Effectiveness of occupation-based interventions on performance’s quality for hemiparetic stroke in community-dwelling: A randomized clinical trial study

Abstract

BACKGROUND:

Occupations define activities that people perform to occupy themselves and that people have meaning and value to them. The use of occupation-based intervention addresses activity daily of living performance.

OBJECTIVES:

This study was to investigate the effects of occupation-based interventions on performance’s quality for hemiparetic stroke in community-dwelling.

METHODS:

Forty-three participants were enrolled in this study with a full understanding of the purpose and method of the research and had a diagnosis with hemiparetic stroke. Participants were randomized to one of two treatment groups: Experimental group (n = 23) or control groups (n = 20). The experimental group applied occupation-based intervention and control group applied action focusing intervention. All participants underwent ten treatment sessions during the study period and conducted pre- and post-assessment. Several instruments were used to measure quality of performance.

RESULTS:

After the intervention training, the qualities of occupational performance were significantly higher in the experimental group applied occupation-based intervention than the control group applied action focusing intervention (p < 0.001).

CONCLUSIONS:

Based on the results of this study, occupation-based intervention has positive effects on quality of performing daily activities and occupational activities independently in persons with hemiparetic stroke.

Keywords

Occupation performance stroke

1 Introduction

Stroke is a major health problem worldwide (World Health Organization [WHO], 2003). The various physical, cognitive, behavioral, and emotional problems associated with stroke can negatively affect participation in daily life (Desrosiers, Demers, Robichaud, Vincent, Belleville, & Ska, 2008; Hartman-Maeir, Soroker, Ring, Avni, & Katz, 2007; Hildebrand, Brewer, & Wolf, 2012). It is important to consider all of rehabilitation process in terms of participation. Stroke patients have difficulty performing in activities and participating in occupations due to impairments even after returning to the community (Sansonetti & Hoffmann, 2013).

Occupational therapy is an essential component in the rehabilitation for hemiparetic stroke in community-dwelling (Langhorne & Pollock, 2002). Occupational therapy practitioners assist people with their ability to engage and participate in meaningful occupations (American Occupational Therapy Association [AOTA], 2014). In occupational therapy, therapist have administered to stroke patients focused on body function and body action using bottom-up approach for a long time, increasing the occupational performance through intervention of performance components (Aiken, Fourt, Cheng, & Polatajko, 2011; McEwen, Polatajko, Davis, Huijbregts, & Ryan, 2010). These intervention methods do not consider the environment and the occupation of the stroke patient. For that reason, the difficulty in characterizing the relationship between occupation and various occupational performance components presents a limitation on the ability to objectively demonstrate a therapeutic effect (Brown, & Chien, 2010).

In occupational therapy practice framework; domain and process, participation in daily life is defined as involvement in a life situation. The importance of client participation in goal setting has involved actively in the process of occupational therapy and is of relevance to client-centered practice. Client participation is essential in client-centered practice; client goals are at the center of all assessment and intervention (Townsend & Polatajko, 2007). Listening to the client, enabling choice, and respecting client values and fostering hope are also integral parts of client-centered practice approaches (Sumsion & Law, 2006).

In the systematic review, the use of occupation-based interventions to address activity daily of living performance, with the best available evidence supporting the use of occupation-based interventions improve participation of occupation in daily living (Wolf et al., 2015). The previous study mentioned occupation as every activity people do to occupy themselves including activities of daily living (ADLs), lesuire, and social participation that have meaning and value to them (Law et al., 1997). The occupation-based intervention establishes an occupational performance goal for the participant, and the therapist assesses the environment of the client. Most occupation-based approaches have the advantage of making directly performance of occupational area possible by setting a goal (Doucet et al., 2014; Pierce, 2009).

Nevertheless, many occupation-based interventions only focus on basic activities of daily living and it remains unclear whether these interventions improve to the ability to engage successfully in occupational performance a several of occupation area (Legg et al., 2007; Trialists, 2004). The effectiveness of rehabilitation relies on improving the quality of performance skill on occupation for hemiparetic stroke in community-dwelling (Skidmore et al., 2015). Therefore, this study goal was to identify the effect of occupation-based intervention on the quality of performance in participants with hemiparetic stroke. Specifically, we undertook the study to examine the relative effectiveness of occupation-based intervention and conventional occupational therapy though randomized experimental research on individual with hemiparetic stroke in community-dwelling.

2 Methods

2.1 Participants

The 43 adult participants, living in the community and diagnosed with chronic stroke were receiving outpatient occupational therapy. The inclusion criteria were as follows: 1) The participant has been diagnosed with stroke and lives in the community; 2) The participant scored above 19 on the Mini-Mental State Examination-Korean (MMSE-K); 3) The participant had no problem with verbal communication; 4) The participant can set a goal for their desired occupational performance; and 5) The participant has agreed to participate in the study.

To select the participants who matched the inclusion criteria of the study, we used the MMSE-K (changed to the Korean version by Kwon and Park in 1989). This study selected research participants from among hemiparetic stroke with an MMSE-K score above 19 points and minimal cognitive impairment. When interpreting the MMSE-K, a score below 19 points (out of a possible 30 points) indicates cognitive impairment (Kwon & Park, 1989).

The number of participant was divided into 2 groups through sample size/power calculation program with the significance standard of 0.05, power value of 0.50. Twenty-five people were selected per group at the rate of 1:1 (control group: experimental group), due to the difficulty of recruitment, 23 people were selected in the experimental group and 20 people were selected in the control group.

2.2 Procedure

This study was conducted through Randomized Clinical Trial Study. The process of study was divided into four stages (Fig. 1). The first stage gathered participants who matched the inclusion criteria. The purpose of the research and method were explained to the research participants. The participants agreed study’s description and agreement, and then the MMSE-K was executed. During the second stage, participants were randomized and allocated to either the experimental group or the control group. By throwing a coin, each participant was randomly assigned to experimental group and control group. Twenty-three people received occupation based intervention in the experimental group and twenty people received action focusing intervention in the control group. In the third stage, participants followed up to assess for the post assessment. The fourth stage analyzed assessment of quality of occupational performance.

Fig.1

Study Process.

Occupation-based intervention focuses on the performance of occupations. The administration of the COPM gauged the participants’ satisfaction with their performance and the PQRS allowed the therapist to evaluate the quality of the participant’s performance. With AMPS, we measured the quality of performance skills to determine the effects of motor and process skills on performance. In this process, the blind method was used to apply random intervention to the participants to prevent influencing the intervention result.

During the all of the intervention and assessment session, researchers with over six years of clinical experience evaluating intervention therapy performed the intervention and outcome measurement.

2.3 Intervention

According to the Taxonomic Code for Occupational Performance (TCOP), the TCOP is seven level framework that follows the typical hierarchical structure of classifications; Voluntary movement, movement pattern, action, task, activity, occupation, and occupational grouping (Polatajko et al., 2004). In this study, according to hierarchy of TCOP the category of occupational grouping and action was selected.

The foundation of occupation-based interventions is category of occupational grouping. This is setting of occupations grouped by a theme, primarily named by the individual or society such as self-care, productivity, and leisure (Polatajko et al., 2004). People have to participate their roles by themselves including activities of daily living, enjoying life, and social participation and have meaning and value to them. This is definition as occupation-based interventions (Polatajko et al., 2004).

The action focusing intervention is category of action. The action is a set of purposeful, observable movement patterns that have a product or outcome and may involve materials. All actions have active, physical, cognitive, and affective components (Polatajko et al., 2004).

The occupation-based intervention provided in this research allowed direct training, conducted by the therapist, to achieve the goal desired by the participant. The treatment protocol called for occupation-based intervention to be provided to the experimental group participants. Intervention was applied to direct occupation. Client -selected occupations were performed using actual tools in an environment similar to reality. The control group applied action focusing intervention that was applied training of the emphasis on focusing body functions, were to restore or remediate client factors such as strength, ROM, stability, coordination, and endurance (Table 1).

Table 1
Category of interventions

Interventions Processes Examples

Occupation-based intervention 1. Client selects self-selective occupational goals.
2. Clients plan to perform the goals.
3. Clients plan the environment to perform their goals.
4. Clients plan the equipment to perform their goals. A bicycle ride; iron out; play catch ball; cook dumpling
soup; peeling out apple etc.

Action focusing intervention 1. Client selects self-selective occupational goals.
2. Therapist plan to perform the goals.
3. Therapist selects action to perform their goals.
4. Therapist applies to facilitate action program to
perform their goals (physical and cognitive
components). Physical component-Walk; transport objects; reach for
and manipulate objects; position the body etc.
Cognitive component- Attention; memory; sequencing; categorizing etc.

Interventions	Processes	Examples
Occupation-based intervention	1. Client selects self-selective occupational goals. 2. Clients plan to perform the goals. 3. Clients plan the environment to perform their goals. 4. Clients plan the equipment to perform their goals.	A bicycle ride; iron out; play catch ball; cook dumpling soup; peeling out apple etc.
Action focusing intervention	1. Client selects self-selective occupational goals. 2. Therapist plan to perform the goals. 3. Therapist selects action to perform their goals. 4. Therapist applies to facilitate action program to perform their goals (physical and cognitive components).	Physical component-Walk; transport objects; reach for and manipulate objects; position the body etc. Cognitive component- Attention; memory; sequencing; categorizing etc.

The main questions of face-to-face interview from the question guide.

We performed interventions twice per week for 60 minutes per session, and ten intervention sessions for 6 weeks were completed.

2.4 Outcome measurements

The Korean Activity Card Sorting (K-ACS) is the Activity Card Sort Test developed by Baum and Edward (2001) and converted into the Korean version by Lee and colleagues (Lee et al., 2010). This assessment tool is a method of card classification, based on the activity level of the participant after seeing the activity picture card. K-ACS card deck includes instrumental activities of daily living, leisure activities, and social activities. The K-ACS determined the participation level of the research participant, and helped the selection of goal activity by use before administering the Canadian Occupational Performance Measure (COPM).

The COPM is the tool used for the assessment of occupational performance ability based on the participant. The interview process was semi-structured and the evaluator aimed to identify the problem in occupational performance. In addition, we executed the assessment based on the 10-point criterion including importance, performance, and satisfaction (Cup, Scholte op Reimer, Thijssen, & van Kuyk-Minis, 2003). In this study, we used this tool for selecting the target activities based on the level of importance and for comparing pre- and post-intervention satisfaction and performance of the selected target activities.

In this study, the Performance Quality Rating Scale (PQRS) is a tool that monitors and measures the quality of performance by operational definition of the therapist after determining the goal activity selected by the participant. PQRS is a very simple method for measuring the qualitative change in an individual activity. We measured the PQRS using a 10-point scale from 1 to 10 points (Martini, Rios, Polatajko, Wolf, & McEwen, 2015). We measured pre- and post-intervention performance in the assessment that has been evaluated for their effectiveness for the target activity.

The Assessment of Motor and Process Skills (AMPS) is an observational assessment that allows for the simultaneous evaluation of motor and process skills and their effect on the ability of an individual to perform complex or instrumental and personal activities of daily living. The AMPS is comprised of 16 motor and 20 process skill items. Motor skills are the observable goal-directed actions people perform during ADLs in order to move themselves or the task objects, and process skills refer to the ability of an individual to logically sequence the actions of the ADLs over time (Merritt, & Fisher, 2003). This study measured the effect of quality of performance about occupation by measuring pre and post-intervention.

2.5 Statistical methods

The independent variable in this study was occupation-based intervention. The dependent variables were the PQRS, COPM, and AMPS on quality of performance. Common characteristics of the participants analyzed from descriptive statistics. Independent t-tests were used to determine whether the changes between the experimental group and control group of the dependents variables. An alpha level of p < 0.05 was used as statistical significance. All statistical analyses were performed using the SPSS statistics version 18.0 (SPSS Inc., Chicago, IL, USA). The mean and standard deviation of experimental group and control group were calculated for Cohen’s d effect size.

3 Results

Table 2 lists the demographic and clinical characteristics of the participants. The average age of the participants was 64.9±2.9 years in the experimental group and 66.4±3.3 in the control group. In the experimental group, 7 people had right hemiparesis (30.4%) and 16 people had left hemiparesis (69.6%). In the control group, 3 people had right hemiparesis (15.0%) and 17 people had left hemiparesis (85.0%). The average post-stroke duration was 42.3±32.8 months in the experimental group and 44.0±29.8 months in the control group.

Table 2
General characteristics of the participants (N = 43)

Characteristic Experimental groups (n = 23) Control groups (n = 20) χ ²/p

Sex

male 12 (52.2) 15 (75.0) 0.206

female 11 (47.8) 5 (25.0)

Age (yr) 64.9±2.9 66.4±3.3 0.308

Post-stroke duration (mo) 42.3±32.8 44.0±29.8 0.078

Diagnosis

Hemorrhage 15 (65.2) 11 (55.0) 0.545

Infarction 8 (34.8) 9 (45.0)

Affected side

Right 7 (30.4) 3 (15.0) 0.294

Left 16 (69.6) 17 (85.0)

MMSE-K 25.7±3.3 28.0±2.1 0.130

Characteristic	Experimental groups (n = 23)	Control groups (n = 20)	χ ²/p
Sex
male	12 (52.2)	15 (75.0)	0.206
female	11 (47.8)	5 (25.0)
Age (yr)	64.9±2.9	66.4±3.3	0.308
Post-stroke duration (mo)	42.3±32.8	44.0±29.8	0.078
Diagnosis
Hemorrhage	15 (65.2)	11 (55.0)	0.545
Infarction	8 (34.8)	9 (45.0)
Affected side
Right	7 (30.4)	3 (15.0)	0.294
Left	16 (69.6)	17 (85.0)
MMSE-K	25.7±3.3	28.0±2.1	0.130

Clinical characteristics of the hemiparetic stroke patients. Notes: Data are presented as mean±standard deviation, N(%), MBI: Modified Barthel Index, MMSE-K: Mini Mental State Examination– Korean.

In this study, PQRS, the quality of performance of goal activity, significantly increased following the training in the experimental group compared to the control group (p < .001). In the performance of COPM, the experimental group exhibited a significant improvement after training unlike the control group (p < 0.001). Nevertheless, the participant satisfaction with the results of the COPM did not show a significant difference in the two groups (p > 0.05). We administered AMPS before and after intervention to examine the effect of performance skill quality, and to compare the influence of motor and process skills when performing occupations. With the AMPS test, the quality of performance skills showed a significant increase in the experimental group compared to the control group (p < 0.001) (Table 3).

Table 3

Comparison between Two Groups in performance of activities (N = 43)

Assessment	Experimental group (n = 23)			Control group (n = 20)			Between groups t-value	Cohen’s d	Effect size r
	Pre-test	Post-test	Within Group t-value	Pre-test	Post-test	Within group t-value
PQRS	4.8±1.0	5.5±0.9	– 5.7^**	5.4±0.8	5.6±0.7	– 3.8^**	– 5.5^**	– 0.1	– 0.061
COPM
Performance	3.6±0.8	4.7±0.6	– 8.7^**	3.8±0.4	4.5±0.4	– 5.1^**	– 3.3^**	0.4	0.192
Satisfaction	3.4±0.6	4.2±0.5	– 6.0^**	4.0±0.1	4.6±0.5	– 4.6^**	– 1.8	– 0.8	– 0.371
AMPS
Motor skills	1.4±0.6	1.5±0.6	– 3.3^*	1.2±0.9	1.2±0.9	– 1.5	– 4.3^**	0.4	0.192
Process skills	0.4±1.1	0.8±0.8	– 2.7^*	0.9±0.9	0.6±0.5	2.0	– 3.2^*	0.3	0.148

Common characteristics of the occupational therapists. Notes: Data are presented as mean±standard deviation, AMPS: Assessment of Motor and Processing Skills, COPM: Canadian. Occupational Performance Measure, PQRS: Performance Quality Rating Scale. ^*p < 0.05, ^**p < 0.001.

Cohen’s d effect size interpretation is as follows: 0.2 = small effect, 0.5 = medium effect, and 0.8 = large effect. At satisfaction of COPM, experimental group had a large effect over control group (d = 0.8) and a medium effect over control group for changes in preformance of COPM and motor skill of AMPS (d = 0.4).

4 Discussion

The objectives of this study were to determine the effectiveness of occupation-based intervention in improving the quality of occupational performance of daily living. We found that occupation-based intervention appeared to be effective at increasing the occupational performance of individual with hemiparetic stroke, and a positive influence toward the acquisition of performance skills.

The research showed a statistically significant increase in quality of performance in the PQRS and performance of COPM before and after intervention. In this research, we administered performance skills using AMPS before and after intervention. We compared the influence on motor and process skills needed for performance and the independence of daily activities. Previous studies have investigated which occupation-based intervention is beneficial for performance skills required in everyday life (Wolf et al., 2015). Therefore, most cases of stroke patients can attribute this towards their performance skills to participate in occupations.

Haslam and colleague found limited evidence to support the use of task specific activity (occupation-based) over remedial (not occupation-based) interventions to improve ADL performance (Haslam, & Beaulieu, 2007). Hershkovitz and colleagues found that significant improvements in functional independence within participants applied in a day usual rehabilitation program (Hershkovitz, Beloosesky, Brill, & Gottlieb, 2004). Nevertheless Abizanda and colleagues found no difference between occupational therapy interventions (ADL training) coupled with conventional treatment (usual rehabilitation) and conventional treatment alone (Abizanda et al., 2011). As with the above study, there were various results on the effectiveness of occupational-based intervention. This study is meaningful that it provided additional evidence that occupational-based intervention is more effective in quality of performance in participants with hemiparetic stroke.

In view of that, occupational therapy relies on a client-centered and occupation-based intervention for performance and participation. Occupation as an intervention involves the use of daily activities as a means to promote improvements in targeted outcomes. Occupation-based interventions are founded on the premise that engagement in specific types of daily activities will improve participation, quality of life, and well-being. Occupational therapy practitioners across all settings can help stroke patients improve their occupational performance. Nevertheless, many occupation-based interventions only focus on basic activities of daily living and it remains unclear whether these interventions improve to the ability to engage successfully in occupational performance a several of occupation area (Legg et al., 2007; Trialists, 2004). The application of occupation-based interventions can participated in occupation grouping, with the best available evidence supporting the use of occupation-based interventions to improve participated the individual or society.

The results of this study provide positive evidence to confirm occupation-based intervention suitable for hemiparetic stroke in community-dwelling. However, evaluation of the results of this study is subject to some limitations. First, this study did not account for the difference in the physical and independent status of each participant. Second, we enrolled only a small number of participants. Third, this study not included an assessment to demonstrate a long-term effect. Future studies should further develop occupation-based intervention with various clients and larger sample sizes and blinded assessors are also needed. For generalization of intervention, it needs to assess other areas of occupation and long-term effect.

In summary, the study identified the effect of occupation-based intervention on the quality of performance in participants for hemiparetic stroke in community-dwelling. This study provided information about research trends related to occupational performance, and this research proposed the occupation-based intervention provided the treatment activity considering the participation level to achieve the goal desired by the participant. This is a meaningful research topic because the topic encourages therapists to focus on occupation in clinic settings.

Conflict of interest

The authors declared no potential conflicts of interest with respect to the authorship and/or publication of this article.

References

Abizanda,

, León,

, Domínguez-Martín,

, Lozano-Berrio,

, Romero,

, Luengo,

,... & Martín-Sebastiá,

(2011). Effects of a short-term occupational therapy intervention in an acute geriatric unit. A randomized clinical trial. Maturitas, 69(3), 273–278.

Aiken,

F. E.

, Fourt,

A. M.

, Cheng,

I. K.

, & Polatajko,

H. J.

(2011). The meaning gap in occupational therapy: Finding meaning in our own occupation. Canadian Journal of Occupational Therapy, 78(5), 294–302.

American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl 1), S1–S48.

Brown,

, & Chien,

C. W.

(2010). Top-down or bottom-up occupational therapy assessment: Which way do we go? British Journal of Occupational Therapy, 73(3), 95.

Cup,

E. H.

, Scholte op Reimer,

W. J. M.

, Thijssen,

M. C.

, & van Kuyk-Minis,

M. A. H.

(2003). Reliability and validity of the Canadian Occupational Performance Measure in stroke patients. Clinical Rehabilitation, 17(4), 402–409.

Desrosiers,

, Demers,

, Robichaud,

, Vincent,

, Belleville,

, & Ska,

(2008). Short-term changes in and predictors of participation of older adults after stroke following acute care or rehabilitation. Neurorehabilitation and Neural Repair, 22(3), 288–297.

Doucet,

B. M.

, Woodson,

, & Watford,

(2014). Moving toward 2017: Progress in rehabilitation intervention effectiveness research. American Journal of Occupational Therapy, 68(4), e124–e148.

Hartman-Maeir,

, Soroker,

, Ring,

, Avni,

, & Katz,

(2007). Activities, participation and satisfaction one-year post stroke. Disability and Rehabilitation, 29(7), 559–566.

Haslam,

T. M.

, & Beaulieu,

(2007). A comparison of the evidence of two interventions for self-care with stroke patients. International Journal of Therapy & Rehabilitation, 14(3), 118–127.

10.

Hershkovitz,

, Beloosesky,

, Brill,

, & Gottlieb,

(2004). Is a day hospital rehabilitation programme associated with reduction of handicap in stroke patients? Clinical Rehabilitation, 18(3), 261–266.

11.

Hildebrand,

, Brewer,

, & Wolf,

(2011). The impact of mild stroke on participation in physical fitness activities. Stroke Research and Treatment, 2012, 548–682.

12.

Kwon,

Y. C.

, & Park,

J. H.

(1989). Korean version of Mini-Mental State Examination (MMSE-K) part I: Development of the test for the elderly. Korean Neuropsychiatric Association, 28(1), 125–135.

13.

Langhorne,

, & Pollock,

(2002). What are the components of effective stroke unit care? Age and Ageing, 31(5), 365–371.

14.

Law,

, Polatajko,

, Baptiste,

, Townsend,

(1997). Core concepts of occupational therapy. InCanadian Association of Occupational Therapists, Enabling occupation: An occupational therapy perspective (pp. 29–56). Ottawa, ON: CAOT Publications ACE.

15.

Lee,

S. H.

, Yoo,

E. Y.

, Jung,

M. Y.

, Park,

S. H.

, Lee,

J. S.

, & Lee,

T. Y.

(2010). Development of the Korean activities card sort. Journal of Korean Society of Occupational Therapy, 18(3), 103–117.

16.

Legg,

, Drummond,

, Leonardi-Bee,

, Gladman,

J. R. F.

, Corr,

, Donkervoort,

,... & Sackley,

(2007). Occupational therapy for patients with problems in personal activities of daily living after stroke: Systematic review of randomised trials. BMJ, 335(7626), 922.

17.

Martini,

, Rios,

, Polatajko,

, Wolf,

, & McEwen,

(2015). The performance quality rating scale (PQRS): Reliability, convergent validity, and internal responsiveness for two scoring systems. Disability and Rehabilitation, 37(3), 231–238.

18.

McEwen,

S. E.

, Polatajko,

H. J.

, Davis,

J. A.

, Huijbregts,

, & Ryan,

J. D.

(2010). ‘There’s a real plan here, and I am responsible for that plan’: Participant experiences with a novel cognitive-based treatment approach for adults living with chronic stroke. Disability and Rehabilitation, 32(7), 541–550.

19.

Merritt,

B. K.

, & Fisher,

A. G.

(2003). Gender differences in the performance of activities of daily living. Archives of Physical Medicine and Rehabilitation, 84(12), 1872–1877.

20.

Pierce,

(2009). Co-occupation: The challenges of defining concepts original to occupational science. Journal of Occupational Science, 16(3), 203–207.

21.

Polatajko,

H. J.

, Davis,

J. A.

, Hobson,

S. J.

, Landry,

J. E.

, Mandich,

, Street,

S. L.

,... & Yee,

(2004). Meeting the responsibility that comes with the privilege: Introducing a taxonomic code for understanding occupation. Canadian Journal of Occupational Therapy, 71(5), 261–264.

22.

Sansonetti,

, & Hoffmann,

(2013). Cognitive assessment across the continuum of care: The importance of occupational performance-based assessment for individuals post-stroke and traumatic brain injury. Australian Occupational Therapy Journal, 60(5), 334–342.

23.

Skidmore,

E. R.

, Whyte,

E. M.

, Butters,

M. A.

, Terhorst,

, & Reynolds,

C. F.

(2015). Strategy training during inpatient rehabilitation may prevent apathy symptoms after acute stroke. PM&R, 7(6), 562–570.

24.

Sumsion,

, & Law,

(2006). A review of evidence on the conceptual elements informing client-centred practice. Canadian Journal of Occupational Therapy, 73(3), 153–162.

25.

Townsend,

E. A.

, & Polatajko,

H. J.

(2007). Advancing an occupational therapy vision for health, well-being, and justice through occupation. Ottawa, ON: CAOT Publications ACE.

26.

Trialists,

O. S.

(2004). Rehabilitation therapy services for stroke patients living at home: Systematic review of randomised trials. The Lancet, 363(9406), 352–356.

27.

Wolf,

T. J.

, Chuh,

, Floyd,

, McInnis,

, & Williams,

(2015). Effectiveness of occupation-based interventions to improve areas of occupation and social participation after stroke: An evidence-based review. American Journal of Occupational Therapy, 69(1), 1–11.

28.

World Health Organization. (2003). The world health report 2003: Shaping the future. Geneva: World Health Organization.