Occupational Therapy Practice Guidelines for Adults With Stroke.

IMPORTANCE: Stroke is a leading cause of disability. Occupational therapy practitioners ensure maximum participation and performance in valued occupations for stroke survivors and their caregivers. OBJECTIVE: These Practice Guidelines are meant to support occupational therapy practitioners' clinical decision making when working with people after stroke and their caregivers. METHOD: Clinical recommendations were reviewed from three systematic review questions on interventions to improve performance and participation in daily activities and occupations and from one question on maintaining the caregiving role for caregivers of people after stroke. RESULTS: The systematic reviews included 168 studies, 24 Level 1a, 90 Level 1b, and 54 Level 2b. These studies were used as the basis for the clinical recommendations in these Practice Guidelines and have strong or moderate supporting evidence. CONCLUSIONS AND RECOMMENDATIONS: Interventions with strong strength of evidence for improving performance in activities of daily living and functional mobility include mirror therapy, task-oriented training, mental imagery, balance training, self-management strategies, and a multidisciplinary three-stages-of-care rehabilitation program. Constraint-induced therapy has strong strength of evidence for improving performance of instrumental activities of daily living. Moderate strength of evidence supported cognitive-behavioral therapy (CBT) to address balance self-efficacy, long-term group intervention to improve mobility in the community, and a wearable upper extremity sensory device paired with training games in inpatient rehabilitation to improve social participation. Practitioners should incorporate problem-solving therapy in combination with CBT or with education and a family support organizer program. What This Article Adds: These Practice Guidelines provide a summary of strong and moderate evidence for effective interventions for people with stroke and for their caregivers.

Interventions for Caregivers of People Who Have Had a Stroke: A Systematic Review.

IMPORTANCE: It is vital that occupational therapy practitioners address caregivers' needs to enable them to maintain participation in caregiving for people poststroke. OBJECTIVE: To explore the evidence for the effectiveness of interventions within the scope of occupational therapy practice for caregivers of people poststroke that facilitate maintaining participation in the caregiver role. DATA SOURCES: We conducted a narrative synthesis systematic review of the literature published in the MEDLINE, PsycINFO, CINAHL, OTseeker, and Cochrane databases between January 1, 1999, and December 31, 2019. Article reference lists were also hand searched. STUDY SELECTION AND DATA COLLECTION: The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA) guidelines were used, and articles were included if they were within the date range and scope of occupational therapy practice and included caregivers of someone poststroke. Two independent reviewers used Cochrane methodology to perform the systematic review. FINDINGS: Twenty-nine studies met the inclusion criteria and were divided into five intervention themes: cognitive-behavioral therapy (CBT) techniques, caregiver education only, caregiver support only, caregiver education and support, and multimodal interventions. Both the CBT technique of problem-solving combined with stroke education and one-on-one caregiver education and support interventions had strong strength of evidence. Multimodal interventions had moderate strength of evidence, and caregiver education only and caregiver support only had low strength of evidence. CONCLUSIONS AND RELEVANCE: Addressing caregiver needs with problem-solving and caregiver support in addition to typical education and training is essential. More research is needed that uses consistent doses, interventions, treatment settings, and outcomes. What This Article Adds: Although more research is needed, occupational therapy practitioners should provide combinations of interventions such as problem-solving techniques, customized support for each caregiver, and individualized education in the care of the stroke survivor.

Interventions Using Cognitive-Behavioral Therapy Techniques for Caregivers of People With Stroke (January 1, 1999- December 31, 2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Project. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on stroke and interventions using cognitive-behavioral therapy techniques for caregivers of people with stroke.

Education and Training Interventions for Caregivers of People With Stroke (January 1, 1999-December 31, 2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from a systematic review on interventions providing only education and training for caregivers of people with stroke.

Multimodal Interventions for Caregivers of People With Stroke (January 1, 1999- December 31, 2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on stroke and multimodal interventions for caregivers of people with stroke.

Education and Support Interventions for Caregivers of Persons With Stroke (January 1, 1999-December 31, 2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from a systematic review on stroke and education and support interventions for caregivers of people with stroke.

Outcomes of an interprofessional intensive comprehensive aphasia program's first five years.

BACKGROUND AND OBJECTIVES: This ICAP program is a collaboration between an institute of health professions and a rehabilitation hospital. It was a 6-week intensive treatment program for people with post-stroke aphasia designed to maximize recovery and return to activities. This retrospective study investigated outcomes of this program offered annually from 2015 to 2019. METHODS: This is an analysis of existing data collected for other purposes. While conducting a therapeutic program for people with aphasia, data were not collected for the purpose of conducting research. The treatment components addressed the activity participation goals of 35 participants. Programming consisted of individual and group speech-language and occupational therapy, adaptive sports, swimming, music therapy, and a wellness mindfulness group.. Participants received a comprehensive evaluation and a treatment plan addressing their individual participation goals, delivered primarily by SLP and OT graduate students under faculty supervision. Pre- and post-treatment outcomes were measured within four WHO ICF domains: impairment, participation, environment, person. Each cohort consisted of seven or eight community-dwelling participants seen four days/week. RESULTS: Significant post-treatment changes were observed on measures within the impairment domain and on self-perception measures of participation, functional communication, and communication confidence. Subsequent analyses found a subset of 15 responders (WAB Aphasia Quotient change of ≥5) drove most significant effects seen on performance-based impairment measures, but that patient-reported self-perception measures showed significant changes in both responders and non-responders. CONCLUSIONS: Results support research indicating that short-term intensive, interprofessional comprehensive aphasia programs (ICAPs) are effective treatment options for people with moderate-to-severe aphasia.

What occupational and physical therapists know about farmers' health.

Farmers are at high risk for losing their occupation because of their susceptibility for developing chronic conditions and incurring injuries. Although, occupational and physical therapists have basic education in return-to-work methods, specialty training is needed to help farmers with disabilities. The North Carolina AgrAbility Partnership, part of the U.S. Department of Agriculture's supported AgrAbility Program, implemented an exploratory survey of North Carolina occupational and physical therapists before developing training curricula for working with farmers. State occupational and physical therapy association members were surveyed on what types of conditions they could treat, how comfortable they were in treating these conditions and making recommendations for environmental modifications, and what resources are available for farmers related to work site accommodations. Findings showed that less than one third of therapists had farm exposure or had ever treated farmers. Significant differences in identifying farmers' typical conditions were found between therapists who had treated and those who had not treated farmers. Physical therapists were more comfortable than occupational therapists in treating farmers for repetitive stress syndromes, work-related trauma, and musculoskeletal disorders while occupational therapists were more comfortable in treating farmers for social isolation and low vision. More physical therapists also rated themselves as competent in farm environmental assessment and adaptation. On the other hand, occupational therapists were aware of more agencies that aid farmers. Finally, few therapists had education on working with farmers or had heard of AgrAbility. To create farmer-centered intervention, therapists should take continuing education courses and investigate resources for helping farmers with chronic conditions and disabilities return to their chosen occupation.

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

This evidence-based review was conducted to evaluate the effectiveness of occupational therapy interventions to prevent or mitigate the effects of psychological or emotional impairments after stroke. Thirty-nine journal articles met the inclusion criteria. Six types of interventions were identified that addressed depression, anxiety, or mental health-related quality of life: exercise or movement based, behavioral therapy and stroke education, behavioral therapy only, stroke education only, care support and coordination, and community-based interventions that included occupational therapy. Evidence from well-conducted research supports using problem-solving or motivational interviewing behavioral techniques to address depression. The evidence is inconclusive for using multicomponent exercise programs to combat depression after stroke and for the use of stroke education and care support and coordination interventions to address poststroke anxiety. One study provided support for an intensive multidisciplinary home program in improving depression, anxiety, and health-related quality of life. The implications of the findings for practice, research, and education are discussed.

Patient Active Time During Therapy Sessions in Postacute Rehabilitation: Development and Validation of a New Measure.

BACKGROUND AND PURPOSE: The accurate measurement of therapy intensity in postacute rehabilitation is important for research to improve outcomes in this setting. We developed and validated a measure of Patient Active Time during physical (PT) and occupational therapy (OT) sessions, as a proxy for therapy intensity. METHODS: This measurement validity study was carried out with 26 older adults admitted to a skilled nursing facility (SNF) for postacute rehabilitation with a variety of main underlying diagnoses, including hip fracture, cardiovascular diseases, stroke, and others. They were participants in a randomized controlled trial that compared an experimental high-intensity therapy to standard-of-care therapy. Patient Active Time was observed by research raters as the total number of minutes that a patient was actively engaging in therapeutic activities during PT and OT sessions. This was compared to patient movement (actigraphy) quantified during some of the same PT/OT sessions using data from three-dimensional accelerometers worn on the patient's extremities. RESULTS: Activity measures were collected for 136 therapy sessions. Patient Active Time had high interrater reliability in both PT (r = 0.995, p < 0.001) and OT (r = 0.95, p = 0.012). Active time was significantly correlated with actigraphy in both PT (r = 0.73, p < 0.001) and OT (r = 0.60, p < 0.001) and discriminated between a high-intensity experimental condition and standard of care rehabilitation: in PT, 47.0 ± 13.5 min versus 16.7 ± 10.1 min (p < 0.001) and in OT, 46.2 ± 15.2 versus 27.7 ± 6.6 min (p < 0.001). CONCLUSIONS: Systematic observation of Patient Active Time provides an objective, reliable, and valid index of physical activity during PT and OT treatment sessions that has utility as a real-world alternative to the measurement of treatment intensity. This measure could be used to differentiate higher from lower therapy treatment intensity and to help determine the optimal level of active therapy time for patients in postacute and other settings.

Enhanced medical rehabilitation increases therapy intensity and engagement and improves functional outcomes in postacute rehabilitation of older adults: a randomized-controlled trial.

OBJECTIVES: For millions of disabled older adults each year, postacute care in skilled nursing facilities is a brief window of opportunity to regain enough function to return home and live independently. Too often this goal is not achieved, possibly because of therapy that is inadequately intense or engaging. This study tested Enhanced Medical Rehabilitation, an intervention designed to increase patient engagement in, and intensity of, daily physical and occupational therapy sessions in postacute-care rehabilitation. DESIGN: Randomized controlled trial of Enhanced Medical Rehabilitation versus standard-of-care rehabilitation. SETTING: Postacute care unit of a skilled nursing facility in St Louis, MO. PARTICIPANTS: Twenty-six older adults admitted from a hospital for postacute rehabilitation. INTERVENTION: Based on models of motivation and behavior change, Enhanced Medical Rehabilitation is a set of behavioral skills for physical and occupational therapists that increase patient engagement and intensity, with the goal of improving functional outcome, through (1) a patient-directed, interactive approach, (2) increased rehabilitation intensity, and (3) frequent feedback to patients on their effort and progress. MEASUREMENTS: Therapy intensity: assessment of patient active time in therapy sessions. Therapy engagement: Rehabilitation Participation Scale. Functional and performance outcomes: Barthel Index, gait speed, and 6-minute walk. RESULTS: Participants randomized to Enhanced Medical Rehabilitation had higher intensity therapy and were more engaged in their rehabilitation sessions; they had more improvement in gait speed (improving from 0.08 to 0.38 m/s versus 0.08 to 0.22 in standard of care, P = .003) and 6-minute walk (from 73 to 266 feet versus 40 to 94 feet in standard of care, P = .026), with a trend for better improvement of Barthel Index (+43 points versus 26 points in standard of care, P = .087), compared with participants randomized to standard-of-care rehabilitation. CONCLUSION: Higher intensity and patient engagement in the postacute rehabilitation setting is achievable, with resultant better functional outcomes for older adults. Findings should be confirmed in a larger randomized controlled trial.

Measuring treatment fidelity in a rehabilitation intervention study.

Attaining and demonstrating treatment fidelity is critical in the development and testing of evidence-based interventions. Treatment fidelity refers to the extent to which an intervention was implemented in clinical testing as it was conceptualized and is clearly differentiable from control or standard-of-care interventions. In clinical research, treatment fidelity is typically attained through intensive training and supervision techniques and demonstrated by measuring therapist adherence and competence to the protocol using external raters. However, in occupational and physical therapy outcomes research, treatment fidelity methods have not been used, which, in our view, is a serious gap that impedes novel treatment development and testing in these rehabilitation fields. In this article, we describe the development of methods to train and supervise therapists to attain adequate treatment fidelity in a treatment development project involving a novel occupational and physical therapy-based intervention. We also present a data-driven model for demonstrating therapist adherence and competence in the new treatment and its differentiation from standard of care. In doing so, we provide an approach that rehabilitation researchers can use to address treatment fidelity in occupational and physical therapy-based interventions. We recommend that all treatment researchers in rehabilitation disciplines use these or similar methods as a vital step in the development and testing of evidence-based rehabilitation interventions.

The impact of mild stroke on participation in physical fitness activities.

Objective. To compare participation in moderate to high intensity physical activities in persons before and after a mild stroke. Methods. We used data from the Cognitive Rehabilitation and Research Group to examine changes in moderate to high intensity physical activity participation in persons who had a mild stroke as defined by an NIH Stroke Scale score of less than 6 (N = 127). Using the Activity Card Sort, we compared the participants' high-demand leisure activity (leisure activities that are moderate to high intensity physical activities) participation at 6-months after stroke with their prestroke level. Results. We found a significant decrease in numbers of high-demand leisure activities in all participants and in each demographic group after mild stroke. Conclusion. These results suggest that persons after mild stroke are not retaining the high-demand leisure activities they were doing prior to their stroke. Health professionals must promote participation in high-demand leisure activities in patients with mild stroke as a tool to enhance health and fitness.

Recruiting older adults into a physical activity promotion program: Active Living Every Day offered in a naturally occurring retirement community.

PURPOSE: This article explores recruitment strategies based on the transtheoretical model (TTM) with older adults living in a naturally occurring retirement community (NORC) to encourage enrollment in a physical activity promotion program, Active Living Every Day (ALED). Reasons for participation or nonparticipation are identified. DESIGN AND METHODS: Recruitment strategies were designed to move older adults through the TTM stages of change to enroll in ALED and were built on meetings and resources established by St. Louis NORC's supportive service program. NORC residents (25 ALED participants and 25 nonparticipants) were interviewed about reasons for enrollment or nonenrollment. RESULTS: A significant difference was found between the two groups on their responses to a physical activity stage-of-change question, although no significant differences were found in their demographics, social resources, and mood/depression. ALED participants' motivation to enroll primarily came from TTM proactive recruitment methods (88%) and less (12%) from reactive methods. Themes for ALED participants' choices to enroll included motivation to exercise, physical activity ideas from peers, social engagement, and trust in sponsoring organizations' staff and programs. Analysis of interview data identified that scheduling and cost were primary reasons for nonenrollment in ALED. IMPLICATIONS: Using theoretically based recruitment methods for older adults and a neighborhood approach through organizations such as a NORC may result in greater numbers of older adults participating in health promotion programs.