Occupational Therapy and Activities of Daily Living Interventions to Improve Performance in Activities of Daily Living for Adults With Stroke (2012

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 occupational therapy and activities of daily living (ADL) interventions to improve ADL outcomes for adults with stroke.

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 occupational therapy (OT) and ADL interventions.

Clinical Scenario

Stroke is a common cause of adult disability in the United States, affecting more than 795,000 people each year (Virani et al., 2020). Stroke survivors frequently have limited independence in ADLs, which may relate to overall life dissatisfaction (Gadidi et al., 2011; Mayo et al., 2002; Hartman-Maeir et al., 2009). OT and ADL interventions are often intended to directly address and improve deficits in ADL participation for stroke survivors. However, to provide the highest quality of care, evidence to support these interventions must be investigated.

Summary of Key Findings

Twelve articles were included in the review for OT/ADL interventions to improve ADL outcomes for stroke survivors. These 12 articles were further divided into three categories: general OT/ADL interventions (10), swallowing (1), and a workplace intervention (1) (Table 1). 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 Occupational Therapy/Activities of Daily Living Interventions to Improve Activities of Daily Living Outcomes for Adults With Stroke

Author YearLevel of EvidenceRisk of Bias (RoB)CountrySetting	Intervention	Statistically Significant Improvement Resulting From Intervention
OT/ADL Interventions: General
Standard ADL Interventions Provided by OT (Compared to Usual Care): One Level 1A study provided moderate strength of evidence for the use of ADL intervention provided by occupational therapists to improve ADL outcomes compared to no intervention or standard care.
Legg et al. (2017) Level 1A—Systematic review with meta-analysis RoB Low Country United Kingdom Setting Hospital Rehabilitation Unit and home setting	Population N = 9 RCT with N = 944 participants and 7 RCTs (n = 749 participants) were included in the meta-analysis of ADL outcomes reported here. Adults with stroke receiving an ADL intervention provided by OTs. Intervention ADL training strategies used by occupational therapists including assessment, treatment (remediation, adaptation, and adaptive technology), and environmental modifications. Control group received no intervention or standard care. Outcome Measures BI (Mahoney & Barthel, 1965), FIM (Granger et al., 1986) Dose Not specified	Between Groups Significant improvement in ADL outcome in intervention group compared with control group with a small effect size.
OT/ADL Interventions in Long-Term Care: One Level 1B study provided low strength of evidence for an OT, patient-centered ADL intervention for long term care residents.
Sackley et al. (2016) Level 1B—RCT RoB Low Country United Kingdom Setting Care Homes	Population N = 1,042 from 228 care homes. Residents of care homes with a history of stroke or TIA Intervention Occupational therapy followed a patient-centered goal setting approach, aiming to improve or maintain functional capacity in personal ADL. Administered according to categories: assessment and goal setting; personal ADL training; communication; environment, including adaptive equipment and seating posture. Control group received usual care. Outcome Measures BI (Mahoney & Barthel, 1965), RMI (Collen et al., 2009) Dose Frequency and duration of visits depended on agreed goals between therapist and resident.	Between Groups No significant differences between groups on basic ADL (BI) or functional mobility (RMI) outcomes.
Three-Stage Multidisciplinary Rehabilitation Program: Two Level 1B studies found strong strength of evidence for a 3 stage multi-disciplinary 6-month rehabilitation program (inpatient and community-based) to improve ADLs compared to no rehabilitation intervention.
Bai et al. (2012) Level 1B—RCT RoB Low Country China Setting Inpatient, Outpatient, Home, Community Centers	Population N = 364. Adults with hemiplegia following acute ICH in an inpatient emergency or neurology unit Intervention Early rehabilitation group received routine internal medical intervention + three-stage rehabilitation program (PT/OT with emphasis on ADL training). Stage 1 focused on basic ADL first month after stroke. Stage 2 focused on balance and walking 2–3 mo poststroke. Stage 3 focused on ADL and motor function 4–6 mo poststroke. Control group received routine internal medicine intervention only and no rehabilitation intervention. Stage 1—inpatient hospital; Stage 2—physical therapy department; Stage 3—home or community centers Outcome Measure mBI (Shah et al., 1989) Dose 45 min/day, 5 days/week for first month after stroke (only dosage for Stage 1 was specified).	Between Groups Intervention group had significantly higher scores on the mBI than the control.
Bai et al. (2014) Level 1B—RCT RoB Low Country China Setting Inpatient Hospital, Rehabilitation Center, and Home	Population N = 165. Adults aged 40–80 stabilized for 1 wk after first stroke in inpatient hospital Intervention Received standard care in hospital + three-stage rehabilitation protocol. Stage 1 (first month poststroke in inpatient hospital) included passive movement, positioning of limbs, active movement, sitting, standing, balance training. Stage 2 (2–3 mo poststroke in rehabilitation center) included PROM/strengthening, walking/balance training, stairs, active exercise related to ADL for the upper limbs. Stage 3 (4–6 mo poststroke at home-based rehab) included ADL training supervised by caregivers with therapy every 2 wk in the home. Control group received standard care in hospital and no rehabilitation intervention. Inpatient hospital (Stage 1), rehabilitation center (Stage 2), home-based (Stage 3) Outcome Measure mBI (Shah et al., 1989) Dose Stage 1: 45 min/day, 5 days/wk (first month poststroke); Stage 2: 45 min 2×/day, 5 days/week (2–3 mo poststroke); Stage 3: Every 2 wk	Between Groups Intervention group had significant improvement in basic ADL outcome compared with the control group at 1, 3, and 6 mo.
Home-Based Exercise and ADL Intervention: One Level 1B study provided moderate strength of evidence for home-based exercise and ADL training to improve ADLs.
Chaiyawat & Kulkantrakorn (2012) Level 1B—RCT RoB Low Country Thailand Setting Home	Population N = 60. Individuals with MCA stroke living at home Intervention Home-based audiovisual individualized program consisting of passive, active, and resistive exercises and ADLs such as preparing a drink, lock and key, donning/doffing shoes, how to use cane or wheelchair. Control group receive usual care, including home and outpatient rehabilitation. Outcome Measure BI (Mahoney & Barthel, 1965) Dose Intervention group received home-based program once a month for 6 mo; 1 hr/session	Between Groups Significant improvement on the ADL outcome measure in the intervention group compared with the control at 2 yr.
ADL Training During Predischarge Home Visits: One Level 1B study provided moderate strength of evidence for ADL training provided during home visits before discharge from inpatient rehabilitation.
Rasmussen et al. (2015) Level 1B—RCT RoB Moderate Country Denmark Setting Inpatient Stroke Unit, Home Setting	Population N = 71. Adults with stroke admitted to inpatient stroke unit Intervention Before discharge from hospital, participants received care from multidisciplinary inpatient rehabilitation team. As an inpatient, the participant was driven home 1–3 times/wk to perform exercises and ADLs before returning to the hospital. After discharge, participants received home-based rehabilitation for 4 wk. They were given written plans for training sessions, received help to perform ADL, and continued rehabilitation training at home 1–5 days/wk. Control group received standard care in stroke unit and standard treatment postdischarge. Outcome Measures mRS (van Swieten et al., 1988), mBI (Shah et al., 1989), MAS (Carr et al., 1985) Dose During inpatient stay, received exercise/ADL training 1–3 times/wk. After discharge, received rehabilitation training 1–5 days/wk for 4 wk	Between Groups Intervention group had significant improvement on basic ADL (mRS) and functional mobility (MAS) outcomes compared with the control 3 mo after stroke onset.
Home-Based ADL Training and Education: One Level 1B study provided moderate strength of evidence for home-based ADL education and training to improve ADL performance.
Sahebalzamani et al. (2016) Level 1B—RCT RoB Moderate Country Iran Setting Home health	Population N = 80. Adults aged 40–70 with hemiplegia after stroke Intervention Education (skill and booklet) in individual hygiene, bathing, nutrition, toileting, grooming, dressing, bowel and bladder control, mobility, using a wheelchair, transferring to and from chair to bed. Control condition not clearly stated. Outcome Measure Katz ADL Scale (Katz et al., 1963) Dose Initial educational session at discharge from acute care hospital, followed by 6–8 sessions over a 45-day period at home; 2 hr per session	Between Groups Significant improvement in intervention group compared with the control in all ADL areas except for urine/stool control
MOHO Intervention: One Level 1B study provided low strength of evidence for a MOHO-based intervention to improve ADLs.
Shinohara et al. (2012) Level 2B-RCT RoB Low Country Japan Setting Health care Facility for Elderly	Population N = 36. Health care facility residents 6–36 mo after stroke Intervention MOHO-driven OT; focused on volition (values, interests, and confidence), role performance (meaningful daily responsibilities), changes to physical environment to improve ADL; some elements from control group intervention, but more emphasis on ADL. Control group received ADL training with biomechanical and neurodevelopmental frames of reference. Outcome Measures C-ADL, P-ADL, SF-36 (Fukuhara et al., 1998) Dose 2×/wk, 20-to-30-min sessions, 3 mo	Between Groups Intervention group significantly improved compared with the control for C-ADL and P-ADL and role of physical functioning (SF-36).
Client-Centered ADL Training: One Level 1B RCT study (two articles) found low strength of evidence for a client-centered ADL intervention compared with usual care ADL training.
Bertilsson et al. (2014) and Guidetti et al. (2015) (12-mo follow up) Level 1B—RCT RoB Moderate Country Sweden Setting Inpatient Rehabilitation, Home	Population N = 280. Individuals with new stroke diagnosis within 3 mo and dependence in at least two ADL domains Intervention Client-centered ADL intervention involved goal-setting process using COPM and use of global problem-solving strategy with guided strategy development with OT and training diary. Intervention focused on transfer of learning to activities outside therapy in the last session. Control group received usual care ADL training with OT. Outcome Measures BI (Mahoney & Barthel, 1965), SIS (Duncan et al., 2003), Katz ADL Index (Katz et al., 1963) Dose Number of OT sessions was not determined in advance for either intervention or control groups. The intervention group received more contacts with OT than the control (19.3 compared with 13.4).	Between Groups No significant differences between groups on ADL outcome measures at 3 and 12 mo after start of the intervention.
OT/ADL Interventions: Swallowing
One Level 1A study provided low strength of evidence for use of behavioral swallowing interventions to improve basic ADL outcomes.
Bath et al. (2018) Level 1A—Systematic review with meta-analysis RoB Low Country United Kingdom Setting Laboratory-based	Population N = 41 RCT, N = 2,660 participants total, n = 1, n = 306 participants reported here for ADL outcomes. Adults with acute and subacute stroke receiving swallowing therapy. Intervention Behavioral interventions for swallowing (swallowing exercises, positioning) vs. control (limited, usual or no treatment). Outcome Measure mRS (van Swieten et al., 1988), BI (Mahoney & Barthel, 1965) Dose Varied	Between Groups No significant difference between intervention groups and control groups on ADL outcome.
OT/ADL Interventions: Workplace Intervention
One Level 1B study provided low strength of evidence for the use of a tailored workplace intervention to improve outcomes in basic ADLs.
Ntsiea et al. (2014) Level 1B—RCT RoB Moderate Country South Africa Setting Inpatient, Outpatient Rehabilitation	Population N = 80. Adults aged 18–60 who were employed at the time of their stroke and less than 8 wk since stroke onset Intervention Workplace intervention program involved usual care + 6-wk tailored program at participants’ place of work. Control group received usual care. Outcome Measure BI (Mahoney & Barthel, 1965), MRMI (Lennon & Johnson, 2009) Dose 4+ hr work skill assessment session and 1-hr weekly sessions for 6 wk	Between Groups ADL scores were not significantly better in the intervention group than the control. Mean change scores were significantly higher in the control that the intervention group on the BI and MRMI, possibly due to a ceiling effect. The intervention group had significantly higher scores than the control at baseline.

Note. ADL = activities of daily living; BI = Barthel Index; C-ADL = Capable ADL; COPM = Canadian Occupational Performance Measure; FIM = Functional Independence Measure; ICH = Intracerebral hemorrhage; MAS = Motor Assessment Scale; mBI = Modified Barthel Index; MCA = Middle cerebral artery; MOHO = Model of Human Occupational; MRMI = Modified Rivermead Mobility Index; mRS = Modified Rankin Scale; OT = occupational therapy; P-ADL = performing ADL; PROM = Passive Range of Motion; RCT = randomized control trial; RMI = Rivermead Mobility Index; SF-36 = Japanese version of the Short-Form Health Survey; SIS = Stroke Impact Scale.

Bottom Line for Occupational Therapy Practice

Generally, moderate strength of evidence supports the use of OT/ADL interventions to improve ADL outcomes for stroke survivors compared with no rehabilitation or usual care (Legg et al., 2017; Rasmussen et al., 2015; Sahebalzamani & Alilu, 2016). In addition, moderate-to-strong evidence supports the use of ADL training combined with exercise within multidisciplinary rehabilitation interventions to improve outcomes (Bai et al., 2012; Bai et al., 2014; Chaiyawat & Kulkantrakorn, 2012). ADL interventions based on the Model of Human Occupation (MOHO) approach may also be considered for improving ADL performance (Shinohara et al., 2012). However, other client- centered ADL interventions were not found to be superior to standard ADL interventions or usual care (Sackley et al., 2016; Bertilsson et al., 2014; Guidetti et al., 2015). Swallowing interventions and a workplace intervention program also did not demonstrate significant improvements in ADL outcomes compared with control groups (Bath et al., 2018; Ntsiea et al., 2014). Little is known about the necessary dosages or superiority of different types of ADL interventions. While occupational therapy practitioners should continue to provide standard ADL interventions to improve outcomes in ADLs, they may also consider use of the MOHO approach or combining ADL interventions with exercise. More research is needed to determine the most effective types and amounts of ADL training to maximize improvements in ADL outcomes for stroke survivors. In addition, as only Level 1A/1B studies were included in this review, there may be emerging evidence from studies with lower levels of evidence that were not included.

Footnotes

*

Indicates articles included in the brief systematic review.

References

*Bai

Zhu

Jiang

, . . ., Fan

(2012). A prospective, randomized, single-blinded trial on the effect of early rehabilitation on daily activities and motor function of patients with hemorrhagic stroke. Journal of Clinical Neuroscience: Official Journal of the Neurosurgical Society of Australasia , 19 , 1376–1379. https://doi.org/10.1016/j.jocn.2011.10.021

*Bai

Y. L.

Y. S.

Zhu

Y. L.

Zhang

Jiang

C. Y.

, . . ., Fan

W. K.

(2014). Long-term three-stage rehabilitation intervention alleviates spasticity of the elbows, fingers, and plantar flexors and improves activities of daily living in ischemic stroke patients: A randomized, controlled trial. Neuroreport , 25 , 998–1005. https://doi.org/10.1097/WNR.0000000000000194

*Bath

P. M.

Lee

H. S.

, & Everton

L. F.

(2018). Swallowing therapy for dysphagia in acute and subacute stroke. Cochrane Database of Systematic Reviews (Vol. 2018, Issue 10). John Wiley and Sons Ltd. https://doi.org/10.1002/14651858.CD000323.pub3

*Bertilsson

A. S.

Ranner

von Koch

Eriksson

Johansson

Ytterberg

, . . ., Tham

(2014). A client-centred ADL intervention: Three-month follow-up of a randomized controlled trial. Scandinavian Journal of Occupational Therapy , 21 , 377–391. https://doi.org/10.3109/11038128.2014.880126

Carr

J. H.

Shepherd

R. B.

Nordholm

, & Lynne

(1985). Investigation of a new motor assessment scale for stroke patients. Physical Therapy , 65 , 175–180. https://doi.org/10.1093/ptj/65.2.175

*Chaiyawat

, & Kulkantrakorn

(2012). Effectiveness of home rehabilitation program for ischemic stroke upon disability and quality of life: A randomized controlled trial. Clinical Neurology and Neurosurgery , 114 , 866–870. https://doi.org/10.1016/j.clineuro.2012.01.018

Collen

F. M.

Wade

D. T.

Robb

G. F.

, & Bradshaw

C. M.

(2009). The Rivermead Mobility Index: A further development of the Rivermead Motor Assessment. International Disability Studies , 13 , 50–54. https://doi.org/10.3109/03790799109166684

Duncan

P. W.

Bode

R. K.

Min Lai

, & Perera

; Glycine Antagonist in Neuroprotection Americans Investigators. (2003). Rasch analysis of a new stroke-specific outcome scale: The Stroke Impact Scale. Archives of Physical Medicine and Rehabilitation , 84 , 950–963. https://doi.org/10.1016/S0003-9993(03)00035-2

Fukuhara

Bito

Green

Hsiao

, & Kurokawa

(1998). Translation, adaptation, and validation of the SF-36 Health Survey for use in Japan. Journal of Clinical Epidemiology , 51 , 1037–1044. https://doi.org/10.1016/S0895-4356(98)00095-X

10.

Gadidi

Katz-Leurer

Carmeli

, & Bornstein

N. M.

(2011). Long-term outcome poststroke: predictors of activity limitation and participation restriction. Archives of Physical Medicine and Rehabilitation , 92 , 1802–1808. https://doi.org/10.1016/j.apmr.2011.06.014

11.

Granger

Hamilton

B. B.

Keith

R. A.

Zielezny

, & Sherwin

F. S.

(1986). Advances in functional assessment for medical rehabilitation. Topics in Geriatric Rehabilitation , 1 , 59–74. https://doi.org/10.1097/00013614-198604000-00007

12.

*Guidetti

Ranner

Tham

Andersson

Ytterberg

, & von Koch

(2015). A “client-centred activities of daily living” intervention for persons with stroke: One-year follow-up of a randomized controlled trial. Journal of Rehabilitation Medicine , 47 , 605–611. https://doi.org/10.2340/16501977-1981

13.

Hartman-Maeir

Soroker

Ring

Avni

, & Katz

(2009). Activities, participation and satisfaction one-year post stroke. Disability and Rehabilitation , 29 , 559–566. https://doi.org/10.1080/09638280600924996

14.

Katz

Ford

A. B.

Moskowitz

R. W.

Jackson

B. A.

, & Jaffe

M. W.

(1963). Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychosocial function. JAMA , 185 , 914–919. https://doi.org/10.1001/jama.1963.03060120024016

15.

*Legg

L. A.

Lewis

S. R.

Schofield-Robinson

O. J.

Drummond

, & Langhorne

(2017). Occupational therapy for adults with problems in activities of daily living after stroke. In Cochrane Database of Systematic Reviews (Vol. 2017, Issue 7). John Wiley and Sons Ltd. https://doi.org/10.1161/STROKEAHA.117.018923

16.

Lennon

, & Johnson

(2009). The modified Rivermead Mobility Index: Validity and reliability. Disability and Rehabilitation , 22 , 833–839. https://doi.org/10.1080/09638280050207884

17.

Mahoney

F. I.

, & Barthel

D. W.

(1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal , 14 , 61–65.

18.

Mayo

N. E.

Wood-Dauphinee

Côté

Durcan

, & Carlton

(2002). Activity, participation, and quality of life 6 months poststroke. Archives of Physical Medicine and Rehabilitation , 83 , 1035–1042. https://doi.org/10.1053/apmr.2002.33984

19.

*Ntsiea

M. V.

Van Aswegen

Lord

, & Olorunju

S. S.

(2014). The effect of a workplace intervention programme on return to work after stroke: A randomised controlled trial. Clinical Rehabilitation , 29 , 663–673. https://doi.org/10.1177/0269215514554241

20.

Oxford Centre for Evidence-Based Medicine. (2009). Levels of evidence (March 2009). https://www.cebm.ox.ac.uk/resources/levels-ofevidence/oxford-centre-for-evidence-based-medicine-levels-ofevidence-march-2009

21.

*Rasmussen

R. S.

Østergaard

Kjær

Skerris

Skou

Christoffersen

, . . ., Overgaard

(2015). Stroke rehabilitation at home before and after discharge reduced disability and improved quality of life: A randomised controlled trial. Clinical Rehabilitation , 30 , 225–236. https://doi.org/10.1177/0269215515575165

22.

*Sackley

C. M.

Walker

M. F.

Burton

C. R.

Watkins

C. L.

Mant

Roalfe

A. K.

, . . ., Peryer

; OTCH investigators. (2016). An Occupational Therapy intervention for residents with stroke-related disabilities in UK Care Homes (OTCH): Cluster randomised controlled trial with economic evaluation. Health Technology Assessment (Winchester, England) , 20 , 1–138. https://doi.org/10.3310/hta20150

23.

*Sahebalzamani

, & Alilu

(2016). The efficacy of self-care education on rehabilitation of stroke patients. https://www.researchgate.net/publication/24281309

24.

Shah

Vanclay

, & Cooper

(1989). Improving the sensitivity of the Barthel Index for stroke rehabilitation. Journal of Clinical Epidemiology , 42 , 703–709. https://doi.org/10.1016/0895-4356(89)90065-6

25.

*Shinohara

Yamada

Kobayashi

, & Forsyth

(2012). The model of human occupation-based intervention for patients with stroke: A randomised trial. Hong Kong Journal of Occupational Therapy , 22 , 60–69. https://doi.org/10.1016/j.hkjot.2012.09.001

26.

U.S. Preventive Services Task Force. (2018). Grade definitions. https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions

27.

van Swieten

J. C.

Koudstaal

P. J.

Visser

M. C.

Schouten

H. J.

, & van Gijn

(1988). Interobserver agreement for the assessment of handicap in stroke patients. Stroke , 19 , 604–607. https://doi.org/10.1161/01.STR.19.5.604

28.

Virani

S. S.

Alonso

Benjamin

E. J.

Bittencourt

M. S.

Callaway

C. W.

Carson

A. P.

, . . ., Heard

D. G.

(2020). Heart disease and stroke statistics—2020 update: A report from the American Heart Association. In Circulation. https://doi.org/10.1161/CIR.0000000000000757

Occupational Therapy and Activities of Daily Living Interventions to Improve Performance in Activities of Daily Living for Adults With Stroke (2012–2019)