily living (IADL) skills over time and explore demographic differences among patients.

DESIGN

Longitudinal observational cohort study with four time points: preintervention, postintervention, 30-day follow-up, and 90-day follow-up.

SETTING

Tertiary hospital general rehabilitation ward.

PARTICIPANTS

Inpatient adults age 18 or older recruited using consecutive sampling from those referred to the group.

INTERVENTION

The LifeSkills group, which focused on repetitive practice of meaningful occupation-based activities.

OUTCOMES AND MEASURES

Demographic data were obtained, and the Canadian Occupational Performance Measure (COPM), Goal Attainment Scaling, Lawton IADL scale, and a self-efficacy scale were administered at each data point.

RESULTS

Thirty people (21 women, 9 men; ages 35-91 yr) participated, with 5 lost to follow-up. A statistically significant increase in scores postintervention occurred on all measures and was also seen at 90-day follow-up for COPM occupational performance, satisfaction, and self-efficacy scores. Lawton IADL scale scores at follow-up were lower than those at preintervention and statistically significant. No significant differences were found for age and diagnosis.

CONCLUSIONS AND RELEVANCE

Positive patient outcomes of goal achievement, occupational performance, satisfaction, and self-efficacy were seen at discharge, with evidence of sustainability over time. This could be a resource alternative for addressing skill retraining because people with different diagnoses and in different age groups benefited equally. What This Article Adds: Occupation-based group programs have encouraging application in general inpatient rehabilitation for addressing patient outcomes.

Interventions to Improve Social Participation, Work, and Leisure Among Adults Poststroke: A Systematic Review

IMPORTANCE

Sustaining a stroke frequently leads to difficulties in returning to work, leisure, and social participation. These outcomes are important for occupational therapy practitioners to address.

OBJECTIVE

To determine the current evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve social participation, work, and leisure among adults poststroke.

DATA SOURCES

MEDLINE, PsycINFO, CINAHL, OTseeker, and Cochrane databases.

STUDY SELECTION AND DATA COLLECTION

Primary inclusion criteria were peer-reviewed journal articles published between January 1, 2009, and December 31, 2019, within the scope of occupational therapy that evaluated an intervention to address work, leisure, or social participation poststroke (levels of evidence ranged from Level 1b to Level 2b). Reviewers assessed records for inclusion, quality, and validity following Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

FINDINGS

Forty-seven articles met the inclusion criteria. Forty-four articles related to social participation were categorized as follows: occupation-based approaches, metacognitive strategy training, education and training approaches, impairment-based approaches, and enriched environment approaches. Three articles related to work and 3 articles related to leisure were not further categorized (2 articles were each included in two categories). Seventeen Level 1b and 30 Level 2b articles were included. The strength of evidence to support occupational therapy interventions for social participation, work, and leisure outcomes is predominantly low.

CONCLUSIONS AND RELEVANCE

Occupational therapy interventions may improve work, leisure, and social participation outcomes poststroke, with the strongest evidence existing for client education, upper extremity training, and cognitive training for improving social participation. What This Article Adds: Occupational therapy practitioners may use the available literature along with clinical reasoning to improve work, leisure, and social participation outcomes among clients poststroke. Additional research is required to build stronger evidence to support clinical decision making in stroke rehabilitation in these areas.

Capability, opportunity, motivation, and social participation after stroke

BACKGROUND

Stroke survivors report limited social participation, despite it being an important rehabilitation outcome. Interdisciplinary interventions for increasing social participation amongst stroke survivors lack theoretical guidance and evidence-based approaches. The Behavior Change Wheel (BCW) theorizes that capability, opportunity, and motivation contribute to behavior change.

OBJECTIVES

This study applied the BCW to understand the relationship between social participation and stroke survivors' capability, opportunity, and motivation.

METHODS

In this cross-sectional study, we recruited 30 community-dwelling adult stroke survivors. Assessments explored the frequency and satisfaction of social participation; physical and psychological capability; environmental accessibility and social opportunity; and motivation. A linear regression analysis was done.

RESULTS

Motivation (R² change = 29.3%, ß = 0.55) and environmental opportunity (R² change = 11%, ß = 0.39) were statistically significant predictors of social participation frequency. Motivation (R² change = 36.9%, ß = 0.61) was the only statistically significant predictor of satisfaction with social performance.

CONCLUSIONS

Motivation and environmental accessibility are statistically significant independent predictors of frequency of social participation after stroke. Motivation is the strongest predictor of satisfaction with social participation. Clinicians may support stroke survivors to promote social participation using approaches that increase motivation and environmental accessibility. Development of such theoretically sound interventions may be guided by the BCW.

Effect of socioeconomic status on the physical and mental health of the elderly: the mediating effect of social participation

BACKGROUND

Previous studies have demonstrated the effect of socioeconomic status on the health status of the elderly. Nevertheless, the specific dimensions of the effect and the mechanism await further investigation. In this study, socioeconomic status was divided into three dimensions and we used social participation as the mediation variable to investigate the specific path of effect.

METHODS

Using the 2018 Waves of Chinese Longitudinal Healthy Longevity Survey (CLHLS) dataset, a total of 10,197 effective samples of the elderly over 65 years old were screened out. Socioeconomic status included income, education level, and main occupation before retirement. The physical health and mental health of the elderly was measured by the Instrumental Activities of Daily Living Scale and the Minimum Mental State Examination, respectively. The social participation of the elderly was the mediation variable, including group exercise, organized social activities and interacting with friends. Omnibus mediation effect analysis was adopted to examine the mediation effect and mediation analysis was completed using the SPSS PROCESS program.

RESULTS

First, the results showed that when the income gap between the elderly reached a certain level, there was a significant difference in health status. Significant differences existed in health status amongst with different education levels. There was no sufficient evidence to show that occupation has a significant effect on the physical health. But when the dependent variable was mental health, the effect was significant. Second, group exercise mediated 64.11% (a_ib = 0.24, 95% CI [0.17,0.3]) and up to 20.44% (a_ib = 0.12, 95% CI [0.07,0.17]) of the disparity in physical and mental health due to income gap, respectively. And it could mediate the effect up to 56.30% (a_ib = 0.62, 95% CI [0.52,0.73]) and 17.87% (a_ib = 0.50, 95% CI [0.4,0.61]) of education on physical and mental health status, respectively. The proportion of relative mediation effect of occupation was up to 28.74% (a_ib = 0.19, 95% CI [0.13,0.25]) on mental health. Interacting with friends mediated only on the path that the education affected the health status of the elderly. The proportion was up to 33.72% (a_ib = 0.29, 95% CI [0.16,0.44]). The relative mediation effect of organized social activities on the health gap caused by income or education level gap was significant at some levels. The proportion was up to 21.20% (a_ib = 0.33, 95% CI [0.26,0.4]).

CONCLUSION

The SES of the elderly including relatively large income gap, different education levels and occupational categories could indeed have a significant effect on health status of the elderly, and the reason why this effect existed could be partly explained by the mediation effect of social participation. Policymakers should pay more attention to the social participation of the elderly.

A Performance-Based Teleintervention for Adults in the Chronic Stage after Acquired Brain Injury: An Exploratory Pilot Randomized Controlled Crossover Study

This pilot study aimed to investigate the initial effect of a remotely delivered performance-based client-centered intervention on activity performance and participation among adults in the chronic phase after acquired brain injury (ABI). Sixteen participants living at home with little to no assistance in basic daily activities were allocated into intervention or waitlist control groups. Assessments were conducted at the baseline, after the 3-month intervention/wait period, and at a 3-month follow-up. The primary outcomes were activity performance using the Canadian Occupational Performance Measure (COPM) and the Performance Quality Rating Scale (PQRS) and participation using the Mayo-Portland Adaptability Inventory-4 (MPAI-4). The intervention included weekly videoconferencing sessions using the Cognitive Orientation to Daily Occupational Performance approach (tele-CO-OP). The participants identified five functional goals, of which three were directly addressed. Wilcoxon signed-ranks test results showed no significant improvements in the control group at the end of the 3-month wait period. Pooled data from both groups showed significant improvements in COPM scores for trained and untrained goals following the intervention. Significant improvements were also found in the PQRS and MPAI-4 scores. Improvements were partially maintained at follow-up. Our preliminary results suggest that tele-CO-OP may positively impact the lives of adults after ABI who are coping with long-term disability.

Implementation strategies and outcomes for occupational therapy in adult stroke rehabilitation: a scoping review

BACKGROUND

Stroke survivors often encounter occupational therapy practitioners in rehabilitation practice settings. Occupational therapy researchers have recently begun to examine the implementation strategies that promote the use of evidence-based occupational therapy practices in stroke rehabilitation; however, the heterogeneity in how occupational therapy research is reported has led to confusion about the types of implementation strategies used in occupational therapy and their association with implementation outcomes. This review presents these strategies and corresponding outcomes using uniform language and identifies the extent to which strategy selection has been guided by theories, models, and frameworks (TMFs).

METHODS

A scoping review protocol was developed to assess the breadth and depth of occupational therapy literature examining implementation strategies, outcomes, and TMFs in the stroke rehabilitation field. Five electronic databases and two peer-reviewed implementation science journals were searched to identify studies meeting the inclusion criteria. Two reviewers applied the inclusion parameters and consulted with a third reviewer to achieve consensus. The 73-item Expert Recommendations for Implementing Change (ERIC) implementation strategy taxonomy guided the synthesis of implementation strategies. The Implementation Outcomes Framework guided the analysis of measured outcomes.

RESULTS

The initial search yielded 1219 studies, and 26 were included in the final review. A total of 48 out of 73 discrete implementation strategies were described in the included studies. The most used implementation strategies were "distribute educational materials" (n = 11), "assess for readiness and identify barriers and facilitators" (n = 11), and "conduct educational outreach visits" (n = 10). "Adoption" was the most frequently measured implementation outcome, while "cost" was not measured in any included studies. Eleven studies reported findings supporting the effectiveness of their implementation strategy or strategies; eleven reported inconclusive findings, and four found that their strategies did not lead to improved implementation outcomes. In twelve studies, at least partially beneficial outcomes were reported, corresponding with researchers using TMFs to guide implementation strategies.

CONCLUSIONS

This scoping review synthesized implementation strategies and outcomes that have been examined in occupational therapy and stroke rehabilitation. With the growth of the stroke survivor population, the occupational therapy profession must identify effective strategies that promote the use of evidence-based practices in routine stroke care and describe those strategies, as well as associated outcomes, using uniform nomenclature. Doing so could advance the occupational therapy field's ability to draw conclusions about effective implementation strategies across diverse practice settings.

Describing the occupational nature of practice: A scoping review

BACKGROUND

Describing how occupation is used in practice can be challenging for occupational therapists. Occupation-centred, occupation-based, and occupation-focussed terminology are frequently used interchangeably and ambiguously to describe practice. However, ambiguous language creates confusion and inadequately demonstrates the value of occupation.

AIMS/OBJECTIVES

This scoping review aimed to identify how occupation-centred, occupation-based, and occupation-focussed terminology are defined and represented in occupational therapy literature.

MATERIALS AND METHODS

A five-step scoping review included papers published between 2014 and 2019 from four databases. Extracted data were summarised to outline how the terms were being used within the literature.

RESULTS

Initial searching yielded 819 articles and 35 papers met inclusion/exclusion criteria. Within current literature, occupation-focussed and occupation-based terminology were inconsistently described. A limited number of articles used occupation-centred and occupation-focussed terminology to describe practice, whilst occupation-based was more prominent. Occupation-based terminology was represented in numerous ways to describe assessments, practice tools, interventions, research, and theory. Discrepancies between the description and implementation of occupation-based practice were most prominent within interventions.

CONCLUSION AND SIGNIFICANCE

Findings demonstrated that occupation-based and occupation-focussed terminology were used interchangeably and inconsistently in literature. It is timely to consider how this is problematic for our professional identity and perceptions of occupation in practice.

Independence in Daily Activities after Stroke among Occupational Therapy Patients and Its Relationship with Unilateral Neglect

More research is needed to better understand the impact of occupational therapy (OT) in stroke patients and syndromes of unilateral neglect (UN) and anosognosia. A prospective, observational, longitudinal design was conducted on a sample of 27 OT patients. The objectives were to examine: (1) the presence of UN and anosognosia; (2) the functional outcomes; and (3) the association of UN at baseline with functional status at discharge from OT. The outcomes were Barthel (functional independence) and the Rivermead Mobility Index (RMI). The baseline proportion of participants with UN was 33% according to the Star Cancellation Test (STC), and 48.1% according to the Catherine Bergego Scale (CBS) therapist-version. There was a significant difference between the therapist and participant-rated CBS scores (p = 0.004). Functional independence improved significantly between the initial and final assessments (p < 0.001); the effect size (r) was large (r = 0.61). There was a significant improvement in RMI scores (p < 0.001), which was large in size (r = 0.59). Both the STC and CBS-therapist scores were significantly correlated with the Barthel (p < 0.001, p = 0.005, respectively) and with the RMI (p = 0.004, p = 0.028, respectively). The participants substantially enhanced their functional status skills. UN and anosognosia were common problems, and neglect was associated with worse OT program outcomes.

Examining components of community psychosocial stroke interventions using concept mapping

BACKGROUND

Stroke impacts psychosocial well-being and engagement in occupation. Psychosocial interventions reduce depression and anxiety but may not impact occupation. Knowledge of key processes and components of community psychosocial stroke interventions can inform future intervention development.

AIM/OBJECTIVE(S)

To determine the essential elements common to three psychosocial interventions for stroke survivors.

MATERIAL(S) AND METHOD(S)

Concept maps were created for three community psychosocial stroke interventions based on published literature and communication with researchers who tested the intervention with stroke survivors. The concept maps were then compared to identify common elements. Ongoing communication with researchers ensured accurate representation of each respective intervention.

RESULTS

Similarities in intervention processes and components included support for autonomy; individualized information exchange; coping, life skill development and adaptation support; competence development; and the incorporation of goals. Differences included intervention delivery (individual versus group), and the avenues in which psychosocial needs are addressed (occupation versus dialogue).

CONCLUSIONS

Concept mapping identified similarities among the three interventions that can be best understood using self-determination theory. Clinicians may utilize findings revealed in the process to inform evidence-based psychosocial stroke interventions.

SIGNIFICANCE

Knowledge of key 'active ingredients' for psychosocial community stroke interventions, can be used to guide clinical reasoning and inform development of interventions.

Impairment and Compensation in Dexterous Upper-Limb Function After Stroke. From the Direct Consequences of Pyramidal Tract Lesions to Behavioral Involvement of Both Upper-Limbs in Daily Activities

Impairments in dexterous upper limb function are a significant cause of disability following stroke. While the physiological basis of movement deficits consequent to a lesion in the pyramidal tract is well demonstrated, specific mechanisms contributing to optimal recovery are less apparent. Various upper limb interventions (motor learning methods, neurostimulation techniques, robotics, virtual reality, and serious games) are associated with improvements in motor performance, but many patients continue to experience significant limitations with object handling in everyday activities. Exactly how we go about consolidating adaptive motor behaviors through the rehabilitation process thus remains a considerable challenge. An important part of this problem is the ability to successfully distinguish the extent to which a given gesture is determined by the neuromotor impairment and that which is determined by a compensatory mechanism. This question is particularly complicated in tasks involving manual dexterity where prehensile movements are contingent upon the task (individual digit movement, grasping, and manipulation…) and its objective (placing, two step actions…), as well as personal factors (motivation, acquired skills, and life habits…) and contextual cues related to the environment (presence of tools or assistive devices…). Presently, there remains a lack of integrative studies which differentiate processes related to structural changes associated with the neurological lesion and those related to behavioral change in response to situational constraints. In this text, we shall question the link between impairments, motor strategies and individual performance in object handling tasks. This scoping review will be based on clinical studies, and discussed in relation to more general findings about hand and upper limb function (manipulation of objects, tool use in daily life activity). We shall discuss how further quantitative studies on human manipulation in ecological contexts may provide greater insight into compensatory motor behavior in patients with a neurological impairment of dexterous upper-limb function.

Understanding activity participation 3-months after stroke: a mixed methodology study

PURPOSE

To investigate stroke survivors' activity participation 3-months after stroke, reasons for activity participation and the change in reason for activity participation.

METHOD

Thirty stroke survivors were administered the Activity Card Sort-Australia concurrent with a semi-structured interview about their activity participation. Data were analyzed using descriptive statistics and spiral content analysis.

RESULTS

Participants had returned, in part, to 96% of their previous leisure, social/educational and household activities 3-months after-stroke; retaining more sedentary and home-based activities but fewer physically demanding and community-based activities. Thirteen participants described a change in their reasons for their activity participation. Personal, environmental and temporal dimensions explained these reasons for activity participation, as well as the changes in reason for activity participation. Full activity participation involved participants' orchestrating a dynamic mix of fulfilling their personal desires according to their current physical, mental and emotional capacity; their social, organizational and physical environmental demands and obligations; and their routines, available time and future plans.

CONCLUSION

Qualitative interviews extend our understanding of the process of returning to participation in life activities and occupations following stroke to reveal that it involves the stroke survivor in a dynamic adaptation process of synchronizing personal, environmental and temporal dimensions in their daily lives.IMPLICATIONS FOR REHABILITATIONRehabilitation professionals need to recognize the unique knowledge and ability stroke survivors have to manage their capacities, activities, occupations and environments.Client-centered practice involving true collaborative partnerships are needed to ensure stroke survivors return more satisfactorily to their activities and occupations.Rehabilitation professionals need to continually consider the ongoing changing relationships that occur between the person, their capacities, social, organizational and physical environments, and the person's activity/occupational participation during recovery from stroke.Returning to full activity/occupational participation after stroke is a dynamic and continuous process.Rehabilitation needs to be provided in different forms at different stages beyond the immediate post-stroke time so that stroke survivors benefit from the "right rehabilitation" at the "right time" throughout their recovery journey.

Participation based intervention with acquired brain injury: Systematic review and meta-analysis

BACKGROUND

Continued long-term rehabilitation programs with acquired brain injury are important for their participation in meaningful daily activities.

OBJECTIVE

This paper investigated the participation-based interventions on outcomes in patients with acquired brain injury.

METHODS

A systematic review and meta-analysis search for randomized control trials published between 1998 and 2019 using PubMed, CINAHL, and MEDLINE was performed. Nine studies were selected and analyzed for systematic review. Five studies analyzed the effectiveness of participation-based intervention using meta-analysis and assessed the level of evidence of qualitative studies.

RESULTS

A total of 843 publications were searched. Nine studies met the inclusion criteria and were of high quality. The effective score for improving participation following participation-based interventions in persons with acquired brain injury was 0.32 and significant in this study (p < 0.05).

CONCLUSIONS

The findings of this systematic review and meta-analysis suggest that, in persons with acquired brain injury, participation-based interventions are essential for community living.

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.

Cognitive strategy training for adults with neurological conditions: a systematic review and meta-analysis exploring effect on occupational performance

Introduction

The objective of this systematic review was to synthesise the evidence for cognitive strategy training to determine its effectiveness to improve performance of activities of daily living in an adult neurological population.

Method

Medline, CINAHL, EMBASE, PSYCInfo, PsycBITE and Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were searched until August 2019. Studies examining the effect of cognitive strategy training on functional performance were included. Population criteria included adults with non-progressive neurological conditions. External and internal validity of included studies was systematically evaluated using an appropriate methodological quality assessment for each study design. A content analysis was conducted of the methodologies used.

Findings

Forty-one studies met the inclusion criteria and were appraised for content, 16 randomised or quasi-randomised trials were meta-analysed. Trial quality was generally ‘good’, Physiotherapy Evidence Database scale scores ranged from 3 to 8 (out of 10). For activity performance outcomes post-intervention, there was a significant benefit of cognitive strategy training over usual care (standardised mean difference 0.79, 95% confidence interval 0.49–1.09; P < 0.00001).

Conclusion

More high-quality research is needed to strengthen the evidence base for cognitive strategy interventions to improve activity performance outcomes for adults with non-progressive neurological conditions.

Systematic review registration

PROSPERO CRD42016033728

Occupational therapy assessment and treatment approach in patients with subacute and chronic stroke: A single-blind, prospective, randomized clinical trial

Objectives

The aim of this study was to examine the effects of occupational therapy (OT) combined with standard rehabilitation (SR) on the activities of daily living, quality of life, and psychological symptoms of hemiplegic patients.

Patients and methods

Between August 2014 and February 2016, a total of 35 hemiplegic patients with post-diagnostic periods (19 males, 16 females; mean age 58.3 years; range 37 to 77 years) were included. The patients were randomized into two groups as OT+SR group (n=17) and SR only group (n=18). The study was completed by 16 patients in each group. The patients in the OT group were given 45-min SR five days a week plus 45-min OT three days a week over an eight-week period, while the patients in the SR group received SR only (of the same duration and frequency as the OT group). The patients were assessed at enrolment (pre-treatment), and again after eight weeks of treatment using the Pinch and Grip Strength and the Purdue Pegboard tests, Global Daily Living Activities Scale, Performance Assessment of Self-care Skills (PASS), Nottingham Extended Activities of Daily Living (NEADL) Scale, Quality of Life Short Form (SF-36) Questionnaire, and Hospital Anxiety and Depression Scale (HAD) for their psychological state.

Results

Significant improvements were observed in within-group scores for PASS, Pinch and Grip Strength Test, NEADL Scale, and Purdue Pegboard test (p<0.05). After treatment, a significant increase was found in the SF-36 physical function, general health and physical total in-group scores of the OT group, whereas a significant increase was observed only in the physical total scores of the SR group (p<0.05). There was no significant improvement in the HAD scores within both groups (p>0.05). Inter-group comparisons revealed a further significant improvement in PASS instrumental daily activity index-physical subscale and Purdue Pegboard Test scores of the OT group (p<0.05). However, there was no significant difference in PASS activity, self-care and instrumental daily activity cognitive subscale, SF-36, HAD and hand grip and pinch strength scores between the groups (p>0.05).

Conclusion

Occupational therapy combined with SR applications has a beneficial impact on certain daily living activities and hand functions. Occupational therapy does not have any additional benefits on the quality of life, pinch and grip strength, and the psychological state.

Exploring stroke survivors' experiences and understandings of occupational therapy

BACKGROUND

Occupational therapists view people with stroke as occupational beings who may experience occupational issues. Concurrently, occupational therapy practice is guided by research evidence that supports predominantly impairment-based practices. There has been limited exploration of how people with stroke experience and understand occupational therapy in the context of the potential tension between the professional philosophy and the research-based evidence.

AIMS/OBJECTIVE

To explore the experience and understanding of occupational therapy with stroke survivors.

MATERIAL AND METHODS

Interpretative phenomenology guided semi-structured interviews with nine participants from five states across Australia.

RESULTS

Three themes emerged: Understanding of occupational therapy grows by 'doing' outlines how participants understood occupational therapy based on their individual experiences over time; Personal factors influence the experience highlights how participants had diverse expectations for recovery that influenced their occupational therapy experience. Context shapes occupational therapy experience identified that the therapeutic relationship and context of occupational therapy were important factors in shaping experiences.

CONCLUSION

Both impairment-based and occupation-based therapy were considered valuable aspects of occupational therapy, representing the proposed tension between the professional philosophy and research-based evidence. Occupation-based and client-centred practice was more often experienced in the outpatient setting, with challenges described for both within the inpatient setting.

Occupation-based group programs in the inpatient hospital rehabilitation setting: a scoping review

PURPOSE

Occupation-based practice involves the inclusion of meaningful occupations in the therapeutic process and is promoted within hospital-based general rehabilitation contexts for individual clients or within a group setting. The purpose of this paper is to summarise the current literature regarding the types of occupation-based group programs used within general inpatient rehabilitation and the reported outcomes.

METHODS

A scoping review was conducted and included papers if they described an occupation-based intervention, delivered in a group setting, conducted in an inpatient rehabilitation hospital context, with an adult population. Studies were collated, summarized and key findings are presented.

RESULTS

Ten articles met inclusion criteria. The results indicate that occupation-based groups are used in inpatient rehabilitation across a variety of settings, the approach is valued by the occupational therapy profession and it appears to have an influence on patient satisfaction and experience. However, the impact on a patient's confidence and occupational performance outcomes post-inpatient rehabilitation remains unclear.

CONCLUSIONS

There is a dearth of evidence on the impact of occupation-based group service focus in the inpatient rehabilitation setting. Considering the importance of occupation to the profession, further investigation into the use of this approach in a group setting is required.Implications for rehabilitationOccupation-based groups are used in inpatient rehabilitation to achieve more therapy time but there is variability in group processes and outcomes measured.Patient centred occupation-based groups appear to have an influence on patient satisfaction and experience.For the occupation-based groups reviewed, providing explicit links between patient goals, therapeutic activity and real life was important for improving outcomes.There is a growing focus for the use of occupation-based groups in occupational therapy and more research is needed to establish effectiveness.

Occupational Therapy's Value in Provision of Quality Care to Prevent Readmissions

Health care systems are prioritizing the quality of outcomes over the quantity of services provided, and health care payers and other stakeholders are focusing on preventing hospital readmissions. This priority supports the effort to reduce the cost of health care by avoiding the most expensive care type and improving the quality of health care by promoting sustained return to the community and remaining in the community. Occupational therapy practitioners have expertise that is critically important in this effort. Occupational therapy places a unique and immediate focus on patients' functional and social needs, which can be important drivers of readmissions if they are not addressed. By addressing activities of daily living, instrumental activities of daily living, functional cognition, psychosocial needs, vision, fear of falling, and safety, occupational therapy practitioners can be a valuable addition to the effort to keep people out of the hospital and participating in their lives. This article reviews the literature supporting the role of occupational therapy in each of these key areas.

Self-perceived functioning and disability after randomized conventional and electromechanically-assisted gait training in subacute stroke: A 6 months follow-up

BACKGROUND

Few previous studies have assessed self-perceived functioning, disability and recovery after electromechanically-assisted gait training (EAGT).

OBJECTIVE

To compare self-perceived functioning, disability and recovery after EAGT and after conventional gait training in the subacute stage after stroke, using the Stroke Impact Scale (SIS), and factors associated with self-perceived recovery, assessed at 6 months after stroke.

METHODS

Patients were randomized into two groups performing a 4-week intervention period of incorporated EAGT using the Hybrid Assistive Limb (HAL) or conventional physiotherapy only.

RESULTS

There were no significant differences in self-perceived strength, ADL, mobility, participation and percentage of recovery between intervention groups (p > 0.05). Self-perceived mobility was associated with improvements in objectively assessed walking speed/endurance and balance (R2 0.717, p = 0.002), and self-perceived recovery with self-perceived activities of daily living (ADL) ability (R2 0.34, p = 0.001).

CONCLUSIONS

This study indicates that EAGT and conventional gait training in the subacute stage after stroke have no differential impact on self-perceived functioning, disability and recovery at 6 months after stroke. Further, the study highlights the importance of interventions targeting ADL and self-care independence during stroke rehabilitation to enhance self-perceived recovery and clinical aspects to be targeted to enhance perceived mobility.

Activity Performance, Participation, and Quality of Life Among Adults in the Chronic Stage After Acquired Brain Injury-The Feasibility of an Occupation-Based Telerehabilitation Intervention

Objective: Acquired brain injury (ABI) is a leading cause of long-term disability. This calls for effective and accessible interventions to support participation in the community over time. One promising avenue to answer this need is telerehabilitation. Prior to conducting a larger trial, the main objective of this pilot study is to explore the feasibility, acceptability, and preliminary efficacy of a metacognitive occupation-based intervention in a telerehabilitation format with adults and older adults in the chronic phase after ABI.

Methods: Five community dwelling participants (ages 65–72), 6–10 months post-ABI, with scores 2–4 on the modified Rankin scale and without dementia, completed the teleintervention. The intervention included ~10 weekly videoconferencing sessions administered by an occupational therapist using the Cognitive Orientation to Daily Occupational Performance approach. Each participant defined five functional goals and three were trained and two were not trained during the intervention. Evaluations were conducted at pre, post, and 3-month follow-up. The primary outcome measures included activity performance (The Canadian Occupational Performance Measure; COPM), participation (the Mayo-Portland Adaptability Inventory-4 Participation Index; MPAI-4-P), and quality of life (QoL) (stroke impact scale; SIS). Other measures included a feedback interview, satisfaction questionnaire, field notes, and a treatment fidelity checklist.

Results: The teleintervention was found to be feasible and the participants expressed a high degree of satisfaction with the intervention and the technology use. A Wilcoxon Signed-Ranks test indicated statistically significant improvements post intervention in COPM performance (z = −2.023, p = 0.043) and satisfaction (z = −2.023, p = 0.043) ratings. Additionally, clinically significant improvements (≥2 points) in both performance and satisfaction with performance were found for each participant in at least three of their five defined functional goals. Trends toward significant improvement were found in MPAI-4-P ratings post intervention (z = −1.826, p = 0.068). Furthermore, clinically significant improvements (≥15 points) post intervention were found for each participant in some subscales of the SIS. Results were partially maintained at 3-month follow-up.

Conclusions: This pilot study demonstrated the feasibility of a metacognitive occupation-based telerehabilitation intervention and its potential benefits in activity performance, participation, and QoL for older adults coping with long-term disability following ABI.

Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03048708.

Results of an occupational self-analysis program in people with acquired brain injury. A pilot study

Purpose: The aim of this study was to evaluate the benefits of an occupational self-analysis program in people with acquired brain injury (ABI) in the areas of subjective health perception and occupational participation.Material and Method: This study explored the benefits of an occupational self-analysis program in people with ABI. The intervention group comprised 7 participants; the control group included 5 participants. Outcomes were measured using the SF-36 Health Survey and the Role Checklist. The contents of solicited participant diaries and a focus group discussion were also analyzed.Results: Compared to the control group, the intervention group showed statistically significant improvements in the SF-36 energy/fatigue subscale. The qualitative analysis revealed that participants in the intervention group increased their occupational participation in activities of daily living (ADL), social involvement, and leisure.Conclusion: The program helped participants improve their health perception and increase their occupational participation through learning about their supports and barriers for engaging in meaningful activities.

Clinical Validation of Nursing Diagnoses Related to Self-Care Deficits in Patients with Stroke

To clinically validate the defining characteristics of nursing diagnoses related to self-care deficits in feeding, bathing, toileting, and dressing in patients with stroke. A diagnostic accuracy study was conducted with a sample of 135 patients with stroke. Sensitivity and specificity were calculated based on the latent class analysis method using the random effects model. The prevalence of diagnoses was 23.5% for Bathing self-care deficit, 18.5% for Dressing self-care deficit, 13.3% for Toileting self-care deficit, and 7.5% for Feeding self-care deficit. Fourteen defining characteristics were sensitive, and 17 were specific. Hemorrhagic stroke and note 4 on the Rankin scale was associated with self-care deficits. Of the 37 defining characteristics of the four diagnoses studied, 19 were clinically validated according to the latent class analysis model. These most accurate clinical indicators contribute to the development of the care plan for patients with stroke.

A Systematic Review of International Clinical Guidelines for Rehabilitation of People With Neurological Conditions: What Recommendations Are Made for Upper Limb Assessment?

Background: Upper limb impairment is a common problem for people with neurological disabilities, affecting activity, performance, quality of life, and independence. Accurate, timely assessments are required for effective rehabilitation, and development of novel interventions. International consensus on upper limb assessment is needed to make research findings more meaningful, provide a benchmark for quality in clinical practice, more cost-effective neurorehabilitation and improved outcomes for neurological patients undergoing rehabilitation.

Aim: To conduct a systematic review, as part of the output of a European COST Action, to identify what recommendations are made for upper limb assessment.

Methods: We systematically reviewed published guidance on measures and protocols for assessment of upper limb function in neurological rehabilitation via electronic databases from January 2007–December 2017. Additional records were then identified through other sources. Records were selected for inclusion based on scanning of titles, abstracts and full text by two authors working independently, and a third author if there was disagreement. Records were included if they referred to “rehabilitation” and “assessment” or “measurement”. Reasons for exclusion were documented.

Results: From the initial 552 records identified (after duplicates were removed), 34 satisfied our criteria for inclusion, and only six recommended specific outcome measures and /or protocols. Records were divided into National Guidelines and other practice guidelines published in peer reviewed Journals. There was agreement that assessment is critical, should be conducted early and at regular intervals and that there is a need for standardized measures. Assessments should be conducted by a healthcare professional trained in using the measure and should encompass body function and structure, activity and participation.

Conclusions: We present a comprehensive, critical, and original summary of current recommendations. Defining a core set of measures and agreed protocols requires international consensus between experts representing the diverse and multi-disciplinary field of neurorehabilitation including clinical researchers and practitioners, rehabilitation technology researchers, and commercial developers. Current lack of guidance may hold-back progress in understanding function and recovery. Together with a Delphi consensus study and an overview of systematic reviews of outcome measures it will contribute to the development of international guidelines for upper limb assessment in neurological conditions.

Reliability and Validity of a Functional Cognition Screening Tool to Identify the Need for Occupational Therapy

IMPORTANCE

The Centers for Medicare & Medicaid Services (CMS) has identified the need to assess functional cognition as part of the postacute care planning process.

OBJECTIVE

We examined the reliability, validity, and clinical utility of the Menu Task (MT) as a screening measure of functional cognition to assess the need for occupational therapy services.

DESIGN

Cross-sectional study testing a convenience sample of community-dwelling older adults (n = 130) and adults hospitalized for elective orthopedic surgery (n = 60). The MT and four neuropsychological screening tests-the Brief Interview of Mental Status, the Montreal Cognitive Assessment, Trail Making Tests A and B, and an instrumental activities of daily living (IADL) scale-were administered.

SETTING

Community-dwelling participants were tested at the University of Wisconsin occupational therapy program and in community settings. Hospitalized participants were tested at the University of Missouri Orthopedic Institute.

PARTICIPANTS

We recruited healthy community-dwelling adults in Madison, WI (community sample; n = 130) and patients hospitalized for elective orthopedic surgery in Columbia, MO (hospital sample; n = 60). Inclusion criteria were age 55 yr or older, living in the community, and willingness to be tested in English; for the hospital sample, participants had to be referred for elective orthopedic surgery requiring a hospital stay and be independent in activities of daily living before being admitted for surgery.

RESULTS

We found significant differences between groups classified as impaired or not impaired on the basis of MT scores. Participants classified as impaired on the MT performed significantly less well than those classified as not impaired on the neurocognitive and IADL measures.

CONCLUSION

The reliability and validity of the MT were supported.

WHAT THIS ARTICLE ADDS

The American Occupational Therapy Association and the occupational therapy experts advising CMS have stressed the importance of a brief performance-based screening tool to identify people who need more comprehensive occupational therapy evaluation. The implementation of a functional cognition screening tool as part of the required CMS assessment protocol should greatly increase the number of patients referred for occupational therapy evaluation and treatment. The MT has the capacity to address the gap in the proposed CMS assessment of Medicare recipients across postacute care settings.

Effectiveness of occupation-based interventions on performance's quality for hemiparetic stroke in community-dwelling: A randomized clinical trial study

BACKGROUND

Occupations define activities that people perform to occupy themselves and that people have meaning and value to them. The use of occupation-based intervention addresses activity daily of living performance.

OBJECTIVES

This study was to investigate the effects of occupation-based interventions on performance's quality for hemiparetic stroke in community-dwelling.

METHODS

Forty-three participants were enrolled in this study with a full understanding of the purpose and method of the research and had a diagnosis with hemiparetic stroke. Participants were randomized to one of two treatment groups: Experimental group (n = 23) or control groups (n = 20). The experimental group applied occupation-based intervention and control group applied action focusing intervention. All participants underwent ten treatment sessions during the study period and conducted pre- and post-assessment. Several instruments were used to measure quality of performance.

RESULTS

After the intervention training, the qualities of occupational performance were significantly higher in the experimental group applied occupation-based intervention than the control group applied action focusing intervention (p < 0.001).

CONCLUSIONS

Based on the results of this study, occupation-based intervention has positive effects on quality of performing daily activities and occupational activities independently in persons with hemiparetic stroke.

Participation, Fear of Falling, and Upper Limb Impairment are Associated with High Sitting Time in People with Stroke

The purpose of this cross-sectional, exploratory study was to explore associations between sitting time and (1) participation, (2) fear of falling, and (3) upper limb impairment after stroke. High sitting time was associated with less participation in meaningful activities involving standing or walking (ρ = -0.519, p = 0.023). A greater fear of falling (ρ = 0.579, p = 0.012) and having an impaired upper limb (mean difference 18.7%, 95% CI: 5.3-32.1, p = 0.012) were associated with greater sitting time. Providing support for stroke survivors to participate in meaningful activities while reducing sitting time is an important consideration when planning occupational therapy interventions, particularly for individuals with an arm impairment and/or those with a fear of falling.

Influence of Environmental Factors on Social Participation Post-Stroke

Objectives

For rehabilitation professionals to adequately address meaningful participation in social activities with their patients after a stroke, there must be a better understanding of neurobehavior, that is, how neurological impairment and its sequelae and environmental factors support or limit social participation. The current study examines how stroke severity (NIH Stroke Scale), its impact on perceived mobility (Stroke Impact Scale mobility domain), and the environment (MOS Social Support–Positive Social Interactions scale and Measure of Stroke Environment receptivity and built environment domains) influence social participation (Activity Card Sort: ACS).

Methods

A correlational, cross-sectional design examined the relationships among neurological impairment, perceived limitations in activity, environmental factors, and social participation. Participants included 48 individuals who were at least 6 months post-stroke both with aphasia (N = 22) and without aphasia (N = 26) living in the community for whom all measures were available for analysis.

Results

No differences in social participation were found between those with and without aphasia, though both groups reported a large (25-30%) decline in participating in their prestroke social activities. For the ACS Social Domain activities and ACS Partner to Do With activities (percent retained), 37% and 35% of the variance, respectively, was accounted for by the predictor variables, with only MOS Social Support making an independent contribution to social participation. In this sample, neurological impairment was not a significant correlate of social participation. Additionally, perceived mobility and the built environment were not found to independently predict participation in social activities.

Conclusions

Perceived social support was found to predict social participation in individuals living in the community 6 months or greater post-stroke. Focusing on social support during post-stroke rehabilitation may provide an avenue for increased social participation and more successful community reintegration.

The Occupation-Based Intervention of Bathing: Cases in Home Health Care

Although bathing skills can be an indicator of long term placement, documentation of occupational therapists doing bathing as an occupation-based intervention is limited. Five clients were referred to a hospital-based home health agency with various diagnoses and at different levels of functioning. Each client was assessed at admission and discharge using the Outcomes and Assessment Information Set and the occupational therapists used the Activities of daily living (ADL) of bathing as the intervention based on client centered expressed needs. Findings reveal a statistically significant change in individuals pre- and post-assessment of bathing (Z = -2.032, p = .042) supporting occupation-based interventions, specifically bathing, should be further researched as a means of significantly improving the functional status of clients.

To what extent does therapy of chronic stroke patients address participation? A content analysis of ambulatory physical and occupational therapy based on the International Classification of Functioning, Disability, and Health framework

Purpose: The study aim was to analyze whether ambulatory therapy of chronic stroke patients contains elements that specifically address "Activity and participation", and to what extent participation as a major goal in rehabilitation is realized in ambulatory care.Method: Qualitative and quantitative content analysis of standard therapy of 71 chronic stroke patients with upper limb impairment. 469 statements on therapy of 34 therapists were analyzed using data-driven and concept-driven coding based on the International Classification of Functioning, Disability and Health framework.Results: Almost half of therapy provided to stroke patients was related to "Upper extremity" (47.5%), as one out of seven identified main categories. Regarding International Classification of Functioning, Disability, and Health framework, 75.1% of therapeutic practices in ambulatory therapy covered "Body functions," but only 13.2% addressed "Activities and participation". Some statements contained specific therapeutic concepts (9.4%) or isolated notes (2.1%) and were not linkable to the International Classification of Functioning, Disability and Health framework.Conclusions: Ambulatory therapy of chronic stroke patients is related, in part, to participation. There is potential for an increase in participation by applying therapeutic approaches, which actively involve the patients in goal-setting and therapeutic exercises to specifically address activities and participation.Implications for rehabilitationTo realize participation as a major goal in the rehabilitation process ambulatory therapy of chronic stroke patients, one should focus on therapeutic approaches and exercises that specifically address activities and participation.Structured goal-setting, which actively involve patients, can be used to identify goals relevant to individual activities and participation.

Leisure as an End, Not Just a Means, in Occupational Therapy Intervention

Leisure is commonly treated as a means instead of an end goal of intervention. This approach, influenced by history and society's past values, does not reflect the fact that leisure is meaningful and unique to its participants and has a significant effect on their health. On the basis of the core values of the occupational therapy profession and its role in the health care system, in this article we advocate that occupational therapists should expand their focus to include leisure as a goal of intervention. Although adopting this proposed approach may not be easy, given that it involves challenges in reimbursement for services, potential competition with other health professions, and a twisting of the deep-rooted existing values of occupational therapists, we believe the proposed solutions address these concerns and shed light on how to make leisure a valued goal of intervention.

Activity limitations and subjective well-being after stroke

OBJECTIVE

As limitations in activities of daily living are major components of many stroke outcome scales, we examined how well activity limitations predicted subjective well-being among stroke survivors in a nationally representative survey.

METHODS

Individuals with a self-reported history of stroke were identified from the National Health and Aging Trends Study. Subjective well-being (primary outcome) was assessed with a validated 7-item measure (higher = greater well-being) assessing emotions (cheerful, bored, full of life, and upset) and self-realization (purpose in life, self-acceptance, and environmental mastery). Activity limitations were defined by the receipt of help in any of 11 activities of daily living/instrumental activities of daily living. Multivariable linear regression assessed predictors of well-being including medical, physical, cognitive, psychological, and environmental factors.

RESULTS

A total of 738 stroke survivors age 65 or older were included (57% female, 9% African American, 6% Hispanic). Activity limitations were modestly associated with well-being after adjusting for demographic characteristics and availability of assistance (estimate -0.49, 95% confidence interval -0.61 to -0.37). However, in the fully adjusted model (R2 = 0.28), neither activity limitations nor physical capacity was associated with subjective well-being. Predictors of lower well-being in the final model included depressive symptoms, chewing/swallowing problems, pain that limited activity, and restricted participation in valued life activities. Income and executive function were modestly associated with improved well-being, while comorbidities and communication technology access were not associated.

CONCLUSIONS

Activity limitations were not associated with stroke survivors' subjective well-being after adjustment for other factors. While some predictors of well-being after stroke were identified, the determinants of well-being remained largely unexplained.

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.

Factors Associated With Success in an Occupational Rehabilitation Program for Work-Related Musculoskeletal Disorders

Work-related musculoskeletal disorders are a significant burden; however, no consensus has been reached on how to maximize occupational rehabilitation programs for people with these disorders, and the impact of simulating work tasks as a mode of intervention has not been well examined. In this retrospective cohort study, the authors used logistic regression to identify client and program factors predicting success for 95 clients in a general occupational rehabilitation program and 71 clients in a comprehensive occupational rehabilitation program. The final predictive model for general rehabilitation included gender, number of sessions completed, and performance of work simulation activities. Maximum hours per session was the only significant predictor of success in the comprehensive rehabilitation program. This study identifies new factors associated with success in occupational rehabilitation, specifically highlighting the importance of intensity (i.e., session length and number of sessions) of therapy and occupation-based activities for this population.