Abstract
These Practice Guidelines provide a summary of strong and moderate evidence for effective interventions for adults with stroke and for their caregivers.
A stroke, also known as a cerebrovascular accident (CVA) or a brain attack, occurs when the brain is deprived of oxygen as a result of blockage (ischemic) or rupture of blood vessels (hemorrhagic) within or leading to the brain. In the United States, it is a leading cause of long-term disability or death (Centers for Disease Control and Prevention [CDC], 2022b). The yearly incidence of stroke is approximately 795,000, of which 77% are new strokes and 23% are recurrent strokes. In 2018, the prevalence of stroke, or the number of adults older than age 20 yr who had a stroke, was estimated to be 2.7%, or 7.6 million Americans, and it is projected to increase to 3.9% of the U.S. population by 2030. Globally, the prevalence of stroke in 2020 was 89.13 million, and the incidence of stroke per year was 11.71 million (Tsao et al., 2022).
Certain factors and health conditions can increase the risk of stroke: hypertension; smoking; diabetes; diet; physical inactivity; obesity; hyperlipidemia; heart disease; sickle cell disease flare-ups; kidney and liver disease; sleep disorders; and psychosocial factors, such as depression, psychological distress, and loneliness. These risks may be mitigated with health management strategies (American Occupational Therapy Association [AOTA], 2020; American Stroke Association [ASA], 2021; Tsao et al., 2022). However, nonmodifiable factors also increase the risk of stroke, such as age; family history; race; gender; and prior occurrence of a stroke, transient ischemic attack, or myocardial infarction (ASA, 2021). A stroke may occur at any age—one in seven strokes occurs in people ages 15 to 49 yr—but the chance of having a stroke doubles every 10 yr after age 55 (CDC, 2022c). Regarding race and ethnicity, statistics show that Black, Hispanic, and Indigenous Americans have a higher incidence of stroke than non-Hispanic White or Asian Americans. In the United States, females have 55,000 more strokes each year and an overall higher lifetime risk of stroke than males. The intersectionality of age, gender, and race increases the risk of stroke among Black and Hispanic women older than age 70 compared with White women (Tsao et al., 2022). In addition, it must be noted that socioeconomic status and racial disparities often play a significant role in stroke outcomes. Socioeconomically deprived populations are less likely to receive effective management of stroke risk factors and equity in and access to good quality poststroke care (Marshall et al., 2015). Ikeme et al. (2022) found that a greater proportion of White patients than of racial minorities used emergency medical services, arrived within 3 hr from the onset of stroke symptoms, and received tissue-type plasminogen activator (tPA) or mechanical thrombectomy, thus negatively affecting stroke outcomes for Black, Hispanic, Asian, and Native American patients.
Other aspects of one’s environment may also create a greater risk of having a stroke and of having poorer stroke outcomes. For example, people in rural areas of the United States experience poorer outcomes poststroke than those in urban areas. This has been hypothesized to be a result of the lack of equal access to evidence-based acute stroke care (Hammond et al., 2020). In addition, exposure to environmental degradation such as air pollution increases stroke risk worldwide (Tsao et al., 2022).
Diagnosis of acute stroke is based on the patient’s history, clinical presentation, identifying signs and symptoms of stroke, a physical examination of stroke severity with the commonly used NIH Stroke Scale (National Institute of Neurological Disorders and Stroke, 2011), and cerebrovascular imaging (Choi et al., 2022; Powers et al., 2019). Diagnosing the type and location of the stroke is essential to ensure the best medical intervention and client outcomes. For instance, a person with an acute ischemic stroke may require tPA to remove blockage and decrease brain damage (Powers et al., 2019), and one with an acute hemorrhagic stroke may require medication or surgery to control bleeding (Unnithan et al., 2022).
The effects of a stroke vary greatly and depend on the location, severity, and type of stroke. In the cerebrum, left hemisphere strokes are thought to be more common than right hemisphere strokes (Portegies et al., 2015). Left hemisphere strokes may result in right-sided hemiplegia or hemiparesis, contralateral sensory impairments, apraxia, and communication difficulties, such as aphasia, and right hemisphere strokes may result in left-sided hemiplegia or hemiparesis, contralateral sensory impairments, unilateral spatial or body neglect, and spatial dysfunction (Johns Hopkins Medicine, 2022). A stroke in either hemisphere may cause dysphagia, cognitive impairments, depression, and visual deficits. Cerebellar strokes may result in ataxia, ataxic dysarthria, and poor postural control. Strokes in the brainstem may cause coma, dysphagia, diplopia, vertigo, or quadriparesis (Johns Hopkins Medicine, 2022).
In 2017, the caregiving that family and friends provided to all adults in need of assistance with daily activities in the United States was valued at about $470 billion per year (Reinhard et al., 2019). Stroke is one of the conditions that most often require caregiving. The ASA emphasizes the vital role that informal caregivers play as members of the stroke rehabilitation team (Collinson & De La Torre, 2017; Winstein et al., 2016). Moreover, the Occupational Therapy Practice Framework: Domain and Practice (4th ed.; OTPF–4; AOTA, 2020) states that caregiving is a co-occupation and that considering caregivers as clients is essential. Informal caregivers may assist with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and medical tasks, such as administering medication and supervising home exercise programs (Reinhard et al., 2019). The effects of caregiving on the caregiver can be positive or negative. Positive effects include feeling good about oneself and becoming closer to the person who has had a stroke. However, caregiving’s negative effects are most often reported and include harm to employment, finances, and mental health (depression, anxiety, stress, and burden or strain), as well as physical health challenges (injury or cardiovascular changes; Collinson & De La Torre, 2017; Loh et al., 2017; Schulz & Eden, 2016). When the caregiver experiences negative effects, the person who has had a stroke has a poorer outcome (Bakas et al., 2014).
Across the continuum of care, stroke patients and caregivers require a sustained and coordinated effort from a multidisciplinary rehabilitation team, of which occupational therapy is a vital part (Winstein et al., 2016). In stroke rehabilitation, occupational therapy practitioners implement the process that supports engagement and participation in occupations and health for both the adult with stroke and their caregiver (AOTA, 2020). Because the effects of a stroke are highly variable, assessment and intervention are client centered and based on holistic occupational therapy models of practice (e.g., the Person–Environment– Occupation model; Law et al., 1996).
Multiple frames of reference grounded in these holistic models guide stroke intervention. The biomechanical frame of reference is used to remediate limitations in range of motion, strength, and endurance caused by stroke (Grice, 2021). For impaired motor function, a motor control and motor learning frame of reference focused on task-oriented interventions improves motor performance and function (Nilsen & Gillen, 2021). Alternatively, for residual impairments after stroke that may be considered chronic or permanent, the occupational therapy practitioner focuses on compensatory or adaptive techniques, using the rehabilitation frame of reference (Winstead, 2021).
In all poststroke care settings, occupational therapy treatment of the person with stroke or the caregiver includes any or all of the intervention approaches enumerated in the OTPF–4: remediation, maintenance, compensation, prevention, and health promotion (AOTA, 2020). Stroke is not only an acute event but is also classified by the CDC (2022a) as a chronic disease if the impairments caused by the stroke limit ADLs or require medical attention for more than 1 yr. Thus, the occupational therapy stroke intervention changes from a focus on remediation to one on compensation, health promotion, and prevention to reduce modifiable stroke risk factors.
These practice guidelines update the previous Occupational Therapy Practice Guidelines for Adults With Stroke (Wolf & Nilsen, 2015) that were based on three systematic reviews addressing interventions within the scope of practice of occupational therapy to improve cognition, motor, and psychological and emotional impairments and one systematic review that examined the evidence for activity- and occupation-based interventions to improve occupation and social participation after stroke. In keeping with the philosophy of occupational therapy and the International Classification of Functioning, Disability, and Health for Children and Youth (World Health Organization, 2007) and the evolution of the literature since the last practice guidelines, the primary focus of these guidelines has shifted from impairment to occupational performance and participation. Therefore, the focus here is solely on ADLs, IADLs, and participation outcome measures, not impairment outcome measures (e.g., Modified Ashworth Scale [Bohannon & Smith, 1987], Fugl-Meyer Assessment [Fugl-Meyer et al., 1975; Gladstone et al., 2002]) or upper limb function (e.g., Action Research Arm Test [Lyle, 1981], Wolf Motor Function Test [Wolf et al., 2005]). These practice guidelines incorporate information from three systematic review questions on improving stroke survivors’ occupational performance and participation in ADLs (Geller, Goldberg, et al., 2023a, 2023b; Geller, Winterbottom, et al., 2023; Goldberg et al., 2023a, 2023b; Winterbottom, Geller, et al., 2023; Winterbottom, Goldberg, et al., 2023); IADLs (Kotler et al., 2023; Mahoney et al., 2023); and education, work, volunteering, leisure, and social participation (Proffitt et al., 2022). In addition, the practice guidelines include findings from one systematic review question on interventions for caregivers that facilitate maintaining their caregiving role (Mack & Hildebrand, 2023), a category that was not in the previous practice guidelines for adults with stroke.
Systematic Review Questions
These Practice Guidelines are based on the following four questions: What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve performance and participation in ADLs for adult stroke survivors? What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve performance and participation in IADLs among adult stroke survivors? What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve the performance of and participation in education, volunteering, social participation, work, and leisure among adults poststroke? What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice for caregivers of people with stroke to facilitate maintaining participation in the caregiver role?
Goals of These Practice Guidelines
Through these Practice Guidelines, AOTA aims to help occupational therapy practitioners, as well as the people who manage, reimburse, or set policy regarding occupational therapy services, understand occupational therapy’s contribution in providing services to people with stroke and their care partners. These guidelines can also serve as a reference for health care professionals, health care facility managers, education professionals, education and health care regulators, third-party payers, managed care organizations, and those who conduct research to advance the care of people with stroke.
These Practice Guidelines were commissioned, edited, and endorsed by AOTA without external funding being sought or obtained. They were financially supported entirely by AOTA and developed without any involvement of industry. All authors of the systematic reviews completed conflict-of-interest disclosure forms, with no conflicts noted. AOTA reviews practice guidelines, and updates them as needed, every 5 yr to keep the recommendations on each topic current according to criteria established by ECRI (2020). Guidelines topics are evaluated by a multidisciplinary advisory group consisting of AOTA members, nonmember content experts, and external stakeholders. These Practice Guidelines were reviewed and revised on the basis of feedback from a group of content experts on people with stroke that included practitioners, researchers, educators, practitioners, and policy experts. Reviewers who agreed to be identified are listed in the Acknowledgments.
These Practice Guidelines report the findings from systematic reviews of published scientific research on focused topic-specific questions. The systematic reviews were conducted according to the Cochrane Collaboration methodology (Higgins et al., 2019) and are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for conducting systematic reviews (Moher et al., 2009). The process included ▪ protocol and question development with input from a multidisciplinary advisory group that also included consumers and information end users, ▪ a literature search conducted by a medical research librarian, and ▪ team evaluation of literature and a synthesis of findings (see Appendix Table A.2).
Interventions that were described in sources other than the published literature and that did not meet the inclusion criteria were excluded from the reviews.
Occupational therapy practitioners should not consider these Practice Guidelines to be a source of comprehensive information about stroke or about application of the occupational therapy process. The occupational therapy practitioner makes the ultimate clinical judgment regarding the appropriateness of a given intervention in light of a specific client’s or group’s circumstances, needs, and response to intervention, as well as the evidence available to support the intervention. Examples of how evidence can inform practice with people with stroke are included in the “Case Studies and Evigraphs” section.
AOTA supported the systematic reviews on the effectiveness of interventions within the scope of occupational therapy for people with stroke as part of its Evidence-Based Practice (EBP) Program. AOTA’s EBP Program is based on the principle that the evidence-based practice 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. The systematic reviews and these Practice Guidelines report the findings from the best available research published since the previous Practice Guidelines. For updated Question 1, that research was published from 2012 through 2019; for Questions 2 to 3, from 2009 through 2019; and for new Question 4, from 1999 through 2019.
Clinical Recommendations for Occupational Therapy Interventions for Adults With Stroke
Clinical recommendations are the final phase of the synthesis of systematic review findings. The findings for each systematic review question are graded in terms of how confident a practitioner can feel that using the interventions presented in the evidence will improve the outcomes of interest to their clients. The grade is based on the specificity of the intervention, number of studies supporting the intervention, level of evidence of the studies, quality of the studies, and significance of the study findings. Interventions included in the clinical recommendations are specific to a population, and the articles that describe them provide sufficient detail for practitioners to understand the intervention and the outcomes of interest.
Describing the strength of clinical recommendations is an important part of communicating an intervention’s efficacy to practitioners and other users. The recommendations for these Practice Guidelines were evaluated and finalized by AOTA staff, the AOTA research methodologist, and the systematic review and Practice Guidelines authors. AOTA uses the grading methodology provided by the U.S. Preventive Services Task Force (2018) for clinical recommendations. The clinical recommendations pertaining to each review, along with the studies’ level of evidence and supporting details, are presented in Tables 1 to 4.
Clinical Recommendations for Interventions to Improve ADL and FM Outcomes
Note: All studies included had statistically significant positive outcomes related to the interventions discussed. ADL/ADLs = activities of daily living; AO = action observation; AROM = active range of motion; CAREN = Computer-Assisted Rehabilitation Environment; CBT = cognitive–behavioral therapy; EMG = electromyography; e-stim = electrical stimulation; FM = functional mobility; HEISS = Health Empowerment Intervention for Stroke Self-Management; H-RT = horse-riding therapy; ICH = intracerebral hemorrhage; IREX = Immersion Rehabilitation Exercise; MCA = middle cerebral artery; Mdn = median; MI = mental imagery; MT = mirror therapy; NDT = neurodevelopmental treatment; OT = occupational therapy; PCSMEI = Patient-Centered Self-Management Empowerment Intervention; PROM = passive range of motion; PT = physical therapy; RCT = randomized controlled trial; R-MT = rhythm and music therapy; ROM = range of motion; TENS = transcutaneous electrical nerve stimulation; TOT = task-oriented training; USN = unilateral spatial neglect; VR = virtual reality.
Clinical Recommendations for Interventions to Improve IADL Outcomes
Note. CIT = constraint-induced therapy; dCIT = distributed constraint-induced therapy; HEISS = Health Empowerment Intervention for Stroke Self-management; IADL/IADLs = instrumental activities of daily living; mCIMT = modified constraint-induced movement therapy; RCT = randomized controlled trial; RT = robotic therapy; TR = trunk restraint; UE = upper extremity.
Clinical Recommendations for Interventions to Improve Social Participation
Note. ADLs = activities of daily living; CBT = cognitive–behavioral therapy; CT = computerized tomography; MRI = magnetic resonance imaging; OT = occupational therapy; RCT = randomized controlled trial; ROM = range of motion; TC = transitional care.
Clinical Recommendations for Interventions to Improve Participation in the Caregiver Role
Note. ADL/ADLs = activities of daily living; CBT = cognitive–behavioral therapy; FSO = family support organizer; QOL = quality of life; RCT = randomized controlled trial.
For the purposes of these Practice Guidelines, we report only recommendations graded A, B, and D, the grades that best support clinical decision making: ▪ A: There is strong evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. Strong evidence was found that the intervention improves important outcomes and that benefits substantially outweigh harms. ▪ B: There is moderate evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. There is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial. ▪ D: It is recommended that occupational therapy practitioners not provide the intervention to eligible clients. At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits. In these reviews, we did not find Grade D evidence.
These grades are reported in Tables 1 to 4 and designated with green, indicating should consider if appropriate (A), or yellow, indicating could consider if appropriate (B).
The complete findings for the four systematic review questions can be found in the systematic review articles (Proffitt et al., 2022; Mack & Hildebrand, 2023) and the Systematic Review Briefs (Geller, Goldberg, et al., 2023a, 2023b; Geller, Winterbottom, et al., 2023; Goldberg et al., 2023a, 2023b; Kotler et al., 2023; Mahoney et al., 2023; Winterbottom, Geller, et al., 2023; Winterbottom, Goldberg et al., 2023) on this topic published in the American Journal of Occupational Therapy. As always, practitioners’ clinical decisions should be informed by the evidence presented in these Practice Guidelines, in combination with their clinical experience and the client’s particular goals.
Translating Clinical Recommendations Into Practice
Clinical Reasoning Considerations
Very rarely will practitioners find an evidence-based intervention that perfectly fits their clinical setting and the client’s specific needs. Occupational therapy practitioners need to consider several questions as they evaluate the research and consider whether they can use an intervention, or adapt it, in a well-reasoned way, to exactly meet the client’s needs (Highfield et al., 2015): Exactly what intervention do I need to provide? What types of client outcomes am I looking for? Do the studies I’ve located provide enough detail on the intervention so that I know what to do and how to do it? How well do the conditions in which I will provide the intervention match those in the studies? What are the demographic characteristics (e.g., age, gender, diagnosis, comorbidities) of the participants in the studies? In which setting (e.g., inpatient, home, community, school) did the studies take place? Do any contextual factors (e.g., resources, policies) that are different from those in the studies influence my ability to provide the intervention? How flexible is the intervention, and how much can I modify or adapt it? If my setting or client population differs from those of the studies, can I modify or adapt the intervention without changing its integrity? If I modify or adapt the intervention, what client characteristics (e.g., comorbidities) do I need to consider? Can I be proactive and plan how to modify or adapt the intervention before I start implementing it? Can I make minimal changes to the intervention, such as reordering the content of the sessions, or does the need for substantial changes indicate that I should select another intervention?
To modify or adapt evidence-based interventions in practice, practitioners must plan and proactively think through the changes they need to make to fit the intervention to the client and the practice setting. In addition, they must document how and why they altered the researched intervention so others in their setting know how to implement the intervention and why the changes were made. If an intervention must be adapted extensively, it may not be the right fit for the situation. If extensive adaptations to the intervention are necessary, the intervention is probably not right for the client or setting. If the practitioner finds that the intervention does not suit the client, they should not use that intervention. Clinical interventions should be as similar as possible to the interventions used in the research.
Case Studies and Evigraphs
The case studies presented in these Practice Guidelines illustrate how occupational therapy practitioners can translate evidence from the systematic reviews to their professional practice when collaborating with people with stroke. Each case study highlights interventions that are supported by evidence and expert opinion. Included with the case studies are decision-making evidence graphics (evigraphs; Figures 1–4) developed by the authors and AOTA staff on the basis of the clinical recommendations. Evigraphs are presented in relation to clinical recommendations for improving ADLs and functional mobility (Figure 1), IADLs (Figure 2), social participation (Figure 3), and participation in the caregiver role (Figure 4).
Evidence-based interventions to improve ADLs and functional mobility after stroke.
Evidence-based interventions to improve IADLs after stroke.
Evidence-based interventions to improve social participation after stroke.
Evidence-based interventions to support participation in the caregiver role.
Evigraphs based on clinical recommendations were developed to assist practitioners with clinical decision making. Practitioners must consider each potential intervention in relation to the client’s individual goals, interests, habits, routines, and environment and choose interventions that strongly align with or are supportive of these factors in the context of the client’s occupational profile. It is important to note that the evigraphs in these Practice Guidelines present simplified examples of the decision-making processes occupational therapy practitioners might use to address their specific clients’ goals in relation to the setting.
Case Study 1: Michelle
Occupational Profile
Michelle presented with right-sided weakness and expressive aphasia. She had difficulty communicating and became easily frustrated, but she could follow two-step commands and accurately answer yes-and-no questions. Michelle lives in a two-bedroom apartment in a building with an elevator and two steps to enter. She lives with her wife Chloe and 17-yr-old daughter Jasmine, who is in high school. They have a shower–bath combo with shower curtains and a three-in-one commode from Chloe’s earlier hip replacement. Michelle works full time as an assistant manager of a retail shoe store and commutes by bus, and her wife works as a teacher. Michelle had difficulty with bed mobility, transfers, and basic ADLs, such as dressing and bathing; however, she was able to groom and feed herself with set-up. Michelle’s family and friends were very supportive and able to assist. Michelle enjoys cooking, reading, and painting. Michelle’s goal is to take care of herself. Chloe reported that household duties were shared; she performed the cleaning and laundry, and Michelle performed money management and meal preparation. Because Chloe has arthritis and a busy schedule as a teacher and parent, she reported being worried about caring for Michelle at home. She stated that it is very important that Michelle be able to perform medication management and other self-care tasks.
Occupational Therapy Initial Evaluation and Findings
The occupational therapist at the inpatient rehabilitation facility completed a comprehensive initial evaluation, including an occupational profile (AOTA, 2021), clinical assessments, the Inpatient Rehabilitation Facility Patient Assessment Instrument (Centers for Medicare & Medicaid Services, 2022) to determine the amount of assistance needed for self-care, the Canadian Occupational Performance Measure (COPM; Law et al., 2019) to identify and prioritize everyday issues, and the Functional Upper Extremity Levels (FUEL; Van Lew et al., 2015) to determine the functional ability of Michelle’s right upper extremity. The physical therapist stated that Michelle required minimal assistance for ambulation with a hemiwalker. The speech-language pathologist recommended that the occupational therapy practitioner speak slowly, provide time for Michelle to process and answer questions, encourage conversation, and use gestures and visual aids. Table 5 summarizes the results of Michelle’s initial assessment. Michelle’s treatment goals were as follows:
Occupational Therapy Evaluation Results for Michelle
Note. AROM = active range of motion; COPM = Canadian Occupational Performance Measure; FUEL = Functional Upper Extremity Levels; IRF–PAI = Inpatient Rehabilitation Facility Patient Assessment Instrument; PROM = passive range of motion; WFL = within functional limits.
Michelle will perform bathing with supervision with use of shower chair and grab bars using adaptive techniques in 2 wk.
Michelle will perform toilet transfer, toileting, and dressing independently with use of adaptive equipment in 2 wk.
Michelle will improve her ability to use her right upper extremity from use as an independent stabilizer to use as a gross assist as per the FUEL to increase independence in ADLs in 2 wk.
With Chloe, Michelle will prepare a simple meal with minimal assistance using adaptive techniques and equipment in 2 wk.
Michelle will manage medications independently using a medication organizer and smartphone cues in 2 wk.
Occupational Therapy Interventions
A multidisciplinary approach in an urban public rehabilitation hospital was used to develop Michelle’s comprehensive plan, which included occupational therapy, physical therapy, social work, speech therapy, nursing, psychology, and physiatry. She was in the rehabilitation unit for 2.5 wk and received occupational therapy 1.0 hr/day, 6 days/wk. ▪ Action observation (AO) with task-oriented training was selected to address ADLs and functional mobility (Peng et al., 2019). ▪ Self-regulatory modified constraint-induced movement therapy (SR–mCIMT) intervention was selected to address IADLs such as meal preparation and medication management (Liu et al., 2016). ▪ Self-management interventions, in collaboration with physical therapy, were used to address stroke management and prevention of further strokes (Chen et al., 2018). ▪ Stroke education, skills training, and problem- solving therapy before discharge were selected for Michelle and Chloe to improve Michelle’s ADL performance and quality of life and to reduce Chloe’s caregiver burden (Deyhoul et al., 2020).
Action Observation and Task-Oriented Training
After reviewing the clinical assessment of the affected upper extremity, the occupational therapist selected AO followed by task-oriented practice (Peng et al., 2019) to improve Michelle’s upper extremity function and ADLs. The occupational therapy practitioner explained to Michelle and Chloe that AO is a multisensory approach that can be used with Michelle’s affected upper extremity and performed in therapy sessions, as well as in the evenings to increase repetition. Michelle and Chloe agreed to try AO. The intervention consisted of Michelle watching videos of healthy individuals performing range-of-motion exercises and functional reaching and grasping movements followed by task practice. For instance, Michelle would watch a video of an individual reaching for a cup on a table and then practice the movement with assistance. AO was implemented in the morning for 20 min 3 days/wk (Peng et al., 2019), and Michelle and Chloe were trained in this method to perform the task in the evenings for 30 min 3–5 days/wk for 2 wk.
Self-Regulatory Modified Constraint-Induced Movement Therapy
The occupational therapist included SR–mCIMT (Liu et al., 2016) for Michelle to improve IADLs, such as meal prep, and health management occupations, for example, medication management. The intervention consisted of 1-hr sessions with the unaffected hand restrained with a mitt, thus forcing use of the affected hand during ADL and IADL activities. However, for safety, the mitt was removed for transfers and ambulation. The first 5 days focused on ADLs such as brushing teeth, upper and lower body dressing, toilet transfer, and bathing, and the remaining 5 days focused on using a phone, preparing a simple meal, folding laundry, putting clothing on hangers, sweeping the floor, and washing dishes. The focus of each session was to have Michelle reflect on her abilities and deficits in performing the tasks while using problem-solving strategies, which included identifying the problem, generating solutions, implementing one solution, and evaluating the results to achieve task independence. The occupational therapist provided guidance throughout the session and used communication strategies recommended by the speech-language pathologist to facilitate Michelle’s learning. Michelle’s unaffected arm was also restrained for an additional 3 hr a day with supervision of the nurse and family (Liu et al., 2016). Michelle and Chloe were taught that they could use the mitt in the evening while performing the AO intervention.
Patient-Centered Self-Management Empowerment Intervention
The occupational therapist included the patient- centered self-management empowerment intervention (Chen et al., 2018) for Michelle, which was designed to improve her self-efficacy regarding stroke knowledge and management, as well as ADL skills, through five individual sessions, one group session, and phone-call follow-up. The individual sessions were held bedside in the morning with Michelle and occurred on for 20 min inpatient Days 3 to 7. These sessions included ADL training, stroke education (e.g., risk factors), self-health monitoring, complication prevention, goal setting, and the creation of action plans regarding stroke management and rehabilitation through discussion and written material. A 60-min group session with six stroke patients was held on Day 7. The group session included watching a 20-min video regarding self- management poststroke, and the remaining 40 min was dedicated to group members sharing their experiences poststroke and the skills learned in their individual sessions (Chen et al., 2018). The occupational therapist collaborated with psychology and nursing professionals to develop these individual sessions and the group session, with speech therapy to assist with Michelle’s communication in the group.
Skills Training Before Discharge
The occupational therapist incorporated several individually tailored training sessions for both Michelle and Chloe to increase Michelle’s ability to perform ADLs and to reduce Chloe’s caregiving burden before discharge (Deyhoul et al., 2020). The occupational therapist collaborated with the physical therapist regarding gait facilitation and with the speech-language pathologist regarding communication. The intervention consisted of four 60-min sessions/day before discharge. The objective of the first 2 days was to provide stroke education and prevention and caregiving strategies for Michelle and Chloe. Stroke education included the following: stroke symptoms; ischemic versus hemorrhagic strokes; risk factors such as hypertension and diabetes; stroke prevention methods such as diet, diabetes, and hypertension monitoring and control; treatment such as AO and CIMT; and stroke complications. Stroke caregiving training for Chloe focused on strategies to increase performance of ADLs and IADLs through lectures, skills training (e.g., transfers, bathing, one-handed dressing strategies, adaptive meal prep equipment), educational slide shows, discussions, and questions. The objective of the third day was to increase self-efficacy through problem-solving therapy training. This included techniques to cope with problems caused by the stroke by identifying a problem, generating solution alternatives, analyzing the solutions, implementing one, and evaluating the results. On the fourth day, Chloe was provided with stroke education handouts and stroke patient care booklets, and competence was assessed by having her provide a verbal summary of the information and training content to Jasmine, their daughter. Even though Chloe demonstrated competence with the stroke education material, Jasmine was asked to remind Chloe about the stroke topics in the first week after discharge at home. In addition, weekly phone calls from one of the rehabilitation team members were provided for 2 mo to address home safety and fall prevention (Deyhoul et al., 2020).
Outcomes
Table 6 summarizes Michelle’s results on discharge outcome measures.
Occupational Therapy Discharge Results for Michelle
Note. AROM = active range of motion; COPM = Canadian Occupational Performance Measure; FUEL = Functional Upper Extremity Levels; IRF–PAI = Inpatient Rehabilitation Facility Patient Assessment Instrument; PROM = passive range of motion; WFL = within functional limits.
▪ Michelle attended all occupational therapy sessions and was consistent with her evening exercise program, including AO, task practice, and SR–mCIMT.
▪ Michelle improved on all outcome measures and met her goals. She improved in feeding, grooming, dressing, toileting, and bathing with adaptive equipment and one-handed techniques.
▪ Michelle continues to require supervision for bathing while seated in a shower chair for safety.
▪ Michelle is able to use her affected upper extremity as a gross assist during functional tasks, such grasping a soda can with her affected hand and opening it with her unaffected hand. However, she continues to have difficulty with opening her affected hand and finger individuation.
▪ Michelle is able to independently manage her medication using a medication sorter and reminder alarms set on her smartphone.
▪ Michelle requires minimal assistance for simple meal preparation, such as managing tight containers and cutting vegetables.
▪ Michelle reported feeling more confident in her ability to go home and is looking forward to returning to work in the near future because she was able to tolerate 3 hr of therapy a day plus additional hours in the evening while participating in homework given by all the therapists.
▪ Chloe reported that she was happy with the home discharge plan for Michelle, although she was anxious about her ability to cope with many facets of her life now, which included care of Michelle. However, she reported feeling more confident with helping Michelle as needed and addressing problems as they came up at home using the problem-solving methods that she learned from the occupational therapist. They both reported wanting some home care assistance and occupational and physical therapy home health visits.
▪ Chloe stated that she would continue to use the stress management techniques she learned and would follow the recommendations of the occupational therapy practitioner to participate in the caregiver stroke support group and seek treatment from a social worker or psychologist for further cognitive–behavioral therapy strategies to address anxiety.
▪ Michelle was discharged home with a shower chair and grab bars for the bath and shower and will use her commode over the toilet and at bedside as needed. Michelle will receive home care 2×/wk for 3 hr for IADLs, home management, and community reentry.
Case Study 2: James
Occupational Profile
Occupational Therapy Initial Evaluation and Findings
On the basis of James’s primary complaints of reduced social interactions as a result of his functional mobility and feeling like a burden because of his difficulties performing ADLs and IADLs, the occupational therapist administered the COPM (Law et al., 2019) to further develop an occupational profile. Additionally, the occupational therapist had James perform some of the identified areas of the COPM while Juanita videorecorded and rated his performance using the Performance Quality Rating System (PQRS; Martini et al., 2015). The occupational therapist screened James for cognitive and visual deficits that might affect his ability to drive using basic visuomotor screening (Gillen & Hreha, 2021), the Snellen eye chart (Hetherington, 1954), and the Montreal Cognitive Assessment (Nasreddine et al., 2005). These findings were included in a referral to a local driving rehabilitation center that has a certified driver rehabilitation specialist (CDRS®) on staff. The physical therapist in the outpatient clinic administered and reported the results of the 6-Minute Walk Test (Dunn et al., 2015). The occupational therapist also asked Juanita to complete the Caregiver Self-Assessment Questionnaire (Epstein-Lubow et al., 2010) to determine whether she should be further evaluated for any significant levels of burden, depression, and burnout. Last, the occupational therapist asked Juanita and James to complete the Safe at Home Checklist (Rebuilding Together, n.d.) to identify any potential environmental safety hazards. Table 7 summarizes the results of James’s initial assessment.
Occupational Therapy Evaluation Results for James
Note. AROM = active range of motion; COPM = Canadian Occupational Performance Measure; MoCA = Montreal Cognitive Assessment; PQRS = Performance Quality Rating Scale; WFL = within functional limits; WNL = within normal limits.
No home safety hazards were identified. The driving evaluation found no cognitive or visual deficits that affected James’s ability to drive. However, slow reaction time resulting from anxiety affected his performance. The CDRS recommended participation in a driving rehab program using a driving simulator and training with a spinner knob for one-handed driving given James’s limited left upper extremity active range of motion. The physical therapist reported that the results of the 6-Minute Walk Test showed that James was significantly impaired in walking speed and endurance (350 m or 382 yd with one 30-s seated rest break using his straight cane). James reported low confidence in his community mobility because of fatigue. Juanita reported caregiver strain and burnout and revealed that she struggles with finding time alone because James is at home most of the day.
On the basis of James’s assessment results, the occupational therapist, James, and Juanita developed the following long-term treatment goals: ▪ James will shower independently by discharge, managing all parts of the shower, including the showerhead and bath products. ▪ James will drive himself in his own car between home and known local destinations (e.g., grocery store, high school) by discharge. ▪ James will increase time spent in valued social activities by 25% at 3 mo and by 50% at 9 mo. ▪ James and Juanita will identify and implement three strategies for Juanita to increase the percentage of time spent alone and mentally unburdened from her caregiving role by 9 mo. ▪ James will increase his confidence in functional mobility in unfamiliar environments and identify and implement strategies to decrease fatigue during community mobility by discharge.
Occupational Therapy Interventions
James participated in occupational therapy in a multidisciplinary center with a specialty in neurological disorders. He initially attended therapy 5×/wk for 2 wk and then 2×/wk for 6 wk. The occupational therapist recommended a constraint-induced therapy (CIT; task-oriented) approach to the intervention for the first 2 wk. After the CIT protocol and the evidence supporting it were explained to them, James and Juanita agreed to try it. During the follow-along phase of CIT in the latter 6 wk, James attended group-based cognitive–behavioral therapy (CBT) paired with task-oriented training for balance and functional mobility led by an occupational therapy assistant and a licensed physical therapy assistant. James’s occupational therapist was not a CDRS, so he was referred to a local driving rehabilitation center. Juanita attended most outpatient sessions with James, and the occupational therapist integrated CBT methods and a problem- solving approach for both James and Juanita into the sessions. Last, the occupational therapist recommended that Juanita attend the local stroke support group and connected her with a clinical psychologist who specialized in CBT methods.
Constraint-Induced Therapy
After reviewing the ADL and IADL evigraphs (Figures 1–2), the occupational therapist, in collaboration with James and Juanita, selected a CIT approach to address James’s concerns with being able to cook and grill for his family and manage all components of taking a shower (Lin et al., 2009 ; Liu et al., 2016). The occupational therapy practitioner followed the dosing in Liu et al. (2016) and Lin et al. (2009), scheduling 1-hr sessions 5 days/wk for 2 wk. James wore a mitt on his right hand during the in-clinic sessions and for up to 4 hr per day. He recorded his performance of several daily tasks on his homework sheet and committed to intensive individual practice and problem solving for up to 2 additional hr/day. The occupational therapist completed an activity analysis of showering and grilling (based on PQRS ratings of videos) and used the findings to tailor the shaping tasks for James. For example, James had difficulty with supination while using the heavy grill spatula to flip hamburgers. For a shaping task, James started with the task of sliding his hand under the page of a board book to turn it. He progressed to turning over playing cards and then pancakes using a light spatula. The occupational therapist also integrated problem solving into the sessions to provide James with strategies to use in other areas of occupational performance. Specifically, the occupational therapist taught James to use the self-regulation strategy to self-identify problems and solutions and practice adapted tasks. For example, James would often become frustrated when he was unable to open various bottles during his shower. Using a self- regulation strategy, James was able to identify that his current approach to opening a bottle of shampoo was not working and to try a different strategy. If the new strategy did not work, he would be able to reflect on what was different, what worked and what did not, and try something different.
Group-Based Cognitive–Behavioral Therapy and Task-Oriented Training
Starting in Wk 3, James attended a group class 2×/wk for 6 wk via videoconferencing (T. W. Liu et al., 2019). The group was co-led by an occupational therapy assistant trained in CBT techniques and a physical therapy assistant. Each class was 90 min long. The first half of the class was led by the occupational therapy assistant and focused on CBT with the purpose of improving balance self-efficacy. The two main strategies were cognitive restructuring and behavior modification. Cognitive restructuring has four steps, including identification of automatic thoughts. This addresses maladaptive thoughts that can influence a person’s balance performance. Behavior modification strategies include helping participants identify potential risks and develop behavioral strategies to help them increase their activity levels. James discovered that he was somewhat fearful of walking alone because he was often scolded by nursing staff in inpatient rehabilitation whenever he tried to get up and walk on his own. He developed a new mantra, “my legs are strong,” and set a timer on his phone to prompt him to get up every hour and take a walk. The second half of the class was led by the physical therapy assistant and included strengthening and balance exercises in addition to task practice. All exercises and tasks were customized for individual participants and group discussion, and participants were encouraged to reassure one another. For James, there was an additional focus on endurance during balance exercises and strengthening.
Driving Rehabilitation
James attended driving rehabilitation at a local center that had a driving simulator for both testing and driving training (Devos et al., 2009). The system included a life-sized car and surround screens. Scenarios and difficulty settings could be programmed by the occupational therapist, who was a CDRS. James began driving rehabilitation in Wk 3, attending a 1-hr session, 1×/wk, for 8 wk. The CDRS focused on improving James’s confidence behind the wheel, gradually increasing the complexity of driving scenarios and challenging his reaction time. James has weakness on the left side, so the occupational therapist trained James in using a spinner knob attached to the steering wheel. The occupational therapist also included training in the other components of driving, such as starting the car, shifting, and fastening a seatbelt with hemiparesis.
Caregiver: Cognitive–Behavioral Techniques and Problem Solving
At the recommendation of James’s usual occupational therapy practitioner, Juanita began attending the local caregiver stroke support group that met once a month via videoconference. The occupational therapy practitioner also continued to use problem-solving training with Juanita via phone calls. The sessions focused on giving her the strategies to define problems, brainstorm solutions, try solutions, and then reflect on how the solution worked (Pfeiffer et al., 2014). Juanita identified a thought pattern similar to James’s, in that she felt anxious leaving him alone, which contributed to burnout. Juanita and the occupational therapist brainstormed a few solutions, such as reframing her anxious thought with a positive one and practicing breathing techniques to calm her anxiety. Juanita also decided that she and James would keep their cell phones with them at all times in case of an emergency. Juanita scheduled an appointment with a clinical psychologist for additional therapy to address her anxiety and depression related to caregiving.
Outcomes
At the end of 8 wk of outpatient rehabilitation, James met several of his goals. James can shower independently, reducing the burden on Juanita. James and Juanita have had several conversations about Juanita’s caregiver role and worked together to restructure the guest bedroom in their house to be a quiet space for Juanita to do yoga, sew, and have alone time. Additionally, James’s confidence in his ability to walk outside has increased, and he now walks with a friend to the town diner three times a week. This gives Juanita time alone in the house. Because of her problem-solving training, Juanita has noticed that she is more confident in her ability to cope with future problems and worries less about James’s safety. She also practices strategies to reframe her anxious thoughts and to calm herself with relaxation techniques. James and Juanita have started taking their elementary-age grandchildren to a local farm to pick fruit and to fish in a pond to further increase James’s confidence in his mobility on uneven surfaces, such as his garden, and to increase his activity tolerance. James plans to plant a small salad garden next spring. He has started implementing strategies from CIT into meal preparation in the kitchen and using the grill. He still requires some assistance with flipping hamburgers because of tone in his left forearm, limiting supination; however, he reports that he finds the tasks more enjoyable and even agreed to help serve hot dogs at the local high school sports department fundraiser. James has attended two of the past five high school football games and plans to attend some basketball games in the coming season. James is still in driving rehabilitation and plans to take his driving test in 2 mo. He has been practicing driving on short, simple routes with his CDRS. Table 8 summarizes James’s results on discharge outcome measures.
Occupational Therapy Discharge Results for James
Note. COPM = Canadian Occupational Performance Measure; PQRS = Performance Quality Rating Scale.
Strengths and Limitations of the Current Body of Evidence
The current body of evidence has strengths and limitations related to the systematic reviews that informed these practice guidelines. Systematic reviews address specific clinical questions that are guided by an a priori protocol for the question development and review process. No systematic review can address all aspects of a topic; the authors decide what to address before conducting the review. Additionally, no review is perfect, and even the most careful searches sometimes miss articles. The way to reduce these potential sources of bias is to conduct the review using best-practice methodology (see the Appendix).
Strengths
At every step of the process, the review authors followed best-practice methodology to the best of their ability, including getting input at all stages from practitioners, researchers, consumers, and experts in the areas included in the reviews. The clinical recommendations are based on findings from the systematic reviews. It is worth noting that the systematic reviews on which these practice guidelines are based include available research published since the previous reviews (2012–2019), or, in the case of the question regarding caregivers of people with stroke, an even greater period of time because this question had not been addressed in the previous reviews (i.e., 1999–2019). The review questions for the systematic reviews were developed with an intentional focus on occupation-based outcomes. Improvement in these outcomes is the goal of occupational therapy, so the systematic reviews targeted studies reporting occupation-based interventions and outcomes. Additionally, the guidelines provide materials to help practitioners see how the research findings might be translated to the practice setting.
The stroke intervention literature is relatively abundant in the areas of research on ADLs and caregivers of people with stroke. The systematic review for ADL outcomes found numerous and disparate interventions that have a strong level of evidence to improve performance. However, many of these interventions, such as mirror therapy or preparatory methods, are not occupation based. The literature on interventions for caregivers of people with stroke is also rich and has strong evidence, even though the outcome measures are typically impairment based. Although the number of interventions for IADLs and social participation are more limited and, in the case of social participation, have a lower level of evidence, the systematic reviews for IADLs and social participation of the stroke survivor identified important research that will be beneficial in guiding occupational therapy intervention and future research.
Limitations: Gaps in the Evidence
Gaps in knowledge exist when the information in the literature about an intervention is insufficient, imprecise, inconsistent, or biased (Robinson et al., 2011). Gaps also exist when the literature is not sufficient to answer a clinical question.
Lack of research supporting specific interventions does not mean practitioners should not use those interventions. When providing occupational therapy services to clients, practitioners considering specific interventions when there is not enough evidence to support evidence-based practice should use expert knowledge and their own training and experience to guide practice. In this section, we pinpoint important gaps in evidence for interventions and approaches practitioners may consider using, as appropriate.
Occupational therapy practitioners need to think about the elements of evidence-based practice as they evaluate these guidelines, considering gaps in the literature related to their clinical practice. Practitioners should consider the following questions when they identify these gaps (Gutenbrunner & Nugraha, 2020): What evidence exists? What are the best practices associated with providing services to this client population? What interventions are contraindicated for this population? What outcomes am I hoping to achieve with this client? Does evidence exist in another field or discipline related to interventions and desired outcomes that are within the scope of occupational therapy practice? What are my client’s preferences and values? Does my client prefer one intervention over another? Are available resources, cost, or time influencing my client’s preference? How might the intervention I am considering affect my client’s performance patterns and roles? Does my client find the intervention I am considering meaningful? What experience and expertise do I have that can help guide my decisions? What types of interventions have I used previously that were effective with similar clients or populations? What types of interventions have I used previously that were ineffective with similar clients or populations? What potential risks does the intervention I am considering pose to my client or this client population? Will the health care system or organization be supportive of this intervention? How will I document this intervention? How will I document the outcomes associated with this intervention? Is it likely that this intervention will be reimbursed?
The following sections present additional information and common occupational therapy interventions for people with stroke that are not addressed in these guidelines because of a lack of current relevant evidence. These sections are based on existing or emerging evidence, expert opinion, or both.
Gaps in the Literature
Gaps in stroke rehabilitation research with respect to the role of occupational therapy can be attributed to several factors. Some topics have minimal research or lower level evidence (e.g., Level 3b), whereas other topics have stronger evidence (e.g., Level 1b) but only within a specific substroke population. Additional gaps include a lack of research participant diversity, limited use of participation as a primary outcome measure, and a focus on changes in impairment rather than changes in occupational performance. Despite these gaps, occupational therapy practitioners should continue to use comprehensive, client-centered, and functional assessments and interventions and are urged to collaborate with researchers to provide evidence for these important topics.
Occupation-Based Methods
The core of occupational therapy is the therapeutic use of everyday occupations (e.g., ADLs, IADLs, leisure, work) for the purpose of increasing occupational performance, life participation, and quality of life (AOTA, 2020). Thus, it is imperative that occupational therapy practitioners use occupations to evaluate and treat clients poststroke. Legg et al. (2017) performed a systematic review and meta-analysis that showed significant improvements in ADL outcomes through ADL training, whether it be through remediation, adaptation, or assistive technology; however, these studies took place only in the home care setting. Future research is needed to assess occupation-based interventions, such as those targeting ADLs, IADLs, work, and leisure, in other settings such as inpatient, outpatient, and acute care. Furthermore, we encourage occupational therapy practitioners to focus on occupation-based interventions and document those interventions that lead to successful ADL outcomes to further validate the importance of occupation-based interventions and strengthen the occupational therapy profession.
Stroke Research With Diverse Groups
Black, Hispanic, and Indigenous Americans have a higher incidence of stroke than non-Hispanic White or Asian Americans, and women have a higher lifetime risk of stroke than men (Tsao et al., 2022). Racial disparities, gender, and socioeconomic status have been shown to lead to poorer stroke outcomes because of poorer access to good-quality stroke care (Ikeme et al., 2022; Marshall et al., 2015). Studies generally did not examine stroke intervention’s effectiveness with people of different races, ethnicities, genders, and socioeconomic status. This disparity in effective stroke intervention should be addressed in future research. In practice, occupational therapy practitioners must consider the unique social determinants of health that affect clients’ stroke risks and outcomes and take care to perform client-centered evaluations and interventions.
Participation Outcome Measures
As a construct, social participation was generally assessed through a component of a broader assessment tool, such as the 36-item Short Form Survey (SF–36; Hays et al., 1993) or the Stroke Impact Scale (Mulder & Nijland, 2016). Additionally, most assessment tools that include questions related to social participation have a narrow and limited scope. Social participation is multifaceted and includes physical abilities as well as emotional and social considerations; thus, changes in a client’s participation in everyday social activities do not occur rapidly (Tipnis et al., 2023). Occupational therapists are encouraged to assess the social participation of each client who has had a stroke and to consider using more robust measures of social participation, such as the PROMIS® Social Function measures (Cella et al., 2010) or the Assessment of Life Habits (Fougeyrollas et al., 2002). Future research should consider a focus on social participation as a primary outcome and design studies that include appropriate time scales for assessment (≥1 yr pre–post).
Similarly, few stroke caregiver studies included outcome measures of the caregivers’ occupational performance or participation. Most caregiver intervention outcomes were impairment based and measured self-reported burden, strain, or coping (e.g., Caregiving Burden Scale; Elmstahl et al., 1996); depression or anxiety (e.g., Center for Epidemiological Studies–Depression scale (Radloff, 1977); or quality of life (e.g., SF–36; Rand Corporation). A few studies measured caregivers’ knowledge of care techniques and their performance of caregiving skills. For example, Mant et al. (2000, 2005) included the Frenchay Activities Index (Schuling et al., 1993) to determine how the intervention affected caregivers’ social activity level. Given the large number of caregivers of people with stroke, their significance as a stroke team member, and the effect of caregiver performance on the stroke patient’s outcomes, practitioners must consider caregivers’ occupational performance and participation in addition to their caregiving capabilities. Future research should also include outcome measures that determine whether caregiver interventions improve performance and participation in caregiving skills and in caregivers’ valued occupations.
Modifiable Risk Factors: Health Promotion and Prevention
The OTPF–4 (AOTA, 2020) designates health management as an occupation within the domain of practice and defines aspects that should be addressed in intervention, such as social and emotional health promotion, communication with health care providers; physical activity; and management of symptoms, conditions, medications, nutrition, and personal care devices. Occupational therapy practitioners should collaborate with interprofessional teams to assess and treat these components of health management in people with stroke to prevent another stroke, to prevent disabilities or complications resulting from stroke, and to support participation in other occupations (AOTA, 2020; Tsao et al., 2022). Researchers should also consider investigating the efficacy of health promotion and prevention interventions for the performance of the occupations that make up health management.
Visuospatial and Neurobehavioral Impairments Related to ADLs, IADLs, and Social Participation
Occupational therapy practitioners should address stroke clients’ visuospatial (e.g., hemianopsia, diplopia) and neurobehavioral impairments (e.g., ideational apraxia, motor apraxia, neglect) because these impairments can negatively affect occupations, occupational performance, and quality of life (Gillen & Hreha, 2021). They should perform a comprehensive assessment of the client’s abilities, limitations, and functional goals and implement a comprehensive client-centered treatment plan. The minimal research in this area has shown improvements, but findings are limited to gains at the impairment level or consist of low-level research related to ADL outcomes (Gillen, 2009; Gillen & Hreha, 2021). Thus, higher levels of research are needed to address visuospatial and neurobehavioral interventions to improve occupational performance in ADLs, IADLs, leisure, and work.
Additional Implications for Occupational Therapy
To complement the clinical recommendations provided in Tables 1 to 4, the sections that follow describe general implications for occupational therapy with people with stroke and their care partners, based on stroke-related evidence and best-practice occupational therapy principles.
Occupation-Based Assessment and Intervention
Occupational therapy practitioners and researchers should focus on occupation-based rather than impairment-based assessments and interventions. Occupation-based intervention can be integrated into stroke rehabilitation in two ways: occupation as ends or occupation as means. Occupation as ends refers to tasks or activities that a client needs to or wants to perform, for example, practicing dressing so that the client will be able to dress in the morning before work. Occupation as means refers to using occupations to improve client factors or performance skills, such as using the Nintendo Wii to improve eye–hand coordination or hand strength. Occupations are the hallmark of the occupational therapy profession and should be the focus of occupational therapy practitioners and researchers.
Interventions That Clients Perform Outside of Therapy Sessions
For individuals poststroke, the context of activity and repetition are important to recovery, specifically to promote neuroplastic changes (Hara, 2015; Rahayu et al., 2020; Singh et al., 2021), making it critical for occupational therapy practitioners to train clients in therapeutic interventions, such as AO, mirror therapy, or CIT, that can be performed independently outside of formal therapy sessions (i.e., in the home or in the evening in the rehabilitation hospital). These approaches are low cost and easy to administer, provide opportunities for increased practice and neuroplastic changes, and subsequently lead to increased occupational performance.
Remote Service Delivery Models
Interventions performed by telephone or telephone follow-up after discharge were found to have strong or moderate evidence for improving ADLs (Chen et al., 2018; Sit et al., 2016), IADLs (Sit et al., 2016), and social participation (Geng et al., 2019) of people with stroke. Telephone interventions were widely used with caregivers of people with stroke. Much research found strong and moderate levels of evidence for providing telephone interventions and follow-up postdischarge in CBT and problem-solving training, education, and support to caregivers (Bishop et al., 2014; Cheng et al., 2018; Deyhoul et al., 2020; Hartke & King, 2003; King et al., 2012; Kuo et al., 2016; Lincoln et al., 2003; Mant et al., 2000; Perrin et al., 2010; Pfeiffer et al., 2014; Shyu et al., 2008). Occupational therapy practitioners should consider offering interventions that would be appropriate to deliver remotely, such as education or support. This may ease the burden and stress caused by in-person therapy sessions for both the person with stroke who may have multiple impairments and the caregiver who has limited time and energy.
Caregiving as a Co-Occupation
Not only is the caregiver an important stroke team member, but they should also be considered as clients and, consequently, should be a focus of interventions for performing caregiving tasks and maintaining their own occupational participation and quality of life (AOTA, 2020). Research has shown that caregivers who are physically and emotionally well provide better care, resulting in better outcomes for the care recipient who has had a stroke (Bakas et al., 2014). However, studies have found that the time therapists spend with caregivers of people with stroke is short, and the topics addressed are limited (Lawson et al., 2015). Occupational therapy practitioners should be familiar with a variety of caregiver assessments and follow the recommendations for best practice in interventions for caregivers in these Practice Guidelines.
Psychotherapeutic Interventions
CBT, problem-solving therapy, self-management techniques, and empowerment coaching were found to be effective tools in improving ADLs and IADLs in people with stroke and in improving caregivers’ quality of life and ability to perform caregiving tasks (Grant et al., 2002; T. W. Liu et al., 2019; Pfeiffer et al., 2014; Sit et al., 2016; Wang et al., 2018). As with any unfamiliar technique, occupational therapy practitioners should consider seeking additional training to implement them skillfully.
Summary
These Practice Guidelines summarize the current evidence to inform occupational therapy practitioners’ clinical decision making when collaborating on interventions with clients with stroke, their caregivers, and interdisciplinary team members. Included are evidence-based interventions to address occupational performance in ADLs, IADLs, and social participation for clients who have had a stroke and interventions for their caregivers to maintain the caregiving role. On the basis of the findings of the systematic reviews, occupational therapy practitioners have many choices of evidence-based interventions to offer their clients with stroke and their caregivers and on which to collaborate with interprofessional team members. These Practice Guidelines also provide two practical case examples and evigraphs to guide evidence-based decision making and intervention planning. Although much research was found, particularly with respect to ADLs, the Practice Guidelines identify gaps in the research that are based on expert opinion and the evidence.
Occupational therapy practitioners have an integral role to play in all practice settings in which people with stroke are treated, from acute care to community programming. They are unique members of the rehabilitation team because of their holistic consideration of the many factors that influence occupational performance and participation. Practitioners should use the evidence in these Practice Guidelines, along with their professional experience and reasoning and the preferences of the client and family. Delivering evidence-based and innovative care to people with stroke and their caregivers in traditional and nontraditional settings is challenging, but the profession must continue to evolve, with practitioners implementing best practice as evidence changes and advances, to ensure that occupational therapy educational programs prepare future practitioners for best practice, and to grow a body of research grounded in occupation.
Footnotes
*Indicates articles included in the systematic reviews.
Acknowledgments
The authors acknowledge and thank the following individuals for their participation in the content review and development of this publication:
Susan Cahill, PhD, OTR/L, FAOTA, Director of Evidence-Based Practice, American Occupational Therapy Association, North Bethesda, MD
Deborah Lieberman, MHSA, OTR/L, FAOTA, Former Vice President, Practice Improvement, American Occupational Therapy Association, North Bethesda, MD
Elizabeth G. Hunter, PhD, OTR/L, Assistant Professor, Graduate Center for Gerontology, College of Public Health, University of Kentucky, Lexington
Hillary Richardson, MOT, OTR/L, AOTA Practice Manager, Knowledge Translation, Evidence-Based Practice and Practice Improvement, American Occupational Therapy Association, North Bethesda, MD, for her contributions to knowledge translation and evigraph development.
Cindy Downing, Stroke Survivor/Consumer; Sara Kate Frye, OTD, MS, OTR/L, ATP; Glen Gillen, EdD, OTR, FAOTA; Carly Goldberg, MS, OTR/L; Mequeil L. Howard, OTD; Samantha Shea Lemoins, BHS, COTA/L, PhD Candidate; Joshua M. Kotler, OTD, OTR/L, CBIS; Amanda Mack, OTD, MS, OTR/L, CLC; Lauren Winterbottom, MS, OTR/L; Timothy J. Wolf, OTD, PhD, MSCI, OTR/L, FAOTA
Anna Boone, PhD, MOT; Daniel Geller, EdD, MPH, OTR/L; Glen Gillen, EdD, OTR/L, FAOTA; Carly Goldberg, MS, OTR/L; Mary Hildebrand, OTD, OTR/L; Josh Kotler, OTD, OTR/L; Amanda Mack, OTD, MS, OTR/L; Danielle Mahoney, OTD, OTR/L; Dawn Nilsen, EdD, OTR/L, FAOTA; Rachel Proffitt, OTD, OTR/L; Olivia Schaffer, MOT; Madison Strickland, MOT; Lauren Winterbottom, MS, OTR/L; Timothy J. Wolf, PhD, OTD, MSCI, OTR/L, FAOTA; Lea Wood, MOT
Appendix: Overview of the Systematic Review Methods and Findings
The systematic reviews completed for these Practice Guidelines were conducted according to the Cochrane Collaboration methodology (Higgins et al., 2019) and are reported in a manner consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (Moher et al., 2009).
Review Questions
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 (ADLs) for adult stroke survivors? What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve performance and participation in instrumental activities of daily living (IADLs) among adult stroke survivors? What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve the performance of and participation in education, work, volunteering, leisure, and on social participation among adult stroke survivors? What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice for caregivers of people who have had a stroke that facilitate maintaining participation in the caregiver role?
Inclusion and Exclusion Criteria,Databases Searched,and Search Terms
Table A.1 summarizes the search strategies for these systematic reviews. Inclusion criteria were as follows: ▪ Peer-reviewed journal articles ▪ Publication in English (unless review authors were able to translate) ▪ Publication dates as follows: Question 1, January 1, 2012–December 31, 2019; Questions 2–3, January 1, 2009–December 31, 2019; Question 4, January 1, 1999–December 31, 2019 ▪ Levels 1a, 1b, 2a, 2b, and 3a evidence, and Level 3b evidence if no higher-level studies are available (see “Levels of Evidence” section) ▪ Interventions within the scope of occupational therapy practice ▪ Participants who were adults ages >18 yr ▪ Participants after stroke, as well as caregivers of adults with stroke.
Exclusion criteria were as follows: ▪ Dissertations, theses, presentations, and proceedings ▪ Published outside the date range of the reviews ▪ Level 4 or 5 evidence ▪ Interventions outside of scope of occupational therapy practice ▪ Average age of participants <18 yr.
The following databases were searched: ▪ MEDLINE ▪ PsycINFO ▪ CINAHL ▪ OTseeker ▪ Cochrane databases ▪ Hand search as needed.
Levels of Evidence
Each article evaluated in the reviews was assigned a level of evidence using the Oxford Centre for Evidence-Based Medicine (2009) framework: ▪ Level 1a: Systematic review of homogeneous randomized controlled trials (RCTs; e.g., similar population, intervention) with or without meta-analysis ▪ Level 1b: Well-designed individual RCT (not a pilot or feasibility study with a small sample size) ▪ Level 2a: Systematic review of cohort studies ▪ Level 2b: Individual prospective cohort study, low-quality RCT (e.g., <80% follow-up or low number of participants, pilot or feasibility study), ecological study, or two-group nonrandomized study ▪ Level 3a: Systematic review of case–control studies ▪ Level 3b: Individual retrospective case–control study, one-group nonrandomized pretest–posttest study, or cohort study ▪ Level 4: Case series (or low-quality cohort or case–control study) ▪ Level 5: Expert opinion without explicit critical appraisal.
Article Screening and Data Extraction
A medical librarian conducted the searches and removed duplicates; review teams (of at least two authors) independently screened titles and abstracts based on the inclusion criteria. Reviewers resolved any differences by discussion and, if necessary, consultation with a third party (an American Occupational Therapy Association Evidence-Based Program team member) until consensus was reached. The review teams then obtained and reviewed the full-text articles to determine inclusion or exclusion. They extracted data from the included studies in an evidence table that summarized each study’s methods, risk-of-bias evaluation, participants, intervention setting, intervention and control conditions, outcome measures, and results.
Quality of the Evidence and Risk of Bias
Two members of the review teams independently assigned quality ratings to each study and collaborated to reach consensus. The review teams evaluated the risk of bias on the basis of study design (controlled or noncontrolled trial). For studies that included a control group (randomized or nonrandomized), they used the Cochrane tool (Higgins et al., 2016); for noncontrolled trials, they used a tool developed by the National Heart, Lung, and Blood Institute (2014).
Strength of Evidence
Each systematic review team grouped the evidence into themes and determined the strength of the evidence for each theme. The strength-of-evidence designations are outlined in Table A.2 and are based on U.S. Preventive Services Task Force (2018) guidelines. Strength-of-evidence designations are a synthesis of number of studies, level of evidence, quality of evidence (risk of bias), and findings of the studies (e.g., significance). Synthesizing these four elements of the evidence enabled the review authors to determine the level of certainty that the interventions discussed in the articles resulted in the outcomes shown.
Overview of Search Results
The searches located 82,357 citations and abstracts for Questions 1–3 and 2,976 for Question 4. The research methodologist completed the first step of eliminating references on the basis of title, removing duplicates and studies clearly not within the parameters of the review (e.g., date of publication, population, intervention). This step reduced the number of citations to 9,411 (Questions 1–3) and 547 (Question 4), which were given to the review teams.
Teams of two or more reviewers with expertise in the content areas carried out the systematic reviews. The review teams completed the next step of eliminating references on the basis of the abstracts, retrieved the full-text versions of potential articles, and determined final inclusion in the reviews on the basis of the inclusion and exclusion criteria.
A total of 168 studies were included in the systematic reviews—24 Level 1a, 90 Level 1b, and 54 Level 2b studies—and served as the basis for the clinical recommendations. Table A.3 lists the number of articles included in each review and their levels of evidence. (Note that some articles addressed multiple outcomes of interest and are discussed in more than one section of these guidelines.) Citations for the systematic review articles and systematic review briefs are as follows: