Abstract
Evidence-based reviews of the literature relevant to adults with stroke are important to the practice of occupational therapy. We describe the four questions that served as the focus for the evidence-based reviews of the effectiveness of occupational therapy interventions for adults with stroke. The questions include occupation- and activity-based interventions to improve occupational performance and social participation after stroke, as well as interventions for motor, cognitive, and psychological and emotional impairments after stroke. We include the background for the reviews; the process followed for addressing each question, including search terms and search strategy; the databases searched; and the methods used to summarize and critically appraise the literature. The final number of articles included in each evidence-based review; a summary of the themes of the results; the strengths and limitations of the findings; and implications for practice, education, and research are presented.
Occupational therapists and occupational therapy assistants, like many other health care professionals facing the demands of payers, regulators, and consumers, increasingly have to demonstrate clinical effectiveness. In addition, they are eager to provide services that are client centered, supported by evidence, and delivered in an efficient and cost-effective manner. Over the past 25 yr, evidence-based practice (EBP) has been widely advocated as one approach to effective health care delivery.
Since 1998, the American Occupational Therapy Association (AOTA) has instituted a series of EBP projects to assist members with meeting the challenge of finding and reviewing the literature to identify evidence and, in turn, use this evidence to inform practice (Lieberman & Scheer, 2002). Following the evidence-based philosophy of Sackett, Rosenberg, Muir Gray, Haynes, and Richardson (1996), AOTA’s projects are based on the principle that the EBP of occupational therapy relies on the integration of information from three sources: (1) clinical experience and reasoning, (2) preferences of clients and their families, and (3) findings from the best available research.
A major focus of AOTA’s EBP projects is an ongoing program of evidence-based review of multidisciplinary scientific literature, using focused questions and standardized procedures to identify practice-relevant evidence and discuss its implications for practice, education, and research. The evidence-based reviews in this issue strengthen the knowledge of current interventions used by occupational therapy practitioners in the delivery of services for adults with stroke.
Background
According to data from the National Health and Nutrition Examination Survey (NHANES) for 2009, 7.2% of the U.S. population self-reported having some form of cardiovascular disease, with 2.7% of the overall population reporting that they had had a stroke at some point in time. Data from NHANES for 2009–2010 indicate that 6.8 million adults in the United States age 20 yr and older have had a stroke (Go et al., 2013). Approximately 795,000 individuals experience a new or recurrent stroke yearly. Of those strokes, 77% are reported to be the first occurrence of stroke, and 13% are recurrent. The estimated yearly direct medical cost for stroke is reported to be $22.8 billion (Go et al., 2013).
According to the Centers for Disease Control and Prevention (CDC; 2014) and the American Heart Association (Roger et al., 2012), stroke is a leading cause of serious long-term disability. Impairments after stroke can include but are not limited to hemiparesis, balance deficits, visual changes, cognitive deficits, fatigue, and psychological and emotional impairments (Go et al., 2013; Jørgensen et al., 1995). These motor, cognitive, and psychological and emotional impairments after stroke may vary depending on the extent of neurological damage and potential recovery and may result in decreased participation in occupations, such as activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Because of the complex nature of impairments after stroke and the diverse needs of the stroke population, occupational therapy practitioners must have the necessary information to provide evidence-based, client-centered, and occupation-based interventions.
An evidence-based perspective is founded on the assumption that scientific evidence of the effectiveness of occupational therapy intervention can be judged to be more or less strong and valid according to a hierarchy of research designs, an assessment of the quality of the research, or both. AOTA uses standards of evidence modeled on those developed in evidence-based medicine. This model standardizes and ranks the value of scientific evidence for biomedical practice and is based on the grading system of Sackett et al. (1996). In this system, the highest level of evidence, Level I, includes systematic reviews of the literature, meta-analyses, and randomized controlled trials (RCTs). In RCTs, participants are randomly allocated to either an intervention or a control group, and the outcomes of both groups are compared. Other levels of evidence include Level II studies, in which assignment to a treatment or a control group is not randomized (cohort or case-control study); Level III studies, which do not have a control group (pretest–posttest, before–after, or cross-sectional studies); Level IV studies, which use a single-case experimental design, sometimes reported over several participants; and Level V studies, which are case reports and expert opinion that include narrative literature reviews and consensus statements.
The evidence-based reviews on adults with stroke were supported by AOTA as part of the Evidence-Based Practice Project. AOTA is committed to supporting the role of occupational therapy in this important area of practice. Previous evidence-based reviews were completed covering the time frame of 1980–2002. The current evidence-based reviews were updated for the period 2003–March 2012, based on the need for occupational therapy practitioners to have access to the results of the latest and best available literature to support intervention within the scope of occupational therapy practice.
The four focused questions developed for the updated review were based on the search strategy of the earlier review. These questions were reviewed by review authors, an advisory group of experts in the field, AOTA staff, and the methodology consultant to the AOTA Evidence-Based Practice Project.
The following four focused questions from the review of occupational therapy interventions for people with stroke were included in reviews:
What is the evidence for the effectiveness of interventions to improve occupational performance for those with motor impairments after stroke?
What is the evidence for the effectiveness of interventions to improve occupational performance for those with cognitive impairments after stroke?
What is the evidence for the effectiveness of activity- and occupation-based interventions to improve areas of occupation and social participation after stroke?
What is the evidence for the effectiveness of interventions to improve occupational performance for those with psychological and/or emotional impairment after stroke?
Method
Search terms for the reviews were developed by the methodology consultant to the AOTA Evidence-Based Practice Project and AOTA staff in consultation with the authors of each question and reviewed by the advisory group. The search terms were developed not only to capture pertinent articles but also to make sure that the terms relevant to the specific thesaurus of each database were included. Table 1 lists the search terms related to population and intervention included in each evidence-based review. A medical research librarian with experience in completing evidence-based review searches conducted all searches and confirmed and improved the search strategies.
Search Terms Used for the Evidence-Based Reviews for Stroke
Note. EMG = electromyography; NDT = neurodevelopmental treatment.
Databases and sites searched included Medline, PsycINFO, CINAHL, AgeLine, and OTseeker. In addition, consolidated information sources, such as the Cochrane Database of Systematic Reviews and the Campbell Collaboration, were included in the search. These databases are peer-reviewed summaries of journal articles and provide a system for clinicians and scientists to conduct evidence-based reviews of selected clinical questions and topics. Moreover, reference lists from articles included in the evidence-based reviews were examined for potential articles, and selected journals were hand searched to ensure that all appropriate articles were included.
Inclusion and exclusion criteria are critical to the evidence-based review process because they provide the structure for the quality, type, and years of publication of the literature incorporated into a review. The reviews for all four questions were limited to peer-reviewed scientific literature published in English. The intervention approaches examined were within the scope of practice of occupational therapy and included a performance-based outcome measure. The literature included in the review was published between 2003 and March 2012 and included study participants with stroke. The earlier reviews included studies published between 1980 and 2002 and more recent studies recommended by experts in the field. These reviews excluded data from presentations, conference proceedings, non–peer-reviewed research literature, dissertations, and theses. Studies from published systematic reviews included in these evidence-based reviews were excluded from individual analysis. Studies included in the reviews are Level I, II, and III evidence. Level IV and V evidence was included only when higher level evidence on a given topic was not found.
The reviews included a total of 12,674 citations and abstracts. The question on motor impairment had 4,930 references, the cognitive and perceptual impairments question had 1,382, the occupation- and activity-based question had 4,101, and the psychological and emotional impairment question had 2,261. The AOTA Evidence-Based Practice Project methodology consultant completed the first step of eliminating references on the basis of citation and abstract. The four evidence-based reviews were carried out as academic partnerships in which academic faculty worked with graduate students to carry out the reviews. Review teams completed the next step of eliminating references on the basis of citations and abstracts. The full-text versions of potential articles were retrieved, and the review teams determined final inclusion in the review on the basis of predetermined inclusion and exclusion criteria.
A total of 273 articles were included in the final review. Table 2 presents the number and levels of evidence of articles included for each review question. The teams working on each focused question reviewed the articles according to their scientific rigor and lack of bias and level of evidence. Each article included in the review was then abstracted using an evidence table that provides a summary of the methods and findings of the article and an appraisal of the strengths and weaknesses of the study on the basis of design and methodology. AOTA staff and the Evidence-Based Practice Project consultant reviewed the evidence tables to ensure quality control.
Articles in Each Review at Each Level of Evidence
Summary of the Themes in the Evidence-Based Reviews
The results of the evidence-based reviews published in this issue of the American Journal of Occupational Therapy provide guidance for occupational therapy practitioners working with people with stroke. By reviewing the scientific literature and appraising and synthesizing specific studies, the authors provide guidance on critical practice questions. The evidence for interventions for motor impairments for people with stroke has themes in the following areas: (1) task-oriented training (TOT) using objects in natural environments, (2) TOT combined with cognitive strategies, and (3) strengthening. The themes for the evidence for interventions for cognitive impairments after stroke are organized by areas of impairment that limit occupational performance. These impairments and themes of the evidence include general cognition, executive dysfunction, apraxia, memory loss, attention deficits, visual dysfunction, and unilateral neglect.
The evidence for occupation- and activity-based interventions was categorized by area of occupation, with subthemes based on the context of service delivery. The areas of occupation included ADLs, IADLs, leisure, social participation, and rest and sleep. Depending on the area of occupation, studies were subcategorized into interventions in inpatient, outpatient, home health, and community settings. The evidence for interventions for psychological and emotional impairment after stroke was divided into six themes according to the type of intervention: exercise, behavioral therapy and stroke education, behavioral therapy only, stroke education only, care support and coordination, and community-based rehabilitation interventions that include occupational therapy. The exercise theme was further subdivided into types of exercise that were represented in the articles. Readers should refer to the individual articles for a summary of the findings of the evidence-based reviews (Gillen et al., 2015; Hildebrand, 2015; Nilsen et al., 2015; Wolf, Chuh, Floyd, McInnis, & Williams, 2015).
Strengths and Limitations of the Reviews and Implications for Practice, Research, and Education
The evidence-based reviews on stroke presented in this issue have several strengths and include many aspects of occupational therapy practice with this population. The reviews included 273 articles, and 92% of the articles provided Level I and II evidence, indicating that the evidence was at the highest level of evidence. The reviews also involved evidence-based methodologies and incorporated quality control measures.
The limitations of the evidence-based reviews are the result of the design and methods of the individual studies, which may include small sample sizes, lack of reporting of treatment fidelity, and heterogeneity in terms of participant characteristics, intervention protocols, and outcome measures. In addition, many of the studies in the review included concurrent interventions, and separating out the effects of a single intervention may be difficult. Please refer to the individual evidence-based reviews for more complete information on results, interpretation of findings, limitations, and implications for practice.
The evidence-based reviews presented in this issue provide summaries of the best scientific literature to answer the focused questions. The results described in these articles can be directly integrated into clinical practice by combining the scientific evidence with clinical expertise and client preferences. In addition, this information may be used when advocating for occupational therapy services to a payer or regulator or providing information and support to a client and caregiver at any point during the intervention process.
In the future, researchers should build on the existing studies discussed in the evidence-based reviews included in this issue. Clearly, more work is needed to definitively answer the four questions that served as the basis of these evidence-based reviews. Although some future research can be conducted in isolation, research questions in the area of stroke are often complex and may best be answered through collaborative research with other disciplines involved with the provision of services to people with stroke, such as rehabilitation medicine, physical therapy, speech–language pathology, psychology, nursing, neurology, and social work.
The future of occupational therapy depends on all occupational therapy practitioners developing a firm grasp of the best available evidence. This agenda is also clear for academic programs training the next generation of occupational therapy practitioners. Educators need to be aware of the results of the evidence-based reviews and present this multifaceted information to students rather than focus on a favored type of intervention. In addition, the evidence should not be presented in a one-size-fits-all framework but should be discussed from a client-centered and occupation-based perspective as described in the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; AOTA, 2014).