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The American Journal of Occupational Therapy 369
Occupational Therapy Activities and Intervention Techniquesfor
Clients With Stroke in Six Rehabilitation Hospitals
Nancy K. Latham, Diane U. Jette, Wendy Coster, Lorie Richards,
Randall J. Smout, Roberta A. James, Julie Gassaway, Susan D.
Horn
OBJECTIVE. To prospectively monitor occupational therapy
activities and intervention techniques used dur-ing inpatient
stroke rehabilitation in order to provide a description of current
clinical practice.
METHODS. Data were collected prospectively from 954 clients with
stroke receiving occupational therapyfrom six U.S. rehabilitation
hospitals. Descriptive statistics summarized frequency, intensity,
and duration ofoccupational therapy sessions; proportion of time
spent in 16 therapeutic activities; and proportion of
thoseactivities that included any of 31 interventions.
RESULTS. Clients received on average 11.8 days (SD = 7.2) of
occupational therapy, with each session last-ing on average 39.4
min (SD = 16.9). Upper-extremity control (22.9% of treatment time)
and dressing (14.2%of treatment time) were the most frequently
provided activities. Interventions provided most frequently
duringupper-extremity control activities were strengthening, motor
learning, and postural awareness.
CONCLUSION. Occupational therapy provided reflected an
integration of treatment approaches. Upper-extremity control and
basic activities of daily living were the most frequent activities.
A small proportion of ses-sions addressed community
integration.
Latham, N. K., Jette, D. U., Coster, W., Richards, L., Smout, R.
J., James, R. A., Gassaway, J., & Horn, S. D.
(2006).Occupational therapy activities and intervention techniques
for clients with stroke in six rehabilitation hospitals.American
Journal of Occupational Therapy, 60, 369378.
Stroke is the third largest cause of death and one of the
leading causes of long-term disability in the United States
(Centers for Disease Control andPrevention, 2000). Significant
progress has been made in stroke care over the past30 years and as
a result the proportion of people who survive a stroke has
increased(Centers for Disease Control and Prevention, 2000). It is
now well established thatdifferences in post-stroke care and
rehabilitation have a significant effect on out-come, with one
systematic review finding that clients who received organized
inpa-tient care in a stroke unit were more likely to be alive,
independent, and living athome 1 year after the stroke (Stroke Unit
Trialists Collaboration, 2003). However,despite evidence that
post-stroke care influences outcomes, the ideal activities
orapproaches to treatment that should be included in stroke
rehabilitation are stillnot well established (Wade & de Jong,
2000).
Occupational therapists play an important role in post-stroke
rehabilitation.The National Board for Certification in Occupational
Therapy (NBCOT) PracticeAnalysis reported that cerebrovascular
accident was the most frequent diagnosisseen by their survey
respondents (NBCOT, 2004). Several recent systematicreviews suggest
that occupational therapy after a stroke improves the performanceof
some functional tasks and reduces some impairments (Ma &
Trombly, 2002;Steultjens et al., 2003; Trombly & Ma, 2002).
However, most trials provide fewdetails about the range of
occupational therapy interventions and activities thatwere used
across the rehabilitation episode.
Few observational studies exist that describe the nature of
occupational thera-py interventions currently being used for stroke
rehabilitation in the United States.Most studies to date have been
conducted in countries outside the United States(Alexander, Bugge,
& Hagen, 2001; Ballinger, Ashburn, Low, & Roderick,
1999;
Nancy K. Latham, PhD, is Research Assistant Professor,Health and
Disability Research Institute, Boston University,53 Bay State Road,
Boston, Massachusetts 02215;[email protected]
Diane U. Jette, DSc, PT, is Professor and Program
Director,Physical Therapy Program, Simmons College,
Boston,Massachusetts.
Wendy Coster, PhD, OTR, is Associate Professor andProgram
Director, Therapeutic Studies and OccupationalTherapy, Boston
University, Boston, Massachusetts.
Lorie Richards, PhD, OTR, is Research Health Scientist,Veterans
Affairs Research Service at the BrainRehabilitation Research
Center, North Florida/SouthGeorgia Department of Veterans Affairs
Medical Center,Gainesville, Florida; and Associate Professor,
OccupationalTherapy Department, University of Florida,
Gainesville,Florida.
Randall J. Smout, MS, is Senior Analyst, InternationalSeverity
Information Systems, Inc., Salt Lake City, Utah.
Roberta A. James is Data Systems Specialist,
InternationalSeverity Information Systems, Inc., Salt Lake City,
Utah.
Julie Gassaway, MS, RN, is Director of
Project/ProductDevelopment, International Severity Information
Systems,Inc., Salt Lake City, Utah.
Susan D. Horn, PhD, is Vice President for Research,International
Severity Information Systems, Inc., Salt LakeCity, Utah.
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370 July/August 2006, Volume 60, Number 4
deWeerdt et al., 2000); have described treatment activitiesonly
in terms of duration or frequency (Alexander et al.,2001;
Bernhardt, Dewey, Thrift, & Donnan, 2004; Sulch,Perez,
Melbourn, & Karla, 2000); or have involved a limit-ed number of
clients (Ballinger et al., 1999; deWeerdt et al.,2000). The
Practice Analysis (NBCOT, 2004) reports thefrequency with which
entry-level practitioners use specificinterventions, but does not
break these down by client con-dition and surveyed therapists only
within the first 3 yearsof their practice.
Given the limitations of reported studies and a lack
ofinformation about how clients with stroke are treated
byoccupational therapists in the United States, we undertooka study
to describe the care provided by occupational ther-apists for
clients with stroke in six hospital-based rehabilita-tion settings
within the United States. Our aim was todescribe the occupational
therapy plan of care by describingthe types of therapeutic
activities that therapists used witheach client. We defined
therapeutic activities as whole tasksthat were the focus of a
therapy session. In addition, wewished to capture the intervention
techniques that theoccupational therapists used during each of
these activities.We defined intervention techniques as specific
treatmentapproaches used by occupational therapy practitioners
tofacilitate activities. Finally, we collected data about
theduration, frequency, and intensity of occupational
therapysessions, and the personnel who provided them. This
infor-mation complements and expands information in theNBCOT
Practice Analysis (2004), by providing moredetailed information
about current practice with a specificclinical population by
practitioners with a broader range ofexperience. In addition, it
may provide guidance to clinicalresearchers about important
elements of occupational ther-apy that need to be documented in
future studies of reha-bilitation outcomes.
Methods
Subjects
As part of the Post-Stroke Rehabilitation Outcomes
Project(PSROP), data were collected between March 2001 toAugust
2003 from consecutive clients with stroke seen at sixrehabilitation
hospitals in the United States (DeJong et al.,2005). The sites were
geographically dispersed (3 in theWest, 1 in the Central Mountain
region, 1 in the South,and 1 in the East). The facilities were a
mixture of free-standing rehabilitation hospitals and
rehabilitation unitsthat were linked to acute care hospitals.
Physical Medicineand Rehabilitation residents were involved in
stroke man-agement in 2 out of 6 of the facilities. For this
observation-
al cohort study, a Clinical Practice Improvement approachwas
used in which detailed client, process, and outcomevariables were
obtained (Horn, 1997). This study wasapproved by the institutional
review boards at BostonUniversity and at each of the participating
hospitals and wasclassified as exempt because of its observational
nature.
Nine hundred and fifty-four clients met the inclusioncriteria,
which were a diagnosis code indicating that theperson had
experienced a stroke (ICD-9-CM of430438.99), was older than 18
years of age, had a recentstroke (within 1 year of admission) as
the reason for admis-sion, and had no interruption in
rehabilitation services ofgreater than 30 days (see Table 1 for
client characteristics).The mean age of clients was 66.2 years (SD
= 14.2). Mencomposed 51% of the sample and women 49%. Fifty-seven
percent of clients were White, 24% were AfricanAmerican, 4.9% were
Asian, and the remaining were ofother backgrounds or unknown race.
Forty-three percentof clients had left-sided hemiplegia, 43% had
right-sidedhemiplegia, 10% had bilateral involvement, and
theremainder had other types of involvement.
A total of 180 occupational therapy staff participated inthis
study, and of these, 61% were occupational therapists,38% were
occupational therapy assistants, and 1% werestudents. In the subset
of therapists who provided detailedinformation about their work
experience (i.e., 27%), theoccupational therapists had an average
of 10.3 years ofexperience (SD = 8.2, range = 132) and the
occupationaltherapy assistants had 8.3 years (SD = 5.6, range =
223).Most occupational therapists or occupational therapy
assis-tants (69%) worked full time (i.e., 40 hr per week).
Themajority of therapists and assistants had obtained someadvanced
training in neurology-related or geriatric-relatedcourses in the
past 2 years. The most frequently reported
Table 1. Client CharacteristicsCharacteristic N = 954
Age (years) Mean 66SD 14Range 1895
Gender % (n)Male 51 (487)Female 49 (467)
Race % (n)White 57.2 (546)African American 24.0 (229)Asian 4.9
(47)Other or unknown 13.9 (132)
Impairment % (n)Left hemiplegia 43.6 (416)Right hemiplegia 43.6
(416)Bilateral involvement 10.1 (96)Other 2.7 (26)
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The American Journal of Occupational Therapy 371
type of training was in neuromuscular interventions (i.e.,NDT or
neurodevelopmental treatment), in which 59% ofrespondents said that
they had participated during the past2 years.
Instrumentation
Forms to record activity and intervention data from
eachoccupational therapy session and definitions for each ofthese
terms were developed with input from occupationaltherapists
involved in care of clients with stroke at eachfacility
participating in the PSROP (DeJong et al., 2004).The data
collection forms allowed occupational therapyproviders to describe
sessions using 16 possible categories ofactivities. These included
Examination/Evaluation andactivities to remediate performance skill
deficits or bodystructure or function impairments (i.e.,
Pre-functional,Upper Extremity Control, Sitting Balance/Trunk
Control,Transfers, Functional Mobility, Bed Mobility); Activities
ofDaily Living (ADL: Bathing, Dressing, Grooming,Toileting,
Feeding/Eating), and Instrumental Activities ofDaily Living (IADL:
Home Management, CommunityIntegration, Leisure Performance,
Wheelchair Manage-ment). Therapists recorded the amount of time
spent oneach activity with the client in 5-min increments and up
to5 specific intervention techniques (from a list of 31) thatthey
used to facilitate performance of that activity. Optionsincluded
neuromuscular interventions (7), musculoskeletalinterventions (4),
cardiopulmonary interventions (2),modality interventions (3),
cognitive/perceptual/sensoryinterventions (4), adaptive and
compensatory interventions(4), equipment interventions (i.e.,
prescription, application,fabrication, and ordering), and education
and traininginterventions (3). Training in the use of assistive
devices orequipment during therapy could be recorded under
eachtreatment activity, with a list of 20 devices provided.
Onecategory was provided for writing in interventions or equip-ment
not provided on the form. Additional informationrecorded on each
session included: the amount of timespent in evaluation, in
cotreatment with other disciplines,and in therapy sessions that
included more than one client,as well as which providers gave care
during the session,including occupational therapists, occupational
therapyassistants, and students (see Figure 1).
Procedure
One occupational therapist at each site was selected as thelead
occupational therapist for this project, and participat-ed in a
90-min train-the-trainer session, which was con-ducted by project
staff. Before this session, each lead occu-pational therapist
received a training manual that containedthe occupational therapy
intervention documentation
form, written instructions for completion of the form,
anddefinitions of all terms used on the form. The training man-ual
also contained case studies that provided scenarios ofthree
occupational therapy sessions. A trainers and atrainees copy of
each case study were provided. The train-ers copy provided
instructions and descriptive notes abouteach case study session,
followed by the actual case studiesthat described an occupational
therapy session, includingamount of time spent on specific
activities and assessmentsand a completed intervention
documentation form. Duringthe train-the-trainer session conducted
by project staff withthe lead occupational therapists, the project
team reviewedthe form, instructions, definitions, and care studies
indetail. Participants were encouraged to ask questions anddiscuss
possible scenarios that might be raised during theirupcoming
training sessions with their colleagues at theirrespective
facilities.
During each sites internal training sessions (lastingabout 60
min), the lead occupational therapy trainerreviewed the
intervention documentation form (of whichmost occupational
therapists were familiar because of par-ticipation in development
efforts), instructions for com-pleting the form, and the
definitions of each term used onthe form. The trainer then reviewed
the first case scenariowith the trainees and described how the
intervention docu-mentation form was completed. Individually,
trainees thenread the second case study and completed the form.
Thetrainer reviewed the second case study with the group
anddiscussed form completion. Trainees then completed thethird case
scenario and discussed completion of the form.
After this training, during the first month of occupa-tional
therapy intervention documentation form use, eachsites lead
occupational therapist conducted random co-ses-sions with other
therapists. During this time, the leadoccupational therapist would
observe an occupational ther-apy session and record it on an
intervention documentationform. The therapist providing the
treatment session wouldalso complete a form and the two were
compared and dis-cussed. The lead occupational therapist continued
to serveas a resource person to the other occupational
therapiststhroughout the entire form use period.
A member of each sites project team (admitting nurse,medical
director, project manager) identified clients toenroll into the
study on admission and flagged the clientchart as being a study
patient. Other rehabilitationproviders (physicians, therapists
[physical, speech, recre-ational], nurses, social workers)
completed their respectiveproject documentation form for each
encounter with eachenrolled client. Data regarding other client
characteristics(e.g., demographics, severity of illness,
medications) werecollected from clients medical records after their
discharge.
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372 July/August 2006, Volume 60, Number 4
Data Analysis
Descriptive statistics were used to examine characteristics
ofclients and characteristics of their episodes of care
includinglength of stay, number of days occupational therapy
wasprovided, number of occupational therapy sessions per day,and
intensity of occupational therapy (defined as the num-ber of days
occupational therapy was provided divided bythe total length of
stay). The content of treatment sessions
was described by determining duration of each session,
theproportion of all occupational therapy time spent directedto the
activities listed above, and the proportion of thoseactivities that
included specific interventions. We examinedthe proportion of all
occupational therapy sessions in whichmore than one client was
treated by a single provider andthe proportion of sessions for
which occupational thera-pists, occupational therapy assistants, or
students wereinvolved in the care. We also determined combinations
of
ISIS [International Severity Information Systems], Inc., 2003.
Reprinted with permission.
Figure 1. Occupational therapy data collection form
Occupat ional Therapy Rehabi l i tat ion Act iv i t ies
Duration of ActivityEnter in 5 minute increments.
InterventionsEnter one intervention code per group of boxes.
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activities provided to clients during sessions, the proportionof
sessions that included examination or evaluation, and theproportion
of clients and families who received an educa-tional
intervention.
Results The mean length of stay for the episode of care was
18.8days (SD = 10.3, range = 175; see Table 2). Clientsreceived
occupational therapy, on average, 11.8 days (SD =7.2, range = 153)
during an episode of care. On days thatthe clients received
occupational therapy, the average num-ber of occupational therapy
sessions per day was 1.6 (SD =0.4, range = 13), and the average
time for each session was39.4 min (SD = 16.9, range = 5240).
Seventy percent of the sessions were provided by occu-pational
therapists, 33% by occupational therapy assistantsor aides, and 7%
by students. The vast majority of the ses-sions (91%) were provided
one-on-one by an occupationaltherapy provider. Only 5% of sessions
consisted of cotreat-ment with another discipline, and in only 11%
of sessions
did a group session occur (i.e., more than one client wastreated
by a single provider). See Table 3.
More than 94% of clients had some form of examina-tion or
evaluation time recorded, and approximately 7% ofsessions included
only examination or evaluation. Table 2gives the percentage time
clients spent in each occupation-al therapy activity.
Upper-extremity control (22.9% of totaltreatment time) and dressing
activities (14.2% of total treat-ment time) were the most
frequently used activities, withexamination or evaluation (10.8%)
and pre-functionalactivities (9%), the third and fourth most common
activi-ties (see Table 3). Upper-extremity control activities
weredefined as the training or facilitation of normal
movement,strength, range of movement, or alignment in the
upperextremity. Dressing activities were defined as
selectingappropriate clothing and accessories, obtaining
clothingfrom storage area, dressing and undressing in a
sequentialfashion, and fastening and adjusting clothing, shoes, or
per-sonal devices. Pre-functional activities were described
asactivities that were related to or provided preparation
forfunctional activities.
Table 4 provides data on the types of interventions
thatoccupational therapy providers used in each therapeuticactivity
with their patients. Of a total of 24 types of directinterventions
from which providers could choose, 19 inter-ventions were used
during at least 5% of the sessions for oneor more of the
therapeutic activities. All seven educationalor equipment provision
interventions were used during 5%of sessions for any activity. A
wheelchair was the only deviceused during at least 5% of sessions
for any activity. Only6.5% of patients used a wheelchair during at
least one ses-sion and it was used primarily in transfer and
wheelchairmanagement activities.
The American Journal of Occupational Therapy 373
Table 2. Episode Characteristics Episodes
Characteristic N = 954
Length of rehabilitation hospital stay (days) Mean 18.8SD
10.3Range 175
Number of days occupational therapy providedMean 11.8SD 7.2Range
153
Number of occupational therapy sessions per dayMean 1.6SD
0.4Range 13
Occupational therapy intensity* Mean 0.64SD 0.19Range
0.021.0
Percentage of total intervention time spent in activity (%)
Upper-extremity control 22.9Dressing 14.2Examination/evaluation
10.8Pre-functional 9.0Functional mobility 7.1Home management
6.2Transfer 6.1Bathing 4.6Grooming 4.5Community integration
3.2Toileting 2.8Sitting balance/trunk control 2.6Eating 2.0Leisure
performance 1.9Bed mobility 0.8Wheelchair 0.8
*Total number of days occupational therapy provided divided by
the length ofstay in days.
Table 3. Session Characteristics Sessions
Characteristic N = 18,359
Duration of Sessions (min)Mean 39.4SD 16.9Range 5240
Sessions with >1 client % (n) 10.8 (1,992) Cotreatment
sessions with other healthcare
disciplines % (n) 5 (1,006)Sessions with occupational therapist
% (n) 70 (12,943)Sessions with OTA or aide % (n) 32 (5,838)Sessions
with student % (n) 7 (1,234)Sessions with >1 occupational
therapy provider % (n) 9 (1,629)Activity combinations during
sessions
(based on N =18,364) %Evaluation only 5.6One activity only
33.3Upper-extremity control 16.1Dressing 5.5Functional mobility
2.3
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Activ
ity
Pre-
Func
tiona
l
Bath
ing
Dres
sing
Groo
min
g
Toile
ting
Eatin
g
Tran
sfer
s
Bed
Mob
ility
Func
tiona
lMob
ility
Hom
eM
anag
emen
t
Com
mun
ityIn
tegr
atio
n
Leis
ure
Perf
orm
ance
Uppe
r-Ext
rem
ityCo
ntro
l
Whe
elch
air
Man
agem
ent
Sitti
ngBa
lanc
e
%of
alls
essi
ons
that
cont
ain
inte
rven
tion
Table 4. Interventions Used To Facilitate Activities
Interventions
NeuromuscularBalance training 37.6 60.5 66.1 62.0 66.6 27.5 76.7
73.5 74.8 49.0 27.8 52.4 38.7 49.7 68.9 44.5Postural awareness 41.0
64.0 64.5 67.9 64.7 48.3 71.2 73.9 61.4 43.4 27.2 43.9 42.3 52.6
87.0 44.7Motor learning 42.0 43.7 54.3 56.8 49.6 45.5 51.4 57.1
45.3 37.5 24.1 39.8 51.4 55.0 46.8 42.6PNF 2.6 5.7 5.4 7.4 4.4 5.9
1.6 1.6 2.3 1.9 0.8 0.3 5.4 3.3 11.8 3.6NDT 16.1 19.3 18.5 24.6
22.7 14.3 26.5 28.6 19.2 15.0 9.8 27.5 31.7 43.6 47.3
19.1Constraint induced therapy 1.8 3.6 3.2 3.3 3.8 1.6 2.5 2.2 3.1
2.7 1.8 1.7 4.1 2.9 2.9 2.7
Adaptive/Compensatory One-handed skills 17.1 37.2 48.8 47.4 28.9
40.8 29.7 40.7 16.2 13.6 7.5 14.6 17.8 30.7 30.0 23.6Energy
conservation 4.7 16.3 11.2 12.7 12.8 10.0 5.5 7.1 8.5 17.7 9.3 4.7
4.4 6.7 5.6 7.0Environmental adaptation 5.7 28.1 14.5 11.3 28.6
12.7 15.8 16.1 13.7 18.2 13.1 10.3 7.1 20.5 4.8 10.5Adaptive
equipment 6.9 28.2 16.7 11.7 27.2 12.5 18.7 16.8 12.3 13.0 6.1 10.0
8.3 29.2 6.0 10.6
MusculoskeletalStrengthening 30.5 17.3 22.9 18.8 22.2 14.3 36.6
37.9 45.6 28.0 12.1 47.9 53.7 35.7 47.2 31.5Mobilization/Manual
therapy 9.4 3.2 4.6 4.9 9.7 3.8 12.4 9.4 9.3 4.5 2.3 5.3 16.5 20.1
12.6 7.7Passive Range of Motion (ROM) 23.8 6.4 9.4 9.6 12.5 7.4
22.9 24.2 18.6 8.2 5.0 29.8 42.5 27.0 32.7 19.4Edema control 3.1
1.1 1.1 1.4 3.5 1.0 5.5 4.2 2.4 1.5 0.4 1.2 7.5 8.7 3.5 3.3Aerobic
exercise 3.9 2.7 2.5 3.0 2.6 1.8 3.0 3.4 5.1 3.5 2.4 3.2 3.7 7.4
3.4 2.8
Cognitive/Perceptual/SensoryCognitive therapy 47.7 44.6 44.5
49.3 43.1 63.0 30.8 35.7 34.3 43.6 38.8 45.6 27.5 42.1 37.4
34.9Perceptual training 34.8 23.4 29.1 34.2 27.0 40.6 23.7 22.7
21.8 21.7 24.0 25.6 18.8 34.5 24.1 22.5Visual training 24.7 8.4
11.3 14.9 11.6 19.6 9.6 13.0 11.4 12.0 14.3 14.6 10.2 15.1 10.6
11.1Sensory training 8.0 3.1 5.1 5.5 4.4 7.2 5.4 4.6 4.8 3.8 3.4
2.9 8.0 8.7 5.0 5.6
EquipmentPrescription 4.0 3.3 0.7 0.6 2.8 0.6 2.5 1.4 1.6 1.0
1.0 0 1.5 2.4 0.8 1.6Application 2.3 1.1 1.2 1.2 1.5 2.8 1.3 0.8
0.8 0.7 0.9 0 1.7 2.4 1.0 1.2Fabrication 2.4 1.6 0.8 1.2 2.5 1.6
2.5 2.4 1.5 1.5 2.0 2.0 2.1 4.9 1.3 1.5Ordering 1.3 0.7 0.3 0.3 1.0
0 0.3 0 0.6 0.4 0.4 0 0.5 1.3 0.1 0.4
EducationalClient education 34.0 30.7 27.3 27.7 34.0 25.8 44.2
42.6 40.6 43.7 60.4 43.1 34.9 60.4 36.1 30.8Caregiver education
10.6 12.7 4.9 4.5 14.0 8.0 12.8 9.5 8.3 10.8 19.2 4.7 7.6 11.1 4.1
7.9Staff education 0.9 0.4 0.26 0.3 0.6 2.1 0.5 0.8 0.3 0.4 0.5 0.2
0.2 1.6 0.1 0.4
Devices UsedWheelchair 3.2 7.0 6.6 5.8 9.1 1.6 16.5 16.1 6.4 2.1
2.9 2.7 4.5 26.7 2.4 4.6aSessions include more than one activity.
bPercentages
-
almost half their time in occupational therapy, clients
wereengaged in activities that directly targeted remediating
per-formance skill deficits or body structure and
functionimpairments (i.e., upper-extremity control, sitting
balance,bed mobility, wheelchair, pre-functional, transfers).
Discussion In this descriptive study of occupational therapy
providedto clients during stroke rehabilitation, about 40% of
theoccupational therapy provided directly targeted life activi-ties
(i.e., ADL and IADL), whereas half of the therapy timetargeted body
function and structure or motor skills that arepresumed to underlie
functional limitations post-stroke.Upper-extremity tasks and
dressing were the most fre-quently provided activities, and
accounted for almost half ofthe treatment that clients received.
Evaluation or examina-tion activities also composed a significant
proportion (10%)of occupational therapy time. In 6% of patients, no
evalua-tion or examination session was documented. It is
probablethat in many of these cases the therapist did do an
evalua-tion, but the time devoted to this was included under
eachactivity (i.e., a dressing evaluation was recorded under
dress-ing instead of examination or evaluation).
When types of activities were compared, there wasclearly a
greater emphasis on basic ADL, such as dressing,grooming, eating,
and toileting than on IADL, such ashome maintenance, or on
community integration andleisure performance. This focus on more
basic activitiesprobably reflects the fact that therapy was taking
place in ahospital setting with clients who were still in the early
reha-bilitation phase. In addition, the average length of stay
wasless than 3 weeks, which could limit the time that is avail-able
for more advanced activities. It is interesting to notethat, in the
Practice Analysis, 65% of therapists reportedthat dressing was the
focus of intervention for more than25% of their clients (NBCOT,
2004). This percentage wasamong the five most frequent
interventions listed in thatanalysis, which covered all practice
areas.
Occupational therapists reported using a variety ofinterventions
to enable each activity. The most commonlyused interventions were
neuromuscular interventions, espe-cially balance training, postural
awareness, and motor learn-ing; however, adaptive approaches, such
as teaching one-handed skills for ADL tasks, were also reported
frequently.The therapists were clearly selective in the
interventionsthat they chose to use with each activity, because
there wasvariation in the interventions that were used in each
activi-ty. For example, whereas strengthening was used overall
in31.5% of sessions, it was used in more than half (53.7%)
ofupper-extremity activity sessions but in less than 1/5 (17%)
of bathing activities. The frequencies for
environmentaladaptations and use of adaptive equipment also varied
byactivity, with certain activities (e.g., bathing and
toileting)having much higher frequencies than others. These
differ-ences likely reflect differences in the movement demands
ofthese important hygiene activities, and the extent to
whichcommonly available adaptive equipment such as showerstools may
be needed to enable early, safe participation inthe activities.
There are few current evidence-based guidelines for theprovision
of intervention to persons with stroke. TheAgency for Health Care
Policy and Research Guidelines forPost-Stroke Rehabilitation
(Gresham et al., 1995) are nowoutdated and the agency cautions that
they should nolonger be viewed as guidance for current practice.
The mostrecent update of the National Clinical Guidelines for
Strokepublished in the United Kingdom (Royal College ofPhysicians,
2004) includes the general guideline thatEmerging evidence is
showing advantages of a task-specif-ic training or practice
approach over impairment focusedapproaches. Giving clients the
opportunity to practice tasksis a major element in improved
outcomes (p. 9). Evidencethat supports this general guideline has
been presented intwo syntheses by Trombly and Ma (Ma & Trombly,
2002;Trombly & Ma, 2002). These authors also present
morespecific guidelines regarding the conditions under
whichparticular approaches appear to improve outcomes (e.g.,that
practicing movements with specific goals appears toresult in more
normalized movement trajectories).However, there is also evidence
that some interventions thattarget body structure and function
impairments also con-tribute to improved rehabilitation outcomes
post-stroke.For example, the Royal College of Physicians (2002)
guide-lines suggest that emerging evidence supports the use
ofresisted exercise to improve motor function, which suggeststhat a
combination of approaches may lead to successfuloutcomes.
Given these recommendations, it is perhaps noteworthythat a
large proportion of occupational therapy time wasspent at the body
structure and function impairment or per-formance skill level, and
16% of sessions involved onlyupper-extremity-control activities.
These activities targetremediation of performance skill deficits
and client factors(American Occupational Therapy Association,
2002). Avariety of interventions appear to be used in these
activities,including balance training (44.5%), motor
learning(42.6%), and strengthening (31.5%). Overall, the
findingssuggest a shift away from neurofacilitation techniques
advo-cated in the 1960s toward more application of motor con-trol
and motor learning approaches. Therapists reportedusing Brunnstrom
techniques (Brunnstrom, 1970) in fewer
The American Journal of Occupational Therapy 375
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than 2% of sessions, and the percent of sessions in
whichproprioceptive neuromuscular facilitation (PNF) techniqueswere
used was also low. However, NDT was reported morefrequently, with a
maximum of 28.6% in bed mobility ses-sions. A recent analysis of
physical therapy intervention withthis same sample noted a similar
shift in intervention pat-terns away from facilitation techniques
toward applicationof motor control and motor learning approaches in
the con-text of functional activities (Jette et al., in press).
Both cognitive therapy and perceptual training werereported as
being used with high frequency during many ofthe ADL. In the data
collection protocol, cognitive therapyis defined as including
impulse control, attention, orienta-tion, memory, problem solving,
sequencing, social skills,safety, insight, and goal setting,
whereas perceptual train-ing includes interventions to address
apraxia, neglect,awareness in space, figure ground, and care of
sensoryimpaired body parts (full definitions are available from
thefirst author of this study). Both of these categories containa
diverse range of approaches, some of which have moresupportive
evidence than others. Trombly and Ma recom-mend cognitive
approaches such as structured instructionand feedback to improve
activity performance (Ma &Trombly, 2002; Trombly & Ma,
2002). Some evidence alsosupports interventions that involve forced
awareness ofneglected space (in persons with unilateral neglect),
whichmay be included in the perceptual training category.
Onelimitation of the present study is that we cannot determinemore
precisely how the reported interventions were appliedand the extent
to which the applications were consistentwith emerging evidence in
this area. This applicationsresearch would be a valuable area for
further investigation.
As recommended by current occupational therapypractice
guidelines, client education was a significant inter-vention
component for all activities. As might be expected,this category
was the most frequent intervention for ses-sions that were
addressing community integration.Caregiver education was a less
frequent intervention formost activities, which is likely explained
by the fact thatfamilies were not present during the majority of
sessions.Nonetheless, caregiver education was a feature of
almost20% of sessions that addressed community integration.Thus, it
appears that practitioners are actively engagingboth the client and
family when discharge with return tocommunity is the focus of
treatment. On the downside,only 5% of sessions addressed either
community integra-tion or leisure performance. The paucity of time
spent incommunity integration or leisure performance is
unfortu-nate because many persons with stroke have
significantrestriction in activities after discharge (Corr &
Bayer, 1992)and activity restriction has been shown to be highly
related
to depression (Nieboer et al., 1998; Williamson, 2000;Williamson
& Schulz, 1992). Button (2000) found thatpatients considered
that the real rehabilitation was thetranslation of learning from
the rehabilitation context to thehome and community context.
Although this study provides an initial description ofactual
occupational therapy practice for persons withstroke, it is
important to note several limitations. Mostimportant, we did not
have specific information about eachclients pattern of impairments,
and thus were unable tolink the choice of specific interventions to
the clientsunique profile of difficulties. Thus, we were not able
toexamine variations in practice for persons with similarimpairment
profiles. This study also summarized the activ-ities for all
clients across their entire therapy episode. Futureanalyses might
explore whether clients with greater func-tional abilities or
clients who were preparing for dischargeparticipated in more
advanced activities.
Although the therapists who provided data for thisstudy were
trained in the use of data collection forms, andwritten definitions
were provided in the training manual,no specific test of reporting
reliability was conducted. Thus,there may have been some degree of
misclassification ofinterventions and activities. However, given
the large num-ber of participants and sessions, we do not expect
these ran-dom errors to have had a large effect on the results.
This study provided a broad sketch of current occupa-tional
therapy practice for persons with stroke. It suggestsan initial
framework to describe intervention techniquesand activities, from
which more refined descriptions may bedeveloped. Without such work
to characterize the actualprocesses of occupational therapy, it
will be difficult to con-duct more precise examinations of the
effectiveness of ourservices. Such studies are needed in order to
identify thespecific elements or approaches that lead to better
outcomesfor persons with stroke.
Conclusion Occupational therapy provided to clients with stroke
at in-patient rehabilitation facilities reflected an integration
ofmultiple treatment approaches to facilitate performance ofdaily
activities. The greatest emphasis was on increasingupper-extremity
control and improving performance ofbasic ADL. Most occupational
therapy was provided on anindividual basis, for an average duration
of about 40 minper session, across an average hospital stay of less
than 3weeks. A small proportion of therapy time was spent onleisure
and community integration, suggesting the need foroccupational
therapy services after discharge that addressthese activities.
s
376 July/August 2006, Volume 60, Number 4
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Acknowledgments Funding for this project was provided by: The
NationalInstitute on Disability & Rehabilitation Research
(NIDRR)Grant # H133B990005 establishing the RehabilitationResearch
and Training Center on Medical RehabilitationOutcomes at Sargent
College in Boston, Massachusetts,with subcontracts to the Institute
for Clinical OutcomeStudies in Salt Lake City, Utah; and the NRH
Center forHealth & Disability Research at the National
Rehabili-tation Hospital and the MedStar Research Institute
inWashington, DC; the U.S. Army & Materiel Command(Cooperative
Agreement Award # DAMD17-02-2-0032)establishing the NRH
Neuroscience Research Center at theNational Rehabilitation Hospital
in Washington, DC; theBoston University Aging Research Center; and
resources atthe North Florida/South Georgia VA Medical
Center,Gainesville, Florida.
The authors wish to acknowledge the role and contri-butions of
the occupational therapists, occupational therapyassistants,
patients, and staff at each of the participating sitesin the Post
Stroke Rehabilitation Outcomes Project. In par-ticular, the authors
wish to acknowledge the contributionsof: Alan Jette (Director,
Health and Disability ResearchInstitute, Boston University);
Brendan Conroy, MD (StrokeRecovery Program, National Rehabilitation
Hospital,Washington, DC); Richard Zorowitz, MD (Department
ofRehabilitation Medicine, University of PennsylvaniaMedical
Center, Philadelphia, Pennsylvania); David Ryser,MD (Rehabilitation
Department, LDS Hospital, Salt LakeCity, Utah); Jeffrey Teraoka, MD
(Division of PhysicalMedicine & Rehabilitation, Stanford
University, Palo Alto,California); Frank Wong, MD, and LeeAnn Sims,
RN(Rehabilitation Institute of Oregon, Legacy Health
Systems,Portland, Oregon); and Murray Brandstater, MD (LomaLinda
University Medical Center, Loma Linda, California).
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378 July/August 2006, Volume 60, Number 4
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