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Guideline Summary
Guideline Title
Occupational therapy practice guidelines for adults with stroke.
Bibliographic Source(s)
Sabari J, Lieberman D. Occupational therapy practice guidelines for adults with stroke. Bethesda (MD): American Occupational Therapy Association (AOTA); 2008. 168 p. [255 references]
Guideline Status

This is the current release of the guideline.

The American Occupational Therapy Association reaffirmed the currency of this guideline in March 2012.

Scope

Disease/Condition(s)

Stroke

Guideline Category
Evaluation
Management
Prevention
Rehabilitation
Risk Assessment
Screening
Treatment
Clinical Specialty
Family Practice
Geriatrics
Internal Medicine
Neurology
Physical Medicine and Rehabilitation
Preventive Medicine
Psychology
Speech-Language Pathology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Health Plans
Hospitals
Managed Care Organizations
Nurses
Occupational Therapists
Physical Therapists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers
Speech-Language Pathologists
Utilization Management
Guideline Objective(s)
  • To provide an overview of the occupational therapy process for stroke
  • To define the occupational therapy domain, process, and intervention that occurs within the boundaries of acceptable practice
  • To help occupational therapists and occupational therapy assistants, as well as those who manage, reimburse, or set policy regarding occupational therapy services, understand the contribution of occupational therapy in treating adults with stroke
  • To serve as a reference for other health care professionals, health care facility managers, education and health care regulators, third-party payers, and managed care organizations
Target Population

Adult stroke survivors

Interventions and Practices Considered
  1. Referral for occupational services
  2. Evaluation
    • Developing the occupational profile
    • Analysis of occupational performance through observation and assessment
  3. Developing an intervention plan
  4. Intervention implementation:
    • Interventions to prevent secondary impairments
    • Interventions to restore performance skills
    • Interventions to modify activity demands and the contexts in which activities are performed
    • Interventions to promote a healthy and satisfying lifestyle
    • Interventions to help maintain performance and health
  5. Intervention review
  6. Outcomes monitoring
  7. Discontinuation, discharge, and follow-up
Major Outcomes Considered
  • Validity and reliability of assessment tools
  • Effectiveness of interventions
  • Motor and process skills
  • Ability to perform activities of daily living
  • Performance skills
  • Performance patterns
  • Secondary impairments
  • Learned nonuse
  • Aspiration
  • Quality of life

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Evidence-based Literature Review

This Guideline is based on two systematic reviews:

  1. An evidence-based literature review conducted in the early 2000s, addressing the effectiveness of occupational therapy with people who had experienced a stroke
  2. A broad-based review conducted in 2003, seeking basic scientific information to develop this Guideline and data on the effectiveness of any therapy in reducing impairment in people who had experienced a stroke.

Methodology for the First Review

The authors of the first review searched the literature published from 1980 to 2000, focusing on therapeutic goals: restoration of roles, tasks, and activities and remediation of impaired bodily functions. Specific inclusion criteria were as follows:

  • The study was published in a peer-reviewed journal from 1980 to 2000, was included in a systematic review published from 1980 to 2000, or was a thesis or dissertation completed from 1980 to 2000 in the English language. The team excluded reports published before 1980 "because knowledge of motor behavior and recovery after central nervous system damage that affect therapeutic procedures as well as the philosophy of occupational therapy practice were different 20 years ago and [might] not be currently applicable."
  • The study measured the effect of occupational therapy treatment of people who had experienced a stroke.
  • The intervention described in each study was designated as occupational therapy or administered by an occupational therapist, or the article was written by an occupational therapist.

The authors first identified key words for the search: occupational therapy AND stroke OR cerebrovascular accident (CVA), cerebrovascular disorders, hemiplegia, hemiparesis, or hemiplegics. Then they searched the literature. They began with a manual search of the following journals:

  • American Journal of Occupational Therapy
  • British Journal of Occupational Therapy
  • Canadian Journal of Occupational Therapy
  • Occupational Therapy in Health Care
  • Occupational Therapy Journal of Research
  • Physical and Occupational Therapy in Geriatrics

Next, they searched the following electronic databases:

  • Cumulative Index to Nursing and Allied Health Literature (1981-2000)
  • Dissertation Abstracts (1980-2000)
  • Excerpta Medica, Volume 19: Rehabilitation and Physical Medicine (1980-2000)
  • Index Medicus (1980-1983)
  • MEDLINE (1984-2000)
  • PsychLit (1980-2000)
  • Social Science Citation Index (1988-2000)

They also examined the reference sections of relevant articles for additional studies, and continued tracking citations until they found no new studies.

The reviewers found 150 articles, which they then evaluated for quality (scientific rigor and lack of bias) and levels of evidence. Thirty-six articles met their criteria and were included in the review.

Fifteen of the 36 articles addressed restoration. (Eight of the 15 also addressed remediation.)

All 15 studies were conducted in a natural setting (in the participants' homes or in clinics). They included an initial total of 984 participants, 895 (91%) of whom completed the studies. Of these, 411 had a lesion on the left side of the brain, and 425 had one on the right side. Two studies did not report the location of the lesion. Participants in 4 studies were in the chronic stage (12 months or more since the stroke), when little spontaneous recovery is expected. Participants in 10 studies were in the acute stage (6 months or less since the stroke, when spontaneous recovery is considered to be occurring). Participants in one study were of mixed chronicity.

Seventeen (59%) studies were applied research on therapy offered in clinical or home settings, and 12 (41%) were reports of experimental treatment or research designed to understand the nature of the clients' responses to treatment applied under laboratory conditions. The 29 studies included an initial total of 832 participants (37 healthy people and 795 stroke survivors), 797 of whom completed the studies. Three hundred seventeen participants had a lesion on the left side of the brain, and 328 on the right. Four studies did not report the location of the lesion. Twelve of the studies included participants who had sustained their strokes at least 1 year earlier. The remaining 12 studies included participants whose stroke had occurred within the past 7 months.

Methodology for the Second Review

This review included 11 questions and focused on two topics areas identified by an expert panel: the neurophysiological basis of poststroke brain reorganization and interventions for poststroke recovery in impairments, activities, and participation. The Guideline incorporates some of the findings from this review. Inclusion criteria varied between the two topics.

The expert group designed the first six questions to target information from the basic sciences needed to write the Guideline. The criteria were as follows:

  • The study or the review was published in a peer-reviewed journal in the English language from 1997-2002 (Note: The original plan was to cover 1992-2002 [starting from when the previous literature search on stroke had ended] but to emphasize the last 5 years [1997-2002]. The review included some pre-1992 classic articles that addressed the questions. After the literature search, because of the number of articles that emerged, the scope was reduced to 1997-2002, except for the pre-1992 classics and a few studies from 1992-1997 that were occupational therapy interventions and directly addressed the questions.).
  • The article specifically addressed the particular question posed and included laboratory animal studies and human studies. The subjects included rats and monkeys as well as humans.

The expert group designed the final five questions around the effectiveness of interventions. The focus of the first intervention question was to evaluate the effectiveness of occupational therapy interventions for remediating impairments or restoring activities and participation after stroke. The criteria were the same as those for the 2002 review described above, except that the search period was from 2000-2002 to cover the time since the 2002 review was completed. Three focused questions addressed the effectiveness of therapeutic interventions to address psychological, social, and perceptual impairments and promote participation. An additional focused question targeted the effectiveness of constraint-induced therapy to improve behavioral outcomes following stroke.

The criteria for this group of focused questions included articles both within and related to the occupational therapy literature:

  • The study or the review was published in a peer-reviewed journal in the English language from 1997-2002.
  • The study measured the effect of interventions within the scope of occupational therapy practice on people who had experienced a stroke.

Key words for the search were stroke AND recovery, functional MRI AND brain reorganization, task-specificity AND recovery, environment AND recovery AND stroke, context AND motor behavior AND stroke, context AND motor behavior, stroke AND hemorrhage AND infarct OR embolism AND outcome, task demand AND recovery, practice AND recovery AND brain, stroke AND recovery AND intensity, learning AND stroke, stroke AND recovery AND unilateral neglect, brain reorganization AND stroke, stroke AND recovery AND cognition, stroke AND recovery AND adaptation, stroke AND recovery AND apraxia, occupational therapy AND stroke (2000-2002), forced use therapy AND stroke and constraint-induced therapy

The reviewer also searched for articles by recognized experts in neuroplasticity: M. Hallett, B. Kopp, J. Liepert, and R. J. Nudo.

The reviewer searched the following resources:

  • Electronic databases (MEDLINE, PsycINFO, Web of Science [Science Citation Index and Social Science Citation Index]).
  • Consolidated information sources (e.g., evidence-based medicine reviews such as the Cochrane Database of Systematic Reviews; the Cochrane Controlled Trials Register; DARE—the Database of Abstracts of Reviews of Effectiveness, published by the British National Health Service; and the National Guideline Clearinghouse, part of the Agency for Healthcare Research and Quality, U.S. National Institutes of Health). The entries in these sources are peer reviewed, but they are not journal articles. The sources provide a system for clinicians and scientists to conduct evidence-based reviews of selected clinical questions and topics.

The reviewer also manually searched journals not indexed in the preceding databases (e.g., Journal of Motor Behavior and Motor Control).

Finally, the reviewer examined the reference sections of relevant articles for classic articles.

The reviewer selected 386 abstracts as possibly pertinent to the questions. On closer examination, she selected 122 for retrieval. She evaluated them for specificity to the questions and, if they reported a study, for quality (scientific rigor and lack of bias) and levels of evidence. She included 106 articles in her review, only 58 (54.7%) of which were research studies.

The results of this review addressing the 11 focused questions can be found in the Evidence-Based Practice section of the member area of the American Occupational Therapy Association (AOTA) Web site.

Since 2003, additional articles were added (including systematic reviews and randomized controlled trials from within and related to the occupational therapy literature) to provide more recent information on specific topics (e.g., neuroplasticity, constraint-induced movement therapy, robotics) with particular relevance to occupational therapy and stroke. All studies identified are summarized in the evidence tables in Appendix B in the original guideline document.

2012 Reaffirmation

Medline, PsycINFO, CINAHL, OTseeker and AgeLine were searched from 2003 to March 2012.

Number of Source Documents

First systemic review: 36 articles.

Second systemic review: 106 articles were included in the original systemic review; additional articles were added at a later date to the review of evidence.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence for Occupational Therapy Outcomes Research

Levels of Evidence Definition
Level I Systematic reviews, meta-analyses, and randomized, controlled trials
Level II Two groups, nonrandomized studies (e.g., cohort, case control)
Level III One group, nonrandomized (e.g., before-after, pretest and posttest)
Level IV Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)
Level V Case reports and expert opinions, which include narrative literature reviews and consensus statements

Note: Adapted from "Evidence-based medicine: What it is and what it isn't." D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, & W. S. Richardson, 1996, British Medical Journal, 312, pp. 71-72.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Studies were evaluated for quality (scientific rigor and lack of bias) and levels of evidence.

The review of the evidence consists of descriptions of selected studies identified in the evidence-based literature review, information about their strengths and weaknesses based on the study design and methodology, and presentations of their findings relevant to the effect of occupational therapy treatment of stroke survivors.

Evidence tables were constructed and are provided in Appendix B of the original guideline document.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

2008 Original Guideline

The developers used an evidence-based perspective and key concepts from the second edition of the Occupational Therapy Practice Framework: Domain and Process (see "Availability of Companion Documents" field) to provide an overview of the occupational therapy process for adults with stroke. The recommendations are based upon the strength of the evidence for a given topic in combination with the expert opinion of review authors and the advisory group reviewing this practice guideline.

2012 Reaffirmation

Content experts were surveyed to examine the focused questions used for the earlier systematic reviews and to make sure that the questions appropriately covered the newer literature. In conjunction with American Occupational Therapy Association (AOTA) staff and a methodology consultant, focused questions were developed for the new review. The content experts also provided additional search terms to appropriately cover the systematic reviews. Review authors for each systematic review came from the pool of content experts. The review authors met throughout the process to determine that all appropriate literature was covered.

Following the development of search terms, a medical librarian with experience in systematic reviews conducted the searches. The methodology consultant completed the first step of eliminating references based on citation and abstract. The review authors and their research teams then reviewed the remaining citations and abstracts to determine which were appropriate for the review. All articles with the potential to be included in the review were placed on a master citation list and this lest was reviewed by AOTA staff and methodology consultant. All included articles were critically appraised by the review authors and this critical appraisal was summarized in an evidence table.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

Not stated

Recommendations

Major Recommendations

Stages of Intervention

Occupational therapy practitioners may provide intervention to stroke survivors with a wide range of neurological impairments in a variety of settings and at various lengths of time after the acute stroke. This document refers to three stages of stroke recovery:

  • The acute stage immediately following stroke
  • The rehabilitation stage
  • The stage of continuing adjustment

Occupational therapy evaluation and intervention will vary on the basis of a person's stage and pattern of stroke recovery, the intervention setting, the environment in which the stroke survivor resides, and the extent of impairment. In addition, each person's individual goals and interests will significantly influence the occupational therapy process.

For the purposes of this Guideline, the acute stage is the initial days following the stroke. Stroke survivors at the acute stage are hospital inpatients, either in the intensive care unit, a designated stroke unit, or a neurological unit. The focus of occupational therapy intervention is on preventing the development of secondary impairments and maximizing recovery of motor and cognitive function.

Some stroke survivors at the rehabilitation stage reside temporarily at a rehabilitation facility or a subacute facility, where they participate in an integrated program of rehabilitation therapies. Others return to their homes and participate in home-based or outpatient rehabilitation. The goals initiated during the acute stage—to prevent development of secondary impairments and to maximize recovery—continue during rehabilitation. However, two important new focuses are added: Occupational therapy intervention promotes skills and activity patterns within the parameters of reemerging motor and cognitive function and also promotes safe and independent occupational performance within the parameters and constraints of available recovery.

The stage of continuing adjustment begins with discharge from a rehabilitation program. Stroke survivors who can function safely in their own homes face daily challenges in structuring their activities and routines to adapt to their current skills. Stroke survivors with more limited recovery or family resources are discharged to long-term nursing homes or assisted living settings where they strive to maintain independent activity performance and meaningful role engagement within a supported environment.

Referral

Referrals for occupational therapy stroke services during the acute stage are generated by attending physicians or other medical professionals as soon as the diagnosis of stroke is established and life-threatening problems are under control. Services often begin within the first 24 hours after a stroke. Referrals may request initial screening for cognitive deficits. Results of cognitive screening determine the need for cognitive reorientation and may influence discharge decisions in later stages of recovery. At many facilities, occupational therapists routinely assess swallowing skills to determine the need for dysphagia interventions. Patients with significant paralysis are referred to occupational therapy for positioning and improving passive range of motion to prevent development of secondary motor impairments. Patients with higher levels of cognitive and motor function may be referred to occupational therapy to begin immediate intervention for restoration of performance skills to prestroke levels.

Referrals during the rehabilitation stage are typically generated by a psychiatrist or other medical professional who requests a comprehensive evaluation (assessment) and intervention to maximize the person's potential for recovery and participation in daily activities. Occupational therapy is an integral component of the interdisciplinary services provided to stroke survivors in rehabilitation facilities, subacute rehabilitation facilities, home health programs, and outpatient programs.

Many stroke survivors and their families require occupational therapy intervention at different times after the formal stage of rehabilitation. Whenever a stroke survivor changes his or her living environment, occupational therapy referral may be indicated to assess the environmental impact on occupational (activity) performance and to implement changes in equipment, strategies, or home design that will maximize safety and independence in valued activities. Referrals for stroke survivors who reside in long-term-care facilities may specifically request occupational therapy assessment and intervention to improve posture and enhance physical comfort through appropriate bed and wheelchair positioning.

Stroke survivors who resume participation in their prestroke communities may request referral to intermittent occupational therapy services for a variety of reasons. The person may need to develop skills and abilities in performing new activities because of changes in his or her context.

Evaluation

Occupational therapists perform evaluations in collaboration with clients and target information specific to the desired outcomes. The two elements of the occupational therapy evaluation are the occupational profile and the analysis of occupational performance.

Occupational Profile

The purpose of the occupational profile is to determine potential goals on the basis of the person's recent roles – in family relationships, social networks, work, and leisure pursuits. Through interview or formal assessment, the occupational therapist determines the person's concerns with regard to meeting task demands in daily life. Formal assessments may include the Canadian Occupational Performance Measure (COPM) and time configuration evaluations, in which the client reflects on a typical day and records in half-hour increments how he or she spends time. The Motor Activity Log (MAL) is an assessment that, although usually viewed as a measure of performance skills (i.e., skilled arm and hand function), can provide an additional dimension to information gathered through the occupational profile. This tool asks stroke survivors to rate the amount and the effectiveness of use of their paretic upper limb during selected daily tasks. It can serve as a valuable guide for the occupational therapist in determining which aspects of arm function are most important to specifically assess before planning treatment goals and interventions.

In developing the occupational profile, the therapist

  • Determines why the client is seeking services
  • Identifies the areas of occupation in which the client is successful and those in which the client has problems
  • Identifies the contexts and environments that support and inhibit engagement in occupations
  • Discusses significant aspects of the client's occupational history
  • Determines the client's priorities and desired outcomes

During the acute stage after stroke, the occupational profile is secondary to an assessment of client factors and performance skills. During the stages of rehabilitation and continuing adjustment, however, occupational therapists must understand the needs and expectations of the client and family in order to assess pertinent aspects of occupational performance, establish targeted outcomes collaboratively, and plan intervention.

Analysis of Occupational Performance

The occupational therapist uses information from the occupational profile to focus on the specific areas of occupation within the client's current context. When analyzing occupational performance the therapist

  • Observes the client as he or she performs the occupations in the natural or least restrictive environment and notes the effectiveness of the client's performance skills and performance patterns
  • Selects specific assessments and assessment methods that will identify and measure the factors that may be influencing the client's performance (see Table 1 in the original guideline document for examples of selected assessments)
  • Interprets the assessment data to identify what supports or hinders performance
  • Develops or refines a hypothesis regarding the client's performance
  • Develops goals in collaboration with the client that address the client's desired outcomes
  • Identifies potential intervention approaches, guided by best practice and the evidence, and discusses them with the client
  • Documents the evaluation process and communicates the results to the appropriate team members and community agencies.

Areas of Occupation

On the basis of the client's age and current lifestyle, the occupational therapist assesses his or her ability to perform basic and instrumental activities of daily living, rest and sleep activities, work activities, leisure activities, activities related to family roles (e.g., parent, grandparent), and activities related to participation in community and social pursuits.

Performance Skills

Stroke survivors present with skill deficits in arm and hand function, balance, functional ambulation, cognition, perception, and communication that range in type and severity. The purpose of assessing performance skills is to determine the extent to which a stroke survivor is able to actively use the motor and cognitive abilities that either have been spared by or recovered after the stroke. Occupational therapists are qualified to administer both standardized and observational assessments of performance skills.

Client Factors

Client factors are the underlying abilities that allow for skilled performance. The client factors of interest in stroke survivors are the primary and secondary impairments associated with stroke. Common primary impairments of interest to occupational therapy practitioners are motor paralysis, sensory loss, and cognitive and perceptual deficits. Secondary impairments are the preventable client factors that, if allowed to develop, will present further obstacles to skill development and performance of valued activities.

Performance Patterns

The habits, routines, roles, and rituals of a person's daily life (performance patterns) contribute significantly to a healthy lifestyle and influence which goals will be most important to each stroke survivor. This area of assessment is less important than others during the acute phase after stroke because people have little control over their performance pattern in the hospital environment. However, evaluation of performance patterns becomes a priority during the rehabilitation phase and the phase of continuing adjustment. During these phases, the occupational therapist interviews the client and family members to determine relevant performance patterns before the stroke.

Context and Environment

A core principle in occupational therapy is that performance is significantly influenced by the contexts in which people participate. Occupational therapists assess physical factors in the environment through accessibility assessments of clients' home, workplace, and community settings. Through interviews and interpersonal contact, occupational therapists also assess individualized factors in a person's cultural, personal, and social contexts. Temporal context, which includes a client's age and phase of stroke recovery, influences decisions about choice of evaluation tools and treatment interventions.

Activity Demands

When a stroke survivor has difficulties performing valued activities, the occupational therapist analyzes the specific activity demands that present challenges. The integrated results of assessing internal factors and activity demands inform the occupational therapist in determining how activities can be modified to facilitate performance or to provide feasible practice opportunities that may foster recovery of emerging skills.

After completing the occupational profile and determining which activities constitute a client's typical life pattern, the occupational therapist assesses the performance demands associated with each activity.

Considerations in Assessment

Bottom-Up and Top-Down Approaches to Assessment

Occupational therapists consider each individual when determining whether to pursue a bottom-up or a top-down approach to evaluation). A bottom-up approach focuses on the client's generic abilities, with the rationale that impairments and abilities in client factors and skills will affect performance in an infinite number of present and future occupations. A top-down approach begins with an occupational profile and continues with a focused evaluation of client factors, performance skills, and performance patterns in the context of their impact on the client’s capacity to perform valued activities and roles.

During the acute stage, a bottom-up assessment approach is advised. Because stroke survivors in the acute stage are adapting to their loss, and because it is virtually impossible to predict recovery levels, assessments of client factors are most critical. The resulting information enables occupational therapists to target intervention toward preventing secondary impairments, maximizing recovery, and making decisions for immediate discharge placement from the hospital setting.

During the rehabilitation stage, assessment is holistic and comprehensive. Occupational therapists dynamically move between top-down and bottom-up approaches.

Bottom-up assessments lose their significance during the stage of continuing adjustment when the emphasis is on improving quality of life and participation in a wide repertoire of meaningful roles. Even though stroke survivors maintain hope for continued recovery, a significant percentage must come to terms with creating a satisfying pattern of life activities in spite of residual losses in motor, cognitive, sensory, or perceptual function. Accordingly, assessments at this stage will focus on activities, contexts, and patterns of performance. Most important, assessments will determine how these factors can be integrated with the client’s available skills to promote activity engagement and participation in valued occupations.

Standardized and Observationally Based Assessments

Depending on the treatment setting and the purposes of assessment, occupational therapists determine whether to use standardized evaluations or nonstandardized clinical observations of client performance in naturalistic contexts. Each type of assessment has its advantages and disadvantages, and occupational therapists are skilled in administering either category of client evaluation.

Standardized evaluations, when administered and scored according to published protocols, provide reliable and valid data for quantitative documentation of clients' progress. In addition, standardized evaluation scores can be used as outcome data for assessing the effectiveness of specific interventions. These assessments, however, may require significant time to administer. In addition, because consistent procedures must be followed on each administration, the evaluation context may fail to capture the environmental conditions under which the client will typically perform the skills or tasks being tested. Observationally based standardized assessments, such as the Assessment of Motor and Process Skills (AMPS) and Arnadottir Occupational Therapy Activities of Daily Living Neurobehavioral Evaluation (A-ONE), provide the benefits of standardized assessment while allowing for observation of behavior in naturalistic contexts.

During the acute stage after stroke, when the person’s status may fluctuate from day to day and the priority is on implementing preventive interventions, occupational therapists rarely use standardized evaluations. During rehabilitation, however, occupational therapists routinely administer standardized evaluations to establish baseline data on admission to the facility. Periodic reevaluations determine an individual client's progress, influence continued treatment and discharge decisions, and provide data for program evaluation. Occupational therapy during the stage of continuing adjustment relies on standardized evaluations to determine clients' eligibility for demanding occupations such as driving or return to work. In addition, periodic standardized assessments during this time, when the natural course of recovery has typically subsided, are critical for determining intervention efficacy. Boxes 2, 3, and 4 in the original guideline document present case studies illustrating the occupational therapy evaluation and intervention process.

Intervention

Occupational therapy intervention with stroke survivors is a collaborative process between practitioner and client. The ultimate goals are engagement in a wide repertoire of personally meaningful occupations and a healthy lifestyle that supports independence, prevention of additional strokes, and prevention of secondary impairments. The intervention process consists of three components: (1) developing an intervention plan in which objective and measurable goals are established, with clear guidelines for treatment approaches, treatment personnel, and frequency and duration of service; (2) intervention implementation; and (3) intervention review.

Intervention Plan

As a part of the occupational therapy process, the occupational therapist develops an intervention plan that documents (1) the client's goals within an occupational framework, (2) the planned intervention approaches, and (3) recommendations or referrals to others. The intervention plan outlines and guides the therapist's actions and is based on the best available evidence to meet the identified outcomes.

Intervention Implementation

The broad goals of occupational therapy intervention with stroke survivors are to:

  • Prevent secondary impairments
  • Restore performance skills
  • Modify activity demands and the contexts in which activities are performed to support safe, independent performance of valued activities within the constraints of stroke-related fatigue and motor, cognitive, or perceptual limitations
  • Promote a healthy and satisfying lifestyle that includes adherence to medication routine, appropriate diet, appropriate levels of physical activity, and satisfying levels of engagement in social relationships and activities
  • Maintain performance and health that the stroke survivor has previously regained or the neuropathology has spared.

Tables 3-7 in the original guideline document provide examples of occupational therapy intervention under the rubric of these five approaches.

Intervention to Prevent Secondary Impairments

Preventive occupational therapy intervention with stroke survivors seeks to minimize the risks of six kinds of secondary impairments:

  • Abnormal changes in postural alignment (postural deformities)
  • Pain associated with immobility or abnormal joint alignment
  • Learned nonuse
  • Injury due to falls
  • Aspiration during feeding, eating, and swallowing
  • Depression following stroke

In each of these areas, occupational therapy intervention is part of a multidisciplinary effort with physicians, nurses, and other rehabilitation professionals.

Prevention of Postural Deformities

Intervention begins immediately following stroke with slow, gentle, passive stretch to all muscle groups.

During the acute stage after stroke, occupational therapists instruct patients in using available motor control in the affected and nonaffected limbs to begin a self-exercise program designed to stretch muscles gently throughout the body. This regimen needs to be continued as a routine exercise program throughout the person’s life. Since motor capabilities are likely to change with recovery and over time with aging, it is important that therapists review and modify the stretching program during subsequent stages of rehabilitation and continuing adjustment. For stroke survivors with more severe disabilities who never regain sufficient motor control to implement their own routine stretching programs, the occupational therapist teaches caregivers passive stretch regimens that are individually tailored to be both appropriate to the survivor's needs and feasible within the context of the caregiver's physical abilities and time demands.

Prevention of Pain and Other Complications Associated with Immobility or Abnormal Joint Alignment

All stroke survivors, at all stages of recovery, may experience pain. The causes of pain after stroke are associated with preventable, secondary impairments such as abnormal shoulder alignment, pressure ulcers, edema, and joint immobility. Studies of stroke-associated shoulder pain consistently show that prevention is more effective than treatment.

Occupational therapy practitioners prevent secondary impairments associated with shoulder pain by teaching stroke survivors effective strategies for self-range of motion. Specifically, clients learn to achieve scapula mobility before attempting to perform active or passive motions at the glenohumeral joint. In addition, they learn to combine glenohumeral with scapular motions, especially when flexing the humerus beyond 90°. Occupational therapy practitioners also provide individualized training to caregivers on proper handling of the shoulder girdle.

Glenohumeral subluxation is commonly seen in hemiplegic clients. Occupational therapists assess the specific type of glenohumeral subluxation and provide a variety of interventions, depending on the type and the severity of misalignment. Interventions include provision of external supports and electrical stimulation to rotator cuff muscles. At present, the evidence is insufficient to support the routine provision of either of these two interventions.

Hand edema, another secondary impairment, is associated with immobility, a dependent position of the hand, and limited natural pumping of extracellular fluid associated with active muscle contraction. First and foremost, occupational therapists prevent hand edema by encouraging active movement of the hand for those clients who have the motor capacity. For those clients who are unable to actively contract the muscles of the hand, positioning to elevate the hand, as well as compression and gentle massage techniques, are recommended interventions. Use of continuous passive motion technology or neuromuscular stimulation in conjunction with elevation of the hand is more effective than elevation alone in reducing edema immediately following stroke.

Pressure ulcers are associated with prolonged immobility. Stroke survivors who fail to achieve the capacity to shift body weight when sitting, or to change their position in bed, are at risk of developing this painful and costly secondary impairment. Stroke survivors who establish daily routines involving movement and frequent adjustment of body weight off bony prominences have little risk of developing pressure ulcers. Therefore, prevention is achieved through the early introduction of activity-based interventions designed to enhance the abilities of stroke survivors to move about in bed and to maintain sitting balance when shifting their center of mass throughout all possible permutations of the three cardinal planes.

Prevention of Learned Nonuse

Beyond the constraints imposed by secondary mechanical impairments, many stroke survivors demonstrate "learned nonuse." This phenomenon describes the common situation in which a person fails to use his or her paretic arm, even when muscle activity and sensory awareness are available.

During the acute and rehabilitation stages after stroke, prevention of learned nonuse is a primary goal in occupational therapy intervention. Therapists use every opportunity to teach the stroke survivor to be aware of and to use the paretic limbs to the limits of current available motor function.

Prevention of Injuries Due to Falls

Occupational therapy practitioners provide interventions to reduce both intrinsic and extrinsic risk factors for falling. Intrinsic client factors in the stroke population include muscle weakness, balance impairments, and attention impairments. Occupational therapy practitioners work with clients in the acute and rehabilitation stages of stroke recovery to provide them with opportunities to practice unsupported sitting and functional standing. In the context of functional activity performance, stroke survivors develop strategies for adjusting to shifts in their body's center of mass to enhance their balance skill and efficacy. To reduce fear of falling and to ensure more favourable outcomes if falls do occur, it is critical that stroke survivors have opportunities for supervised practice performing bathroom and other household activities, as well as getting themselves back into an upright position from the floor.

Extrinsic risk factors for falls among stroke survivors can be significantly reduced through assessment of the home environment and introduction of structural adaptations designed to meet individual needs for external supports for stability in the bathroom, kitchen, bedroom, and other living spaces. Multifaceted interventions by occupational therapists with elderly people in the community have been shown to be effective in reducing the risk of falls and related injuries.

Prevention of Aspiration During Feeding, Eating, and Swallowing

Dysphagia — difficulty eating and swallowing due to motor or cognitive impairments — is common immediately following stroke, but often subsides after the acute stage of recovery. In acute stroke care settings, occupational therapists are members of the professional team that provides evaluation and intervention to prevent aspiration during feeding. Initially, the occupational therapist assesses oral motor skills and swallowing efficiency to help the physician determine when the client may proceed from alternative feeding to a specified sequence of solid and liquid food consistencies.

When a client is cleared for oral intake, occupational therapists provide positioning intervention to ensure that the client's seated posture contributes to safe and efficient swallowing. In addition, occupational therapists use techniques to improve sensation, strength, and muscle tone of oral structures to maximize the potential for safe, independent eating.

Similar interventions may be indicated after the acute stage for clients who continue to demonstrate continued feeding impairments. These individuals are most typically seen in nursing facilities or are living at home with significant levels of caregiver assistance.

Prevention of Depression following Stroke

Occupational therapists play two important roles in preventing depression after a stroke. First, through their close contact with stroke survivors, occupational therapists can recognize signs and symptoms of depression and communicate with other health professionals to ensure that clients receive appropriate medical and psychological intervention. Second, by promoting independence, autonomy, participation, and hope for the future, occupational therapists can reduce the overwhelming emotional burdens of adjusting to life after a stroke.

For examples of interventions to prevent secondary impairments, see Table 3 in the original guideline document.

Intervention to Restore Performance Skills

Occupational therapy provides stroke survivors with structured practice opportunities to maximize emerging skills. Doing this is not nearly as simple as it sounds. When people practice maladaptive strategies, they learn patterns of behavior that may be counterproductive to future improvements in functional performance. To provide appropriate practice opportunities, therapists must clearly envision the intended practice outcomes and skillfully manipulate a variety of factors during each practice session. These factors include instructions, feedback, activity parameters, salient conditions in the practice environment, and practice schedules. The ultimate goal is for clients to generalize their new skills to enhanced performance of activities in their daily lives.

Motor skills include the abilities to maintain balance and postural alignment during activity performance in sitting and standing postures and to use the paretic arm and leg for functional tasks.

The occupational therapist designs tasks that challenge emerging movement capacities without promoting the development of secondary impairments that may constrain a person’s potential to develop functional motor skills.

Cognitive skills include the abilities to attend to environmental stimuli; remember relevant information; plan, organize, and sequence activity performance; and assess actions. Perceptual skills include the abilities to interpret sensory information and navigate the spatial environment.

Occupational therapy intervention for stroke survivors with cognitive and perceptual impairments begins with structured assessment (see Table 1 in the original guideline document) to determine the following:

  • Their level of self-awareness of the neurobehavioral deficit that they exhibit during task performance, which will critically affect the person's capacity to improve skills or apply compensatory strategies
  • Their potential to improve impaired skills through structured, graded practice
  • Their potential to apply new strategies that might facilitate compensation for cognitive or perceptual deficits

On the basis of their findings from these assessments, occupational therapists develop individualized treatments designed to accomplish the following goals:

  • Enhance clients' awareness of their neurobehavioral impairments
  • Provide clients with graded practice opportunities to improve specific skills that are amenable to change
  • Enable clients to assess their own activity performance to make decisions that will enhance their success in performing specific tasks
  • Teach clients alternative strategies to maximize their performance in task situations that present cognitive or perceptual challenges

Through carefully selected activity challenges and guided questions before, during, and after task performance, occupational therapists help stroke survivors develop insight into their cognitive–perceptual assets and limitations.

Emotional coping skills include a core of effective strategies that stroke survivors must develop to negotiate their interactions with others and return to full participation in their communities. The emotional challenges of living with the sequelae of stroke are enormous. The physical difficulties of paralysis, impaired balance, and fatigue, often combined with difficulties processing information or communicating, significantly affect a person's core identity.

Stroke survivors need opportunities to practice the skills that they will need to cope with the emotional challenges they face every day. Through role-playing and practice in real environments, such as at the bank, on the bus, and in the workplace, occupational therapists help stroke survivors begin to problem-solve. The goal is to develop day-to-day strategies that they can use in emotionally challenging situations. Occupational therapists design "homework" in which stroke survivors perform specific self-selected tasks and report the outcome in the next therapy session. Homework assignments and practice opportunities are geared toward each person's present and anticipated environmental contexts.

For examples of interventions to restore performance skills, see Table 4 in the original guideline document.

Intervention to Modify Activity Demands and the Contexts in Which Activities Are Performed

Even with appropriate medical care and excellent rehabilitation services, many stroke survivors may fail to achieve full recovery of motor, cognitive, or perceptual skills. In addition, stroke-related fatigue may further limit their ability to perform daily activities. Participation and quality of life can be enhanced considerably through the use of strategies and equipment designed to compensate for residual impairments.

During the acute stage of stroke recovery, the focus is on adapting routine self-care activities. Early rehabilitation goals include feeding oneself independently and safely, getting dressed, bathing, and performing daily grooming tasks. Although techniques are available for achieving these activities while seated and solely with the use of one arm, the skillful occupational therapist structures self-care activity performance to provide therapeutic challenges to each person's emerging balance and motor skills. Accordingly, compensatory techniques are individualized to match each person's residual skills, desire for challenge, and preferred methods of task performance.

During the rehabilitation stage, stroke survivors refine their skills in self-care activities and instrumental activities of daily living to facilitate their discharge back home. During the rehabilitation stage, occupational therapists challenge stroke survivors to identify activities that are important to them within the repertoire of participation in family, community, and work roles.

In the stage of continuing adjustment, people are faced with the everyday challenges of resuming their lives. Occupational therapy intervention to assist in problem solving for activity modification is particularly critical at this phase.

For examples of interventions to modify activity demands, contexts, and performance patterns, see Table 5 in the original guideline document.

Environmental Modifications

Environmental modifications for safety and independence depend on each client's ambulation status and capacity to use the paretic arm. For stroke survivors who are dependent on wheelchair use for mobility, occupational therapists assess the home and workplace according to national standards for wheelchair accessibility. They make recommendations regarding ways to provide sufficient space in a driveway or garage to allow safe transfer from car to wheelchair and determine architecturally appropriate strategies to provide wheelchair accessibility at entrances, doorways, hallways, bathrooms, and rooms. Wheelchair accessibility includes sufficient space for entering; turning; and accessing switches, outlets, closets, and appliances.

Most stroke survivors who return to community living have some ability to walk. Functional ambulation, even if only for short distances, makes a significant difference in a person's ability to live safely and independently without the need for extensive environmental modifications. For ambulatory clients, the occupational therapist recommends modifications for stairways, helps families reorganize passage areas for unimpeded walking, and prescribes essential modifications to ensure bathroom safety. Stairway solutions may be as simple as the addition of an extra set of handrails to be used with the unaffected arm when ascending and descending the stairs. In the case of an ambulatory stroke survivor who is unable to navigate a flight of stairs, a stair glide may enable the person to maintain a bedroom safely on the second floor of the home. Bathroom modifications such as a raised toilet seat; 3-in-1 commode; tub seat; handheld shower nozzle; and safety bars for the tub, near the toilet, and at other strategic locations are critical safety interventions for stroke survivors whose balance or standing endurance is impaired.

Adaptive Equipment

Adaptive equipment enables stroke survivors to perform self-care, homemaking, work, and leisure activities with varying levels of skilled motor function. Equipment selection is highly individualized and is based on the constellation of factors assessed in the occupational therapy evaluation. Some examples of widely used equipment to facilitate one-handed activity performance are a rocker knife for one-handed cutting, nonslip pads to place under plates, holders for books or playing cards, stabilizing devices for activities that traditionally require two-handed performance (e.g., cutting vegetables, cleaning dentures), and keyboards adapted for one-handed computer use. Adaptive equipment needs for driving depend on whether the left or the right limb has been affected by stroke. Most stroke survivors will benefit from a driving evaluation by a specially trained occupational therapist. Recommendations may include appropriate adaptive equipment such as a spinner knob for one-handed control of the steering wheel to enable the stroke survivor to safely return to driving. People with right hemiparesis will need adaptations allowing the left foot to control the brake and accelerator.

Intervention to Promote a Healthy and Satisfying Lifestyle

Occupational therapy practitioners help stroke survivors establish performance patterns that support adherence to medication routine, appropriate diet, appropriate levels of physical activity, and satisfying levels of engagement in social relationships and activities. Beyond developing the capacities for activity performance, stroke survivors need to establish daily routines that support their physical and emotional well-being. Engagement in activity to support participation and health is the ultimate goal of occupational therapy intervention. Artful use of the occupational profile enables an occupational therapist to target all aspects of a person’s activity performance and time allocation that contribute to a healthy and satisfying lifestyle. In addition, occupational therapy intervention in every stage of stroke recovery must emphasize continued attention to the prevention of secondary impairments described earlier in this Guideline. Because stroke affects each person differently, and the context of each person's life significantly influences activity performance, each stroke survivor requires an individualized approach to promote a healthy and satisfying lifestyle.

For examples of interventions to promote a healthy lifestyle, see Table 6 in the original guideline document.

Intervention to Maintain Performance and Health

Education of clients, family, and caregivers is an important aspect of occupational therapy intervention designed to maintain performance and health after services have ended. In addition, occupational therapists develop and supervise performance of routine exercise programs designed to prevent the development of secondary impairments. Occupational therapy interventions that modify tasks and environments seek an optimal balance between safety, efficiency, and challenge to remaining skills. The presence of appropriate challenge is essential to maintaining performance capacities. Finally, occupational therapy interventions to establish active, healthy daily routines contribute further to maintaining the performance capacities of each stroke survivor and preventing an avoidable decline toward inactivity, loss of social roles, and emotional depression.

For examples of interventions to maintain performance and health, see Table 7 in the original guideline document.

Intervention Review

Intervention review is a continuous process of reevaluating and reviewing the intervention plan, the effectiveness of its delivery and the progress toward targeted outcomes. Reevaluation normally substantiates progress toward goal attainment, indicates any change in functional status, and directs modifications to the intervention plan, if necessary.

Outcome Monitoring

Occupational therapists regularly monitor the results of their intervention by readministering standardized and nonstandardized assessments used in evaluation (see Table 1 in the original guideline document). This reassessment determines the need to continue or modify the intervention plan or to discontinue intervention and refer the client to other agencies or professionals. In addition, at the acute and rehabilitation stages of stroke recovery, results of occupational therapy outcomes assessment are used in determining discharge plan.

Occupational therapy practitioners document outcomes just as they document evaluation findings and interventions. They complete this documentation within the time frames, formats, and standards established by practice settings, agencies, external accreditation programs, and payers.

In addition to monitoring outcomes of individuals, occupational therapists use aggregate data from outcomes assessments to evaluate the effectiveness of specific interventions. This use of standardized outcomes data is critical for program development and the establishment of a research foundation for evidence-based practice.

Discontinuation, Discharge Planning, and Follow-up

Ideally, planning for discharge begins at the time a stroke survivor starts to participate in an occupational therapy treatment program.

Early planning ensures that treatment will provide the best preparation for the person's future success after services are discontinued. In many situations, clients are discharged from occupational therapy services at a particular site before all the treatment goals have been met. In these cases, it is important to document which outcomes have not yet been achieved and to recommend occupational therapy and other professional services that are provided through other venues. For example, when a stroke survivor is discharged home from a rehabilitation facility, home-based or outpatient occupational therapy services usually are indicated. When home-based services must be terminated for reimbursement reasons, clients need access to potential resources for private-pay or grant-funded interventions. In the absence of resources for continued occupational therapy intervention, therapists are obligated to provide clients and caregivers with clear, written instructions for ongoing home management and information about community agencies providing continuing support or activity programs.

Occupational therapy services may be indicated at several points throughout the life of a stroke survivor. There is significant research evidence that occupational therapy services can promote independence, health, and quality of life. The current health care system needs to develop improved mechanisms to ensure that stroke survivors can access short-term occupational therapy services to meet their evolving needs, as determined by changes in physical status, environment, and life roles.

Definitions:

Levels of Evidence for Occupational Therapy Outcomes Research

Levels of Evidence Definition
Level I Systematic reviews, meta-analyses, and randomized, controlled trials
Level II Two groups, nonrandomized studies (e.g., cohort, case control)
Level III One group, nonrandomized (e.g., before-after, pretest and posttest)
Level IV Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)
Level V Case reports and expert opinions, which include narrative literature reviews and consensus statements

Note: Adapted from "Evidence-based medicine: What it is and what it isn't." D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, & W. S. Richardson, 1996, British Medical Journal, 312, pp. 71-72.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations
  • Studies on restoration (first systematic review): Level I studies (10), Level II studies (2), Level III studies (3)
  • Studies on remediation (first systematic review): Level I studies (17), Level II studies (9), Level III studies (2), and Level IV study (1)

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

This guideline may be used to improve quality of care, enhance consumer satisfaction, promote appropriate use of services, and reduce cost by assisting:

  • Occupational therapists and occupational therapy assistants in communicating about their services to external audiences
  • Other health care practitioners and program administrators in determining whether referral for occupational therapy services would be appropriate
  • Third-party payers in determining the medical necessity for occupational therapy
  • Health and education planning teams in determining the need for occupational therapy
  • Legislators, third-party payers, and administrators in understanding the professional education, training, and skills of occupational therapists and occupational therapy assistants
  • Program developers, administrators, legislators, and third-party payers in understanding the scope of occupational therapy services
  • Program evaluators and policy analysts in this practice area in determining outcome measures for analyzing the effectiveness of occupational therapy intervention
  • Policy, education, and health care benefit analysts in understanding the appropriateness of occupational therapy services for stroke
  • Occupational therapy educators in designing appropriate curricula that prepare future occupational therapy practitioners to work with adults with stroke
Potential Harms

Not stated

Qualifying Statements

Qualifying Statements
  • This Guideline does not discuss all possible methods of care. Although it does recommend some specific methods of care, the occupational therapist makes the ultimate judgment regarding the appropriateness of a given procedure in light of a specific person's circumstances and needs.
  • This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold or distributed with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional services. If legal advice or other expert assistance is required, the services of a competent professional person should be sought.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Staff Training/Competency Material
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Sabari J, Lieberman D. Occupational therapy practice guidelines for adults with stroke. Bethesda (MD): American Occupational Therapy Association (AOTA); 2008. 168 p. [255 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2008 (reaffirmed 2012 Mar)
Guideline Developer(s)
American Occupational Therapy Association, Inc. - Professional Association
Source(s) of Funding

American Occupational Therapy Association, Inc.

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Authors: Joyce S. Sabari, PhD, OTR, FAOTA, Associate Professor and Chairperson, Occupational Therapy Program, State University of New York, Downstate Medical Center, Brooklyn; Deborah Lieberman, MHSA, OTR/L, FAOTA, Series Editor, Program Director, Evidence-Based Practice, Staff Liaison to the Commission on Practice, American Occupational Therapy Association, Bethesda, MD

Evidence-based Literature Review: Marian Arbesman, PhD, OTR/L; Catherine Trombly Latham, ScD, OTR/L, FAOTA; Hui-ing Ma, ScD, OTR

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

The American Occupational Therapy Association reaffirmed the currency of this guideline in March 2012.

Guideline Availability

Electronic copies: Not available at this time.

Print copies: Available for purchase from The American Occupational Therapy Association (AOTA), Inc., 4720 Montgomery Lane, Bethesda, MD 20814, Phone:1-877-404-AOTA (2682), TDD: 800-377-8555, Fax: 301-652-7711. This guideline can also be ordered online at the AOTA Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Occupational therapy practice framework: domain and process (2nd ed.). 2008. American Journal of Occupational Therapy (AOTA), 62, 625–83. Electronic copies: Available to subscribers from the AOTA Web site External Web Site Policy.
  • Webcast: paradigm shift and innovations in stroke rehabilitation. Continuing Medical Education (CME). 2009. American Occupational Therapy Association (AOTA). Electronic copies: Available for purchase from the AOTA Web site External Web Site Policy.

In addition, three case studies, Acute Phase of Stroke, Rehabilitation Phase of Stroke, and Continuing-Adjustment of Stroke, are available in the original guideline document.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on October 28, 2010. The currency of the guideline was reaffirmed by the developer in March 2012 and this summary was updated by ECRI Institute on October 22, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

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The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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