Preparatory Interventions to Support ADL Performance for Adults With Stroke (2012–2019)

Abstract

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings for preparatory interventions to support performance in activities of daily living for adults with stroke, such as early mobilization, bilateral priming, passive range of motion, sensory retraining, and shoulder taping.

Full Systematic Review Question

This systematic review addressed the question “What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve performance and participation in activities of daily living (ADL) for adult stroke survivors?”

Current Theme Reported

The main theme of the studies included in this systematic review brief is preparatory interventions to support performance in ADL (i.e., early mobilization, bilateral priming, early supported discharge, passive range of motion [PROM], sensory retraining, and taping).

Clinical Scenario

There are more than 7 million stroke survivors, with stroke as the leading cause of adult disability in the United States (Tsao et al., 2022). Stroke often leaves survivors with limitations in activities of daily living (Gadidi et al., 2011), which is correlated with overall life dissatisfaction (Hartman-Maeir et al., 2007). Certain interventions to support performance in ADL, such as stretching and taping, used prior to participation in task-oriented training, can be useful in return to participation in ADL after stroke (Wolf & Nilsen, 2015). The systematic review theme presented here addresses early mobilization, bilateral priming, early supported discharge, PROM, sensory retraining, and taping for adults who had a stroke and the effectiveness of these interventions to support performance in ADL (i.e., functional independence measure [Ottenbacher et al., 1996] and Barthel Index [Mahoney & Barthel, 1965]) and functional mobility (i.e., Timed Up and Go [Podsiadlo & Richardson, 1991] and Berg Balance Scale [Stevenson, 2001]).

Summary of Key Findings

Two Level 1A (meta-analyses) and five Level 1B (randomized control trial [RCT]) studies met the criteria for inclusion and provided evidence for the effectiveness of interventions to support performance in ADL (Table 1). The risk of bias for a majority of the studies was low, but two studies had moderate risk of bias. The studies in this theme involved several types of interventions to support performance in ADL including early mobilization, bilateral priming, early supported discharge, PROM, sensory retraining, and taping. The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009). The strength-of- evidence designations are based on the guidelines of the U.S. Preventive Services Task Force (2018).

Table 1.

Evidence Table for Preparatory Interventions to Improve ADL Performance for Adults With Stroke

AuthorYearLevel of EvidenceRisk of Bias (RoB)CountrySetting	Intervention	Statistically Significant Improvement Resulting From Intervention
Early Mobilization
Two Level 1B studies provided moderate strength of evidence due to inconsistent findings supporting the use of early mobilization after stroke. Both studies recruited patients within the first 24 hr after stroke onset and began mobilization as early as possible.
Chippala et al. (2016) Level 1B—RCT RoB Moderate Country India Setting Acute Hospital	Population N = 86. Acute stroke over 18 yr of age, admitted within 24 hr of symptom onset. Intervention Upright and out of bed activities started as soon as practical after recruitment and determined by patient’s tolerance. Delivery Method Individual Dose Sessions lasted 5–30 min, two times per day for seven days or until discharge (whichever was sooner).	ADL Significant improvement on ADL performance at discharge as well as at 3-mo follow-up, in favor of the intervention.
Cumming et al. (2011) Level 1B—RCT RoB Low Country Australia Setting Acute Hospital	Population N = 71. 18 yr or older, able to be randomized within 24 hr of symptom onset of a first or recurrent stroke. Intervention Participants mobilized as soon as practical after randomization, with the first mobilization within 24 hr after stroke onset. Delivery Method Individual Dose At least twice per day (session length not reported) for the first 14 days after stroke or until discharge (whichever was sooner).	ADL No significant findings.
Passive Range of Motion
One Level 1B study provided moderate strength of evidence, supporting the use of passive range of motion to increase performance of ADL.
Kim et al. (2014) Level 1B—RCT RoB Moderate Country Korea Setting Intensive Care Unit	Population N = 37. Acute stroke patients in the neuroscience intensive care unit, with muscle strength below Grade 3. Intervention PROM performed to bilateral upper extremities Delivery Method Individual Dose 15-min session, twice per day, five days a week, for 4 wk	ADL Significant improvements in self-care score in favor of experimental group.
Sensory Retraining
One Level 1A study provided moderate strength of evidence, supporting the use of sensory retraining to increase performance of ADL. This systematic review included patients with somatosensory impairments of the leg.
Chia et al. (2019) Level 1A—Systematic Review/Meta-Analysis RoB High Country Multiple Setting Inpatient rehabilitation	Population N = 430. Adults 18 and older with leg somatosensory impairment after stroke. Eight studies were set in inpatient rehab, and all the included studies were executed in nine different countries. Intervention (Varies per study) Compelled body weight shift (2 studies); assisted movement with enhanced sensation + EMG feedback (1 study); Nintendo Wii (1 study); underwater unstable surface (1 study); education and proprioception training on affected foot (1 study); proprioception, localization, vibration, pressure discrimination and TENS + NDT (1 study); AROM and PROM of affected leg (1 study); motor imagery + proprioceptive training (1 study); education, detection, localization, discrimination, and proprioception on the affected big toe and ankle (1 study); aerobic deep-water walking (1 study); treadmill training with eyes closed (1 study); hardness discrimination perceptual learning exercises (1 study); TENS using sock electrode on affected foot (2 studies) Delivery Method Individual, in person, 8 studies inpatient rehabilitation Dose Varies per study—20–45-min sessions, 2–5× week, for 2–9 wk	ADL Significant improvement in favor of experimental group on balance and ADL performance.
Bilateral Priming
One Level 1B study provided low strength of evidence, due to no significant findings and lack of additional evidence, supporting the use of a device to couple the two hands mechanically to produce symmetrical movements.
Stinear et al. (2014) Level 1B—RCT RoB Low Country New Zealand Setting Inpatient rehabilitation	Population N = 57. Inpatient rehab patients aged 18 or older with first-ever monohemispheric stroke. Intervention Portable device worn to produce rhythmic, continuous, bilateral mirror symmetrical movements of the two hands. Delivery Method In person Dose 15 min spent wearing device prior to usual upper limb therapy every weekday for 4 wk.	ADL No significant findings
Taping
One Level 1A study provided low strength of evidence, due to no significant findings and lack of additional evidence, for the use of shoulder strapping to improve ADL outcomes in adults with stroke.
Appel et al. (2014) Level 1A—Systematic Review RoB Low Country Multiple Setting Multiple	Population N = 340. (Varies per study) Ranging from within 4 wk of stroke onset to up to 5 yr poststroke, both infarction and hemorrhagic stroke. Intervention Any form of strapping applied to shoulder with therapeutic intent Delivery Method (Varies per study) Applied by treating therapist (n = 3); applied by an alternative therapist, nurse or relative (n = 4); not specified (n = 1). Dose (Varies per study) Ranging from 5 days to 6 wk and reapplied every 3 to 4 days.	ADL No significant findings

Note. ADL = activities of daily living; RCT = randomized control trial; PROM = passive range of motion; EMG = electromyography; TENS = transcutaneous electrical nerve stimulation; NDT = neurodevelopmental treatment; AROM = active range of motion.

Bottom Line for Occupational Therapy Practice

Overall, evidence in favor of the use of preparatory interventions to support performance in ADL after stroke is limited by the diverse nature of the interventions within this theme. Although the focus of occupational therapy is task-oriented training (Wolf & Nilsen, 2015) and “occupations as means and end” (Trombly, 1995), there are certain practices that are not occupation based themselves but are helpful in preparing the client for occupation-based intervention. The literature demonstrates moderate strength of evidence in support of early mobilization after stroke (Chippala et al., 2016), specifically when initiated in the first 24 hr after stroke. This intervention dosage varied, as a key component is individualized adjustment according to patient tolerance, and significant improvements on ADL outcomes were found to be sustained even three months after the intervention. Passive range of motion also showed moderate strength of evidence to increase performance of ADL after stroke (Kim et al., 2014), suggesting practitioners should be incorporating it into treatment; however, no conclusive protocol can be recommended at this time. Sensory retraining was found to have moderate strength of evidence to improve ADL outcomes after stroke. Guidance is not provided in regard to optimal timing of intervention nor dosage; however, this is an intervention that should be incorporated into care as appropriate. The included systematic review (Chia et al., 2019) looked at various methods and protocols to address lower extremity somatosensory impairment.

Several interventions were found to have insignificant evidence to support use within care of patients with stroke. Bilateral priming, which mechanically coupled movement of the involved and uninvolved upper extremities, used prior to usual occupational therapy intervention was not found to have a statistically significant effect on ADL outcome (Stinear et al., 2014). Early supported discharge, where a patient was discharged home as soon as possible after stroke and followed by an interdisciplinary team, was also found to have low strength of evidence (Fjærtoft et al., 2011) due to no significant findings and lack of additional research. Additionally, shoulder taping was also found to have low strength of evidence to support ADL outcomes (Appel et al., 2014) due to no significant findings and lack of additional research. This systematic review pooled data for eight studies, which all demonstrated a variety of intervention, both in delivery method and dosage. Although interventions to support performance in ADL can often target impairments rather than participation, moderate strength of evidence supports the use of early mobilization, PROM, and sensory retraining to improve ADL outcomes after stroke.