Current Trends in Occupational Therapy Treatment for People with Stroke

The purpose of this study was to describe typical practice in stroke rehabilitation based on selfreports of currently practicing occupational therapists and to determine if research evidence is a factor in treatment decisions. Two hundred and fifty surveys were sent to occupational therapists who were members of the Physical Disabilities Special Interest Section of the American Occupational Therapy Association and 76 completed surveys were returned. The findings indicated that most ADL were addressed commonly with clients post-stroke and that occupationbased methods were used more often than more traditional remediation approaches. Also, there were several treatment methods which therapists commonly used for each impairment often seen following stroke. Clinical experience guided treatment decisions more often than research evidence. This study begins to clarify the complexity of stroke rehabilitation by linking the interventions that are used most often by occupational therapists with specific impairments often seen following stroke. OCCUPATIONAL THERAPY FOR STROKE 1 Current Trends in Occupational Therapy Treatment for People with Stroke According to the Centers for Disease Control and Prevention (CDC) (2010), in 2006 stroke was the third leading causing of death and the number one cause of disability in the U.S. It is estimated that 550,000 strokes occur each year and that there are 3 million stroke survivors in the U.S. today (Bartels, 2010). The majority of cerebrovascular accidents (CVAs) occur in people over the age of 65 (Woodson, 2008). As the “baby boomer” generation grows older and there are more people at the age where strokes are more likely to occur, it is expected that the incidence of stroke will increase (Woodson, 2008). The amount and type of impairment that occurs due to a CVA varies depending on where the stroke occurs in the brain and the severity of the damage. There may be deficits in movement, speech, cognition, sensation, vision, and perception (Chang & Hasselkus, 1998). In general, a right CVA (RCVA) may result in left hemiplegia or hemiparesis, difficulties with visuospatial memory, neglect of the left side of the body, poor judgment, and impulsivity, while a left CVA (LCVA) may cause right hemiplegia or hemiparesis, aphasia, and apraxia (Bartels, 2010). Occupational therapists play a large role in helping people recover after having a stroke. Occupational therapists working in physical disability settings see patients with CVA more often than those with any other diagnosis (Woodson, 2008). Given the variability in stroke sequelae, occupational therapists need to have a wide repertoire of techniques to help each client. According to Ma and Trombly (2002), treatment techniques may include using occupational tasks to help improve cognitive abilities, teaching adaptations to meaningful activities to keep the client involved, and using task-specific movement to help with range of motion and motor control. The role of occupational therapists in CVA rehabilitation is particularly important because they focus on functional outcomes and getting clients back to doing everyday activities OCCUPATIONAL THERAPY FOR STROKE 2 as independently as possible (Brodie, Holm, & Tomlin, 1994). While occupational therapists are aware of the basic differences in impairments after CVA, it is important for them to be familiar with the latest evidence for treatment approaches so that they provide client care with the best possible outcomes. In order to stay current with the most effective treatment approaches in stroke rehabilitation, occupational therapists need to critically appraise the research evidence. The concept of evidence-based practice is relatively new to the field of occupational therapy. When Margo Holm challenged occupational therapists to become evidence-based practitioners in her Eleanor Clarke Slagle lecture in 2000, there was a push towards using evidence to guide clinical practice. In that lecture Holm (2000) asserted that the occupational therapy profession was being driven to justify what, why, and how occupational therapy improves functional outcomes of clients. This concept of evidence-based practice needs to be applied to every population that occupational therapists encounter, including clients who have had a stroke. While there are numerous studies about stroke rehabilitation in the occupational therapy literature, they often focus on one specific impairment commonly seen after stroke, such as unilateral neglect (Lin, 1996), communication difficulties (Borod et al., 2000), or visualperceptual impairments (York & Cermak, 1995). More studies that describe the techniques that occupational therapists use to treat the many impairments seen following a stroke and whether treatments are based on current research evidence are needed in order help determine the best approaches for rehabilitation after CVA. Background and Significance Many descriptive studies of stroke rehabilitation and occupational therapy have been conducted in the last decade (Landi et al., 2006; Latham et al., 2006; Lavelle & Tomlin, 2001; OCCUPATIONAL THERAPY FOR STROKE 3 Ma & Trombly, 2002; Phipps & Richardson, 2007; Smallfield & Karges, 2009; Steultjens et al., 2003; Trombly & Ma, 2002). While the findings have been important, none have described how impairments impact the occupational therapist’s selection of intervention strategies. Some studies have investigated well-defined impairments following a CVA that may be more common with an infarct in one hemisphere over the other, but none have explored whether or not treatments were chosen based on the current available research evidence (Borod et al., 2000; Lin, 1996; York & Cermak, 1995). Brodie et al. (1994) carried out a retrospective descriptive study exploring factors that may affect outcomes in stroke rehabilitation. They found that occupational therapists were spending more time working on remediation of the underlying impairments rather than focusing on how the disability was interfering with daily activities (Brodie et al., 1994). While this study examined intervention techniques used by occupational therapists, its retrospective design made it difficult to determine the exact factors that correlated with better discharge outcomes. Ballinger, Ashburn, Low, and Roderick (1999) conducted a pilot study investigating the treatment strategies of occupational therapists for clients with stroke. Occupational therapists recorded the interventions they used with the clients in a day hospital. Variables such as treatment time, types of intervention, and frequency of intervention were considered. While the study focused on how often interventions were used, the conclusion was made that stroke rehabilitation is too complex for frequency of interventions to be enough to fully describe it. Ballinger et al. (1999) made a valuable contribution but did not expound on the specific treatments used by occupational therapists based on the impairments seen or on why they chose certain interventions. OCCUPATIONAL THERAPY FOR STROKE 4 Landi et al. (2006) conducted a quasi-experimental study focused on activities of daily living (ADL) of fifty patients on a post-acute rehabilitation unit of a hospital receiving occupational therapy over an eight week period. All participants started treatment with a moderate to severe impairment in ADL. Treatment was focused on improving independence in tasks such as toilet use, feeding, dressing, grooming, and mobility. Interventions included training in functional mobility, neuromuscular re-education, muscle tone management, and contracture prevention (Landi et al., 2006). This study revealed improvement in several ADL following eight weeks of occupational therapy and provided support for the use of occupational therapy in stroke rehabilitation; however, it did not address specific treatments used or whether treatments were varied based on the type of impairments that were initially seen. Several recent descriptive studies specifically explored occupational therapy interventions and outcomes in stroke rehabilitation. Latham et al. (2006) collected data on clients with stroke at six hospitals around the U.S. The data evaluated included length of stay in the hospital, the number of days and number of times per day occupational therapy was provided, and total time spent on specific activities during occupational therapy sessions (Latham et al., 2006). They concluded that a variety of interventions were used by occupational therapists to help with each activity (i.e., dressing, grooming, eating, toileting). The intervention that was used the most was neuromuscular education, which included balance training and motor learning. This study provided a clearer picture of occupational therapy interventions, but it did not indicate how the clients fared after these treatments or how the treatments were varied depending on the pattern of impairments for individual clients. It reinforced the idea that occupational therapists must have many tools at their disposal to provide treatment for clients with stroke, but did not indicate which tools the therapists used based on the types of impairments seen. OCCUPATIONAL THERAPY FOR STROKE 5 Smallfield and Karges (2009) asserted that the research describing specific strategies that occupational therapists use during inpatient stroke rehabilitation was limited and thus focused their study on intervention. They specifically investigated how often occupational therapists concentrated on prefunctional versus functional activity with clients. Prefunctional activities were those that did not directly focus on areas of occupation but dealt more with body structures and functions. Smallfield and Karges (2009) found that about half of all occupational therapy sessions addressed ADL, but prefunctional activities were done in almost two-thirds of the sessions. This study showed that occupational therapists did not use functional, meaningful activities more than any other intervention during treatment sessions. An important limitation in this study was that their sample came from one hospital, which makes it difficult to generalize. Also, the way therapists documented their interventions varied, making some difficult to categorize. Lavelle and Tomlin (2001) conducted a retrospective study at an on-campus student occupational therapy clinic to determine whether people with stroke could still benefit from occupational therapy after the acute phase of rehabilitation. They found that the majority of clients made some progress toward their goals and that there was no significant difference in progress between clients with a LCVA or RCVA. This study was limited by inconsistent terminology in goals and different occupational therapy students providing treatment to each client. The lack of experience of the occupational therapy students may also have affected the results. Also, since it was conducted at one on-campus clinic, the results may lack generalizability to other rehabilitation facilities. Krzyminski (2005) did a follow-up study at the same on-campus clinic with similar results. OCCUPATIONAL THERAPY FOR STROKE 6 Phipps and Richardson (2007) studied occupation-based outcomes using the Canadian Occupational Performance Measure (COPM) with clients with stroke or traumatic brain injury. They found an overall increase in perceived performance and satisfaction of clients after occupational therapy. This study showed the importance of having client-centered and occupation-based interventions in occupational therapy, but did not go into detail about the types of interventions used based on the results of the COPM. While this study found information that can be very helpful for occupational therapists, it was limited by the retrospective design and lack of control over occupational therapy treatments. The studies conducted by Latham et al. (2006), Smallfield and Karges (2009), Lavelle and Tomlin (2001), Krzyminski (2005), and Phipps and Richardson (2007) add important information about overall interventions used by occupational therapists to improve outcomes in people who have had a stroke, but none explore why certain interventions are chosen and whether decisions are made based on current research evidence. Recent studies have clarified the interventions used by occupational therapists, but whether or not the interventions match the current research evidence is still unclear. Several literature reviews have been performed in recent years in order to describe best practice for occupational therapy in stroke rehabilitation. Steultjens et al. (2003) did a systematic review of literature in order to determine whether occupational therapy interventions were effective in improving outcomes for clients with CVA. They found that occupational therapy improved performance in ADL, IADL, and social participation. The main limitation of this study was that different strategies were used at each facility or within each study investigated. Steultjens et al. concluded that occupational therapy was helpful within a multidisciplinary team and that more evidence was needed to determine best practice for occupational therapy in stroke rehabilitation. OCCUPATIONAL THERAPY FOR STROKE 7 Trombly and Ma (2002) conducted an evidence-based literature review specifically exploring role, task, and activity performance of clients with stroke receiving occupational therapy. Their search revealed that participation in occupational therapy after stroke increased performance in ADL and IADL. The authors recommended that occupational therapists use meaningful activities in familiar environments and use adaptations when necessary in order to ensure that clients with stroke have the best possible outcome (Trombly & Ma, 2002). One main limitation of this study was that each piece of literature that was reviewed used different terminology when describing interventions, so it was unclear which aspects of treatment were essential for improving performance. Furthermore, this study did not clarify which interventions worked best depending on the particular pattern of impairments seen in each individual with CVA. In the second part of this literature review, Ma and Trombly (2002) focused on the impact of occupational therapy on impairments after a stroke. The studies explored different aspects of rehabilitation after CVA, including cognition, visual-perception, range of motion, endurance, and coordination (Ma & Trombly, 2002). The lack of studies describing specific interventions used after stroke made it difficult to make recommendations for best practice in occupational therapy. However, Ma and Trombly (2002) concluded “that treatments used by occupational therapists to remediate impairments after stroke are, in general, effective, especially those involving activity or occupation to effect the change” (p. 272). Now this information needs to be expanded to incorporate the rationale behind occupational therapists’ choice of interventions, particularly if they choose their treatment methods based on current research evidence. While it is understood that occupational therapy helps in showing improvements in those who have had a CVA, the specific treatment methods that are most helpful to this population are still unclear. It is important to understand what occupational therapists do to provide the best OCCUPATIONAL THERAPY FOR STROKE 8 therapy based on the pattern of impairments and whether interventions are chosen based on current research evidence. The purpose of this study, therefore, was to describe, based on the self-report of currently practicing occupational therapists, typical practice when working with clients who have had a CVA. Also of interest in this study were the sources occupational therapists use to justify their interventions.