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The American Journal of Occupational Therapy 369

Occupational Therapy Activities and Intervention Techniquesfor Clients With Stroke in Six Rehabilitation Hospitals

Nancy K. Latham, Diane U. Jette, Wendy Coster, Lorie Richards, Randall J. Smout, Roberta A. James, Julie Gassaway, Susan D. Horn

OBJECTIVE. To prospectively monitor occupational therapy activities and intervention techniques used dur-ing inpatient stroke rehabilitation in order to provide a description of current clinical practice.

METHODS. Data were collected prospectively from 954 clients with stroke receiving occupational therapyfrom six U.S. rehabilitation hospitals. Descriptive statistics summarized frequency, intensity, and duration ofoccupational therapy sessions; proportion of time spent in 16 therapeutic activities; and proportion of thoseactivities that included any of 31 interventions.

RESULTS. Clients received on average 11.8 days (SD = 7.2) of occupational therapy, with each session last-ing on average 39.4 min (SD = 16.9). Upper-extremity control (22.9% of treatment time) and dressing (14.2%of treatment time) were the most frequently provided activities. Interventions provided most frequently duringupper-extremity control activities were strengthening, motor learning, and postural awareness.

CONCLUSION. Occupational therapy provided reflected an integration of treatment approaches. Upper-extremity control and basic activities of daily living were the most frequent activities. A small proportion of ses-sions addressed community integration.

Latham, N. K., Jette, D. U., Coster, W., Richards, L., Smout, R. J., James, R. A., Gassaway, J., & Horn, S. D. (2006).Occupational therapy activities and intervention techniques for clients with stroke in six rehabilitation hospitals.American Journal of Occupational Therapy, 60, 369–378.

Stroke is the third largest cause of death and one of the leading causes of long-term disability in the United States (Centers for Disease Control and

Prevention, 2000). Significant progress has been made in stroke care over the past30 years and as a result the proportion of people who survive a stroke has increased(Centers for Disease Control and Prevention, 2000). It is now well established thatdifferences in post-stroke care and rehabilitation have a significant effect on out-come, with one systematic review finding that clients who received organized inpa-tient care in a stroke unit were more likely to be alive, independent, and living athome 1 year after the stroke (Stroke Unit Trialists’ Collaboration, 2003). However,despite evidence that post-stroke care influences outcomes, the ideal activities orapproaches to treatment that should be included in stroke rehabilitation are stillnot well established (Wade & de Jong, 2000).

Occupational therapists play an important role in post-stroke rehabilitation.The National Board for Certification in Occupational Therapy (NBCOT) PracticeAnalysis reported that cerebrovascular accident was the most frequent diagnosisseen by their survey respondents (NBCOT, 2004). Several recent systematicreviews suggest that occupational therapy after a stroke improves the performanceof some functional tasks and reduces some impairments (Ma & Trombly, 2002;Steultjens et al., 2003; Trombly & Ma, 2002). However, most trials provide fewdetails about the range of occupational therapy interventions and activities thatwere used across the rehabilitation episode.

Few observational studies exist that describe the nature of occupational thera-py interventions currently being used for stroke rehabilitation in the United States.Most studies to date have been conducted in countries outside the United States(Alexander, Bugge, & Hagen, 2001; Ballinger, Ashburn, Low, & Roderick, 1999;

Nancy K. Latham, PhD, is Research Assistant Professor,Health and Disability Research Institute, Boston University,53 Bay State Road, Boston, Massachusetts 02215;[email protected]

Diane U. Jette, DSc, PT, is Professor and Program Director,Physical Therapy Program, Simmons College, Boston,Massachusetts.

Wendy Coster, PhD, OTR, is Associate Professor andProgram Director, Therapeutic Studies and OccupationalTherapy, Boston University, Boston, Massachusetts.

Lorie Richards, PhD, OTR, is Research Health Scientist,Veterans Affairs Research Service at the BrainRehabilitation Research Center, North Florida/SouthGeorgia Department of Veterans Affairs Medical Center,Gainesville, Florida; and Associate Professor, OccupationalTherapy Department, University of Florida, Gainesville,Florida.

Randall J. Smout, MS, is Senior Analyst, InternationalSeverity Information Systems, Inc., Salt Lake City, Utah.

Roberta A. James is Data Systems Specialist, InternationalSeverity Information Systems, Inc., Salt Lake City, Utah.

Julie Gassaway, MS, RN, is Director of Project/ProductDevelopment, International Severity Information Systems,Inc., Salt Lake City, Utah.

Susan D. Horn, PhD, is Vice President for Research,International Severity Information Systems, Inc., Salt LakeCity, Utah.

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370 July/August 2006, Volume 60, Number 4

deWeerdt et al., 2000); have described treatment activitiesonly in terms of duration or frequency (Alexander et al.,2001; Bernhardt, Dewey, Thrift, & Donnan, 2004; Sulch,Perez, Melbourn, & Karla, 2000); or have involved a limit-ed number of clients (Ballinger et al., 1999; deWeerdt et al.,2000). The Practice Analysis (NBCOT, 2004) reports thefrequency with which entry-level practitioners use specificinterventions, but does not break these down by client con-dition and surveyed therapists only within the first 3 yearsof their practice.

Given the limitations of reported studies and a lack ofinformation about how clients with stroke are treated byoccupational therapists in the United States, we undertooka study to describe the care provided by occupational ther-apists for clients with stroke in six hospital-based rehabilita-tion settings within the United States. Our aim was todescribe the occupational therapy plan of care by describingthe types of therapeutic activities that therapists used witheach client. We defined therapeutic activities as whole tasksthat were the focus of a therapy session. In addition, wewished to capture the intervention techniques that theoccupational therapists used during each of these activities.We defined intervention techniques as specific treatmentapproaches used by occupational therapy practitioners tofacilitate activities. Finally, we collected data about theduration, frequency, and intensity of occupational therapysessions, and the personnel who provided them. This infor-mation complements and expands information in theNBCOT Practice Analysis (2004), by providing moredetailed information about current practice with a specificclinical population by practitioners with a broader range ofexperience. In addition, it may provide guidance to clinicalresearchers about important elements of occupational ther-apy that need to be documented in future studies of reha-bilitation outcomes.

Methods

Subjects

As part of the Post-Stroke Rehabilitation Outcomes Project(PSROP), data were collected between March 2001 toAugust 2003 from consecutive clients with stroke seen at sixrehabilitation hospitals in the United States (DeJong et al.,2005). The sites were geographically dispersed (3 in theWest, 1 in the Central Mountain region, 1 in the South,and 1 in the East). The facilities were a mixture of free-standing rehabilitation hospitals and rehabilitation unitsthat were linked to acute care hospitals. Physical Medicineand Rehabilitation residents were involved in stroke man-agement in 2 out of 6 of the facilities. For this observation-

al cohort study, a Clinical Practice Improvement approachwas used in which detailed client, process, and outcomevariables were obtained (Horn, 1997). This study wasapproved by the institutional review boards at BostonUniversity and at each of the participating hospitals and wasclassified as exempt because of its observational nature.

Nine hundred and fifty-four clients met the inclusioncriteria, which were a diagnosis code indicating that theperson had experienced a stroke (ICD-9-CM of430–438.99), was older than 18 years of age, had a recentstroke (within 1 year of admission) as the reason for admis-sion, and had no interruption in rehabilitation services ofgreater than 30 days (see Table 1 for client characteristics).The mean age of clients was 66.2 years (SD = 14.2). Mencomposed 51% of the sample and women 49%. Fifty-seven percent of clients were White, 24% were AfricanAmerican, 4.9% were Asian, and the remaining were ofother backgrounds or unknown race. Forty-three percentof clients had left-sided hemiplegia, 43% had right-sidedhemiplegia, 10% had bilateral involvement, and theremainder had other types of involvement.

A total of 180 occupational therapy staff participated inthis study, and of these, 61% were occupational therapists,38% were occupational therapy assistants, and 1% werestudents. In the subset of therapists who provided detailedinformation about their work experience (i.e., 27%), theoccupational therapists had an average of 10.3 years ofexperience (SD = 8.2, range = 1–32) and the occupationaltherapy assistants had 8.3 years (SD = 5.6, range = 2–23).Most occupational therapists or occupational therapy assis-tants (69%) worked full time (i.e., 40 hr per week). Themajority of therapists and assistants had obtained someadvanced training in neurology-related or geriatric-relatedcourses in the past 2 years. The most frequently reported

Table 1. Client CharacteristicsCharacteristic N = 954

Age (years) Mean 66SD 14Range 18–95

Gender % (n)Male 51 (487)Female 49 (467)

Race % (n)White 57.2 (546)African American 24.0 (229)Asian 4.9 (47)Other or unknown 13.9 (132)

Impairment % (n)Left hemiplegia 43.6 (416)Right hemiplegia 43.6 (416)Bilateral involvement 10.1 (96)Other 2.7 (26)



type of training was in neuromuscular interventions (i.e.,NDT or neurodevelopmental treatment), in which 59% ofrespondents said that they had participated during the past2 years.

Instrumentation

Forms to record activity and intervention data from eachoccupational therapy session and definitions for each ofthese terms were developed with input from occupationaltherapists involved in care of clients with stroke at eachfacility participating in the PSROP (DeJong et al., 2004).The data collection forms allowed occupational therapyproviders to describe sessions using 16 possible categories ofactivities. These included Examination/Evaluation andactivities to remediate performance skill deficits or bodystructure or function impairments (i.e., Pre-functional,Upper Extremity Control, Sitting Balance/Trunk Control,Transfers, Functional Mobility, Bed Mobility); Activities ofDaily Living (ADL: Bathing, Dressing, Grooming,Toileting, Feeding/Eating), and Instrumental Activities ofDaily Living (IADL: Home Management, CommunityIntegration, Leisure Performance, Wheelchair Manage-ment). Therapists recorded the amount of time spent oneach activity with the client in 5-min increments and up to5 specific intervention techniques (from a list of 31) thatthey used to facilitate performance of that activity. Optionsincluded neuromuscular interventions (7), musculoskeletalinterventions (4), cardiopulmonary interventions (2),modality interventions (3), cognitive/perceptual/sensoryinterventions (4), adaptive and compensatory interventions(4), equipment interventions (i.e., prescription, application,fabrication, and ordering), and education and traininginterventions (3). Training in the use of assistive devices orequipment during therapy could be recorded under eachtreatment activity, with a list of 20 devices provided. Onecategory was provided for writing in interventions or equip-ment not provided on the form. Additional informationrecorded on each session included: the amount of timespent in evaluation, in cotreatment with other disciplines,and in therapy sessions that included more than one client,as well as which providers gave care during the session,including occupational therapists, occupational therapyassistants, and students (see Figure 1).

Procedure

One occupational therapist at each site was selected as thelead occupational therapist for this project, and participat-ed in a 90-min train-the-trainer session, which was con-ducted by project staff. Before this session, each lead occu-pational therapist received a training manual that containedthe occupational therapy intervention documentation

form, written instructions for completion of the form, anddefinitions of all terms used on the form. The training man-ual also contained case studies that provided scenarios ofthree occupational therapy sessions. A trainer’s and atrainee’s copy of each case study were provided. The train-er’s copy provided instructions and descriptive notes abouteach case study session, followed by the actual case studiesthat described an occupational therapy session, includingamount of time spent on specific activities and assessmentsand a completed intervention documentation form. Duringthe train-the-trainer session conducted by project staff withthe lead occupational therapists, the project team reviewedthe form, instructions, definitions, and care studies indetail. Participants were encouraged to ask questions anddiscuss possible scenarios that might be raised during theirupcoming training sessions with their colleagues at theirrespective facilities.

During each site’s internal training sessions (lastingabout 60 min), the lead occupational therapy trainerreviewed the intervention documentation form (of whichmost occupational therapists were familiar because of par-ticipation in development efforts), instructions for com-pleting the form, and the definitions of each term used onthe form. The trainer then reviewed the first case scenariowith the trainees and described how the intervention docu-mentation form was completed. Individually, trainees thenread the second case study and completed the form. Thetrainer reviewed the second case study with the group anddiscussed form completion. Trainees then completed thethird case scenario and discussed completion of the form.

After this training, during the first month of occupa-tional therapy intervention documentation form use, eachsite’s lead occupational therapist conducted random “co-ses-sions” with other therapists. During this time, the leadoccupational therapist would observe an occupational ther-apy session and record it on an intervention documentationform. The therapist providing the treatment session wouldalso complete a form and the two were compared and dis-cussed. The lead occupational therapist continued to serveas a resource person to the other occupational therapiststhroughout the entire form use period.

A member of each site’s project team (admitting nurse,medical director, project manager) identified clients toenroll into the study on admission and flagged the clientchart as being a study patient. Other rehabilitationproviders (physicians, therapists [physical, speech, recre-ational], nurses, social workers) completed their respectiveproject documentation form for each encounter with eachenrolled client. Data regarding other client characteristics(e.g., demographics, severity of illness, medications) werecollected from clients’ medical records after their discharge.



Data Analysis

Descriptive statistics were used to examine characteristics ofclients and characteristics of their episodes of care includinglength of stay, number of days occupational therapy wasprovided, number of occupational therapy sessions per day,and intensity of occupational therapy (defined as the num-ber of days occupational therapy was provided divided bythe total length of stay). The content of treatment sessions

was described by determining duration of each session, theproportion of all occupational therapy time spent directedto the activities listed above, and the proportion of thoseactivities that included specific interventions. We examinedthe proportion of all occupational therapy sessions in whichmore than one client was treated by a single provider andthe proportion of sessions for which occupational thera-pists, occupational therapy assistants, or students wereinvolved in the care. We also determined combinations of

©ISIS [International Severity Information Systems], Inc., 2003. Reprinted with permission.

Figure 1. Occupational therapy data collection form

Occupat ional Therapy Rehabi l i tat ion Act iv i t ies

Duration of ActivityEnter in 5 minute increments.

InterventionsEnter one intervention code per group of boxes.


activities provided to clients during sessions, the proportionof sessions that included examination or evaluation, and theproportion of clients and families who received an educa-tional intervention.

Results The mean length of stay for the episode of care was 18.8days (SD = 10.3, range = 1–75; see Table 2). Clientsreceived occupational therapy, on average, 11.8 days (SD =7.2, range = 1–53) during an episode of care. On days thatthe clients received occupational therapy, the average num-ber of occupational therapy sessions per day was 1.6 (SD =0.4, range = 1–3), and the average time for each session was39.4 min (SD = 16.9, range = 5–240).

Seventy percent of the sessions were provided by occu-pational therapists, 33% by occupational therapy assistantsor aides, and 7% by students. The vast majority of the ses-sions (91%) were provided one-on-one by an occupationaltherapy provider. Only 5% of sessions consisted of cotreat-ment with another discipline, and in only 11% of sessions

did a group session occur (i.e., more than one client wastreated by a single provider). See Table 3.

More than 94% of clients had some form of examina-tion or evaluation time recorded, and approximately 7% ofsessions included only examination or evaluation. Table 2gives the percentage time clients spent in each occupation-al therapy activity. Upper-extremity control (22.9% of totaltreatment time) and dressing activities (14.2% of total treat-ment time) were the most frequently used activities, withexamination or evaluation (10.8%) and pre-functionalactivities (9%), the third and fourth most common activi-ties (see Table 3). Upper-extremity control activities weredefined as the training or facilitation of normal movement,strength, range of movement, or alignment in the upperextremity. Dressing activities were defined as selectingappropriate clothing and accessories, obtaining clothingfrom storage area, dressing and undressing in a sequentialfashion, and fastening and adjusting clothing, shoes, or per-sonal devices. Pre-functional activities were described asactivities that were related to or provided preparation forfunctional activities.

Table 4 provides data on the types of interventions thatoccupational therapy providers used in each therapeuticactivity with their patients. Of a total of 24 types of directinterventions from which providers could choose, 19 inter-ventions were used during at least 5% of the sessions for oneor more of the therapeutic activities. All seven educationalor equipment provision interventions were used during 5%of sessions for any activity. A wheelchair was the only deviceused during at least 5% of sessions for any activity. Only6.5% of patients used a wheelchair during at least one ses-sion and it was used primarily in transfer and wheelchairmanagement activities.


Table 2. Episode Characteristics Episodes

Characteristic N = 954

Length of rehabilitation hospital stay (days) Mean 18.8SD 10.3Range 1–75

Number of days occupational therapy providedMean 11.8SD 7.2Range 1–53

Number of occupational therapy sessions per dayMean 1.6SD 0.4Range 1–3

Occupational therapy intensity* Mean 0.64SD 0.19Range 0.02–1.0

Percentage of total intervention time spent in activity (%) Upper-extremity control 22.9Dressing 14.2Examination/evaluation 10.8Pre-functional 9.0Functional mobility 7.1Home management 6.2Transfer 6.1Bathing 4.6Grooming 4.5Community integration 3.2Toileting 2.8Sitting balance/trunk control 2.6Eating 2.0Leisure performance 1.9Bed mobility 0.8Wheelchair 0.8

*Total number of days occupational therapy provided divided by the length ofstay in days.

Table 3. Session Characteristics Sessions

Characteristic N = 18,359

Duration of Sessions (min)Mean 39.4SD 16.9Range 5–240

Sessions with >1 client % (n) 10.8 (1,992) Cotreatment sessions with other healthcare

disciplines % (n) 5 (1,006)Sessions with occupational therapist % (n) 70 (12,943)Sessions with OTA or aide % (n) 32 (5,838)Sessions with student % (n) 7 (1,234)Sessions with >1 occupational therapy provider % (n) 9 (1,629)Activity combinations during sessions

(based on N =18,364) %Evaluation only 5.6One activity only 33.3Upper-extremity control 16.1Dressing 5.5Functional mobility 2.3


Activ

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Pre-

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Bath

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Table 4. Interventions Used To Facilitate Activities

Interventions

NeuromuscularBalance training 37.6 60.5 66.1 62.0 66.6 27.5 76.7 73.5 74.8 49.0 27.8 52.4 38.7 49.7 68.9 44.5Postural awareness 41.0 64.0 64.5 67.9 64.7 48.3 71.2 73.9 61.4 43.4 27.2 43.9 42.3 52.6 87.0 44.7Motor learning 42.0 43.7 54.3 56.8 49.6 45.5 51.4 57.1 45.3 37.5 24.1 39.8 51.4 55.0 46.8 42.6PNF 2.6 5.7 5.4 7.4 4.4 5.9 1.6 1.6 2.3 1.9 0.8 0.3 5.4 3.3 11.8 3.6NDT 16.1 19.3 18.5 24.6 22.7 14.3 26.5 28.6 19.2 15.0 9.8 27.5 31.7 43.6 47.3 19.1Constraint induced therapy 1.8 3.6 3.2 3.3 3.8 1.6 2.5 2.2 3.1 2.7 1.8 1.7 4.1 2.9 2.9 2.7

Adaptive/Compensatory One-handed skills 17.1 37.2 48.8 47.4 28.9 40.8 29.7 40.7 16.2 13.6 7.5 14.6 17.8 30.7 30.0 23.6Energy conservation 4.7 16.3 11.2 12.7 12.8 10.0 5.5 7.1 8.5 17.7 9.3 4.7 4.4 6.7 5.6 7.0Environmental adaptation 5.7 28.1 14.5 11.3 28.6 12.7 15.8 16.1 13.7 18.2 13.1 10.3 7.1 20.5 4.8 10.5Adaptive equipment 6.9 28.2 16.7 11.7 27.2 12.5 18.7 16.8 12.3 13.0 6.1 10.0 8.3 29.2 6.0 10.6

MusculoskeletalStrengthening 30.5 17.3 22.9 18.8 22.2 14.3 36.6 37.9 45.6 28.0 12.1 47.9 53.7 35.7 47.2 31.5Mobilization/Manual therapy 9.4 3.2 4.6 4.9 9.7 3.8 12.4 9.4 9.3 4.5 2.3 5.3 16.5 20.1 12.6 7.7Passive Range of Motion (ROM) 23.8 6.4 9.4 9.6 12.5 7.4 22.9 24.2 18.6 8.2 5.0 29.8 42.5 27.0 32.7 19.4Edema control 3.1 1.1 1.1 1.4 3.5 1.0 5.5 4.2 2.4 1.5 0.4 1.2 7.5 8.7 3.5 3.3Aerobic exercise 3.9 2.7 2.5 3.0 2.6 1.8 3.0 3.4 5.1 3.5 2.4 3.2 3.7 7.4 3.4 2.8

Cognitive/Perceptual/SensoryCognitive therapy 47.7 44.6 44.5 49.3 43.1 63.0 30.8 35.7 34.3 43.6 38.8 45.6 27.5 42.1 37.4 34.9Perceptual training 34.8 23.4 29.1 34.2 27.0 40.6 23.7 22.7 21.8 21.7 24.0 25.6 18.8 34.5 24.1 22.5Visual training 24.7 8.4 11.3 14.9 11.6 19.6 9.6 13.0 11.4 12.0 14.3 14.6 10.2 15.1 10.6 11.1Sensory training 8.0 3.1 5.1 5.5 4.4 7.2 5.4 4.6 4.8 3.8 3.4 2.9 8.0 8.7 5.0 5.6

EquipmentPrescription 4.0 3.3 0.7 0.6 2.8 0.6 2.5 1.4 1.6 1.0 1.0 0 1.5 2.4 0.8 1.6Application 2.3 1.1 1.2 1.2 1.5 2.8 1.3 0.8 0.8 0.7 0.9 0 1.7 2.4 1.0 1.2Fabrication 2.4 1.6 0.8 1.2 2.5 1.6 2.5 2.4 1.5 1.5 2.0 2.0 2.1 4.9 1.3 1.5Ordering 1.3 0.7 0.3 0.3 1.0 0 0.3 0 0.6 0.4 0.4 0 0.5 1.3 0.1 0.4

EducationalClient education 34.0 30.7 27.3 27.7 34.0 25.8 44.2 42.6 40.6 43.7 60.4 43.1 34.9 60.4 36.1 30.8Caregiver education 10.6 12.7 4.9 4.5 14.0 8.0 12.8 9.5 8.3 10.8 19.2 4.7 7.6 11.1 4.1 7.9Staff education 0.9 0.4 0.26 0.3 0.6 2.1 0.5 0.8 0.3 0.4 0.5 0.2 0.2 1.6 0.1 0.4

Devices UsedWheelchair 3.2 7.0 6.6 5.8 9.1 1.6 16.5 16.1 6.4 2.1 2.9 2.7 4.5 26.7 2.4 4.6aSessions include more than one activity. bPercentages <5% not reported. Note. PNF = proprioceptive neuromuscular facilitation; NDT = neurodevelopmental treatment.

Overall, 97% of patients or their families received someeducational intervention and 22.8% of all sessions for allpatients included some form of education. Of all the ses-sions with some form of patient and caregiver education,28.2% included education related to community integra-tion, 24.2% included education related to home manage-ment, and 20.8% included education related to upper-extremity control activities.

We looked particularly at the interventions used in themost frequent activities cited: upper-extremity control anddressing. Interventions provided most frequently to addressupper-extremity control were strengthening (included in53.7% of sessions for upper-extremity control), motorlearning (51.4% of sessions), passive range of motion

(42.5% of sessions), and postural awareness (42.3% of ses-sions). In all the sessions that addressed dressing activities,the interventions most frequently provided were balance(included in 66.1% of sessions for dressing activities), pos-tural awareness (64.5% of sessions), motor learning (54.3%of sessions), one-handed skills (48.8% of sessions), and cog-nitive therapy (44.5% of sessions). These data probablyreflect the large emphasis placed on regaining sensorimotorskills in this population.

A total of 40.2% of therapy time was spent on directpractice of daily life activities, the majority of this time(28.1%) in basic ADL. Clients engaged in the more com-plex activities of leisure performance, home management,or community integration 12.1% of the time. During



almost half their time in occupational therapy, clients wereengaged in activities that directly targeted remediating per-formance skill deficits or body structure and functionimpairments (i.e., upper-extremity control, sitting balance,bed mobility, wheelchair, pre-functional, transfers).

Discussion In this descriptive study of occupational therapy providedto clients during stroke rehabilitation, about 40% of theoccupational therapy provided directly targeted life activi-ties (i.e., ADL and IADL), whereas half of the therapy timetargeted body function and structure or motor skills that arepresumed to underlie functional limitations post-stroke.Upper-extremity tasks and dressing were the most fre-quently provided activities, and accounted for almost half ofthe treatment that clients received. Evaluation or examina-tion activities also composed a significant proportion (10%)of occupational therapy time. In 6% of patients, no evalua-tion or examination session was documented. It is probablethat in many of these cases the therapist did do an evalua-tion, but the time devoted to this was included under eachactivity (i.e., a dressing evaluation was recorded under dress-ing instead of examination or evaluation).

When types of activities were compared, there wasclearly a greater emphasis on basic ADL, such as dressing,grooming, eating, and toileting than on IADL, such ashome maintenance, or on community integration andleisure performance. This focus on more basic activitiesprobably reflects the fact that therapy was taking place in ahospital setting with clients who were still in the early reha-bilitation phase. In addition, the average length of stay wasless than 3 weeks, which could limit the time that is avail-able for more advanced activities. It is interesting to notethat, in the Practice Analysis, 65% of therapists reportedthat dressing was the focus of intervention for more than25% of their clients (NBCOT, 2004). This percentage wasamong the five most frequent interventions listed in thatanalysis, which covered all practice areas.

Occupational therapists reported using a variety ofinterventions to enable each activity. The most commonlyused interventions were neuromuscular interventions, espe-cially balance training, postural awareness, and motor learn-ing; however, adaptive approaches, such as teaching one-handed skills for ADL tasks, were also reported frequently.The therapists were clearly selective in the interventionsthat they chose to use with each activity, because there wasvariation in the interventions that were used in each activi-ty. For example, whereas strengthening was used overall in31.5% of sessions, it was used in more than half (53.7%) ofupper-extremity activity sessions but in less than 1/5 (17%)

of bathing activities. The frequencies for environmentaladaptations and use of adaptive equipment also varied byactivity, with certain activities (e.g., bathing and toileting)having much higher frequencies than others. These differ-ences likely reflect differences in the movement demands ofthese important hygiene activities, and the extent to whichcommonly available adaptive equipment such as showerstools may be needed to enable early, safe participation inthe activities.

There are few current evidence-based guidelines for theprovision of intervention to persons with stroke. TheAgency for Health Care Policy and Research Guidelines forPost-Stroke Rehabilitation (Gresham et al., 1995) are nowoutdated and the agency cautions that they should nolonger be viewed as guidance for current practice. The mostrecent update of the National Clinical Guidelines for Strokepublished in the United Kingdom (Royal College ofPhysicians, 2004) includes the general guideline that“Emerging evidence is showing advantages of a task-specif-ic training or practice approach over impairment focusedapproaches. Giving clients the opportunity to practice tasksis a major element in improved outcomes” (p. 9). Evidencethat supports this general guideline has been presented intwo syntheses by Trombly and Ma (Ma & Trombly, 2002;Trombly & Ma, 2002). These authors also present morespecific guidelines regarding the conditions under whichparticular approaches appear to improve outcomes (e.g.,that practicing movements with specific goals appears toresult in more normalized movement trajectories).However, there is also evidence that some interventions thattarget body structure and function impairments also con-tribute to improved rehabilitation outcomes post-stroke.For example, the Royal College of Physicians (2002) guide-lines suggest that emerging evidence supports the use ofresisted exercise to improve motor function, which suggeststhat a combination of approaches may lead to successfuloutcomes.

Given these recommendations, it is perhaps noteworthythat a large proportion of occupational therapy time wasspent at the body structure and function impairment or per-formance skill level, and 16% of sessions involved onlyupper-extremity-control activities. These activities targetremediation of performance skill deficits and client factors(American Occupational Therapy Association, 2002). Avariety of interventions appear to be used in these activities,including balance training (44.5%), motor learning(42.6%), and strengthening (31.5%). Overall, the findingssuggest a shift away from neurofacilitation techniques advo-cated in the 1960s toward more application of motor con-trol and motor learning approaches. Therapists reportedusing Brunnstrom techniques (Brunnstrom, 1970) in fewer



than 2% of sessions, and the percent of sessions in whichproprioceptive neuromuscular facilitation (PNF) techniqueswere used was also low. However, NDT was reported morefrequently, with a maximum of 28.6% in bed mobility ses-sions. A recent analysis of physical therapy intervention withthis same sample noted a similar shift in intervention pat-terns away from facilitation techniques toward applicationof motor control and motor learning approaches in the con-text of functional activities (Jette et al., in press).

Both cognitive therapy and perceptual training werereported as being used with high frequency during many ofthe ADL. In the data collection protocol, cognitive therapyis defined as including “impulse control, attention, orienta-tion, memory, problem solving, sequencing, social skills,safety, insight, and goal setting,” whereas perceptual train-ing includes “interventions to address apraxia, neglect,awareness in space, figure ground, and care of sensoryimpaired body parts” (full definitions are available from thefirst author of this study). Both of these categories containa diverse range of approaches, some of which have moresupportive evidence than others. Trombly and Ma recom-mend cognitive approaches such as structured instructionand feedback to improve activity performance (Ma &Trombly, 2002; Trombly & Ma, 2002). Some evidence alsosupports interventions that involve forced awareness ofneglected space (in persons with unilateral neglect), whichmay be included in the “perceptual training” category. Onelimitation of the present study is that we cannot determinemore precisely how the reported interventions were appliedand the extent to which the applications were consistentwith emerging evidence in this area. This applicationsresearch would be a valuable area for further investigation.

As recommended by current occupational therapypractice guidelines, client education was a significant inter-vention component for all activities. As might be expected,this category was the most frequent intervention for ses-sions that were addressing community integration.Caregiver education was a less frequent intervention formost activities, which is likely explained by the fact thatfamilies were not present during the majority of sessions.Nonetheless, caregiver education was a feature of almost20% of sessions that addressed community integration.Thus, it appears that practitioners are actively engagingboth the client and family when discharge with return tocommunity is the focus of treatment. On the downside,only 5% of sessions addressed either community integra-tion or leisure performance. The paucity of time spent incommunity integration or leisure performance is unfortu-nate because many persons with stroke have significantrestriction in activities after discharge (Corr & Bayer, 1992)and activity restriction has been shown to be highly related

to depression (Nieboer et al., 1998; Williamson, 2000;Williamson & Schulz, 1992). Button (2000) found thatpatients considered that the real rehabilitation was thetranslation of learning from the rehabilitation context to thehome and community context.

Although this study provides an initial description ofactual occupational therapy practice for persons withstroke, it is important to note several limitations. Mostimportant, we did not have specific information about eachclient’s pattern of impairments, and thus were unable tolink the choice of specific interventions to the client’sunique profile of difficulties. Thus, we were not able toexamine variations in practice for persons with similarimpairment profiles. This study also summarized the activ-ities for all clients across their entire therapy episode. Futureanalyses might explore whether clients with greater func-tional abilities or clients who were preparing for dischargeparticipated in more advanced activities.

Although the therapists who provided data for thisstudy were trained in the use of data collection forms, andwritten definitions were provided in the training manual,no specific test of reporting reliability was conducted. Thus,there may have been some degree of misclassification ofinterventions and activities. However, given the large num-ber of participants and sessions, we do not expect these ran-dom errors to have had a large effect on the results.

This study provided a broad sketch of current occupa-tional therapy practice for persons with stroke. It suggestsan initial framework to describe intervention techniquesand activities, from which more refined descriptions may bedeveloped. Without such work to characterize the actualprocesses of occupational therapy, it will be difficult to con-duct more precise examinations of the effectiveness of ourservices. Such studies are needed in order to identify thespecific elements or approaches that lead to better outcomesfor persons with stroke.

Conclusion Occupational therapy provided to clients with stroke at in-patient rehabilitation facilities reflected an integration ofmultiple treatment approaches to facilitate performance ofdaily activities. The greatest emphasis was on increasingupper-extremity control and improving performance ofbasic ADL. Most occupational therapy was provided on anindividual basis, for an average duration of about 40 minper session, across an average hospital stay of less than 3weeks. A small proportion of therapy time was spent onleisure and community integration, suggesting the need foroccupational therapy services after discharge that addressthese activities. ▲



Acknowledgments Funding for this project was provided by: The NationalInstitute on Disability & Rehabilitation Research (NIDRR)Grant # H133B990005 establishing the RehabilitationResearch and Training Center on Medical RehabilitationOutcomes at Sargent College in Boston, Massachusetts,with subcontracts to the Institute for Clinical OutcomeStudies in Salt Lake City, Utah; and the NRH Center forHealth & Disability Research at the National Rehabili-tation Hospital and the MedStar Research Institute inWashington, DC; the U.S. Army & Materiel Command(Cooperative Agreement Award # DAMD17-02-2-0032)establishing the NRH Neuroscience Research Center at theNational Rehabilitation Hospital in Washington, DC; theBoston University Aging Research Center; and resources atthe North Florida/South Georgia VA Medical Center,Gainesville, Florida.

The authors wish to acknowledge the role and contri-butions of the occupational therapists, occupational therapyassistants, patients, and staff at each of the participating sitesin the Post Stroke Rehabilitation Outcomes Project. In par-ticular, the authors wish to acknowledge the contributionsof: Alan Jette (Director, Health and Disability ResearchInstitute, Boston University); Brendan Conroy, MD (StrokeRecovery Program, National Rehabilitation Hospital,Washington, DC); Richard Zorowitz, MD (Department ofRehabilitation Medicine, University of PennsylvaniaMedical Center, Philadelphia, Pennsylvania); David Ryser,MD (Rehabilitation Department, LDS Hospital, Salt LakeCity, Utah); Jeffrey Teraoka, MD (Division of PhysicalMedicine & Rehabilitation, Stanford University, Palo Alto,California); Frank Wong, MD, and LeeAnn Sims, RN(Rehabilitation Institute of Oregon, Legacy Health Systems,Portland, Oregon); and Murray Brandstater, MD (LomaLinda University Medical Center, Loma Linda, California).

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