Documente Academic
Documente Profesional
Documente Cultură
Nancy K. Latham,
Diane U. Jette,
Wendy Coster,
Lorie Richards,
Randall J. Smout,
Roberta A. James,
Julie Gassaway,
Susan D. Horn
OBJECTIVE. To prospectively monitor occupational therapy activities and intervention techniques used during inpatient stroke rehabilitation in order to provide a description of current clinical practice.
METHODS. Data were collected prospectively from 954 clients with stroke receiving occupational therapy
from six U.S. rehabilitation hospitals. Descriptive statistics summarized frequency, intensity, and duration of
occupational therapy sessions; proportion of time spent in 16 therapeutic activities; and proportion of those
activities that included any of 31 interventions.
RESULTS. Clients received on average 11.8 days (SD = 7.2) of occupational therapy, with each session lasting on average 39.4 min (SD = 16.9). Upper-extremity control (22.9% of treatment time) and dressing (14.2%
of treatment time) were the most frequently provided activities. Interventions provided most frequently during
upper-extremity control activities were strengthening, motor learning, and postural awareness.
CONCLUSION. Occupational therapy provided reflected an integration of treatment approaches. Upperextremity control and basic activities of daily living were the most frequent activities. A small proportion of sessions addressed community integration.
Latham, N. K., Jette, D. U., Coster, W., Richards, L., Smout, R. J., James, R. A., Gassaway, J., & Horn, S. D. (2006).
Occupational therapy activities and intervention techniques for clients with stroke in six rehabilitation hospitals.
American Journal of Occupational Therapy, 60, 369378.
troke is the third largest cause of death and one of the leading causes of longterm disability in the United States (Centers for Disease Control and
Prevention, 2000). Significant progress has been made in stroke care over the past
30 years and as a result the proportion of people who survive a stroke has increased
(Centers for Disease Control and Prevention, 2000). It is now well established that
differences in post-stroke care and rehabilitation have a significant effect on outcome, with one systematic review finding that clients who received organized inpatient care in a stroke unit were more likely to be alive, independent, and living at
home 1 year after the stroke (Stroke Unit Trialists Collaboration, 2003). However,
despite evidence that post-stroke care influences outcomes, the ideal activities or
approaches to treatment that should be included in stroke rehabilitation are still
not well established (Wade & de Jong, 2000).
Occupational therapists play an important role in post-stroke rehabilitation.
The National Board for Certification in Occupational Therapy (NBCOT) Practice
Analysis reported that cerebrovascular accident was the most frequent diagnosis
seen by their survey respondents (NBCOT, 2004). Several recent systematic
reviews suggest that occupational therapy after a stroke improves the performance
of some functional tasks and reduces some impairments (Ma & Trombly, 2002;
Steultjens et al., 2003; Trombly & Ma, 2002). However, most trials provide few
details about the range of occupational therapy interventions and activities that
were used across the rehabilitation episode.
Few observational studies exist that describe the nature of occupational therapy interventions currently being used for stroke rehabilitation in the United States.
Most studies to date have been conducted in countries outside the United States
(Alexander, Bugge, & Hagen, 2001; Ballinger, Ashburn, Low, & Roderick, 1999;
369
Methods
Subjects
Age (years)
Mean
SD
Range
Gender % (n)
Male
Female
Race % (n)
White
African American
Asian
Other or unknown
Impairment % (n)
Left hemiplegia
Right hemiplegia
Bilateral involvement
Other
Characteristic
N = 954
66
14
1895
51
49
(487)
(467)
57.2 (546)
24.0 (229)
4.9 (47)
13.9 (132)
43.6 (416)
43.6 (416)
10.1 (96)
2.7 (26)
Oc c u p a t i on a l T h e r a p y R e h a b i l i t a t i o n A ct i vi t i e s
Duration of Activity
Interventions
ISIS [International Severity Information Systems], Inc., 2003. Reprinted with permission.
Data Analysis
Descriptive statistics were used to examine characteristics of
clients and characteristics of their episodes of care including
length of stay, number of days occupational therapy was
provided, number of occupational therapy sessions per day,
and intensity of occupational therapy (defined as the number of days occupational therapy was provided divided by
the total length of stay). The content of treatment sessions
372
Results
The mean length of stay for the episode of care was 18.8
days (SD = 10.3, range = 175; see Table 2). Clients
received occupational therapy, on average, 11.8 days (SD =
7.2, range = 153) during an episode of care. On days that
the clients received occupational therapy, the average number of occupational therapy sessions per day was 1.6 (SD =
0.4, range = 13), and the average time for each session was
39.4 min (SD = 16.9, range = 5240).
Seventy percent of the sessions were provided by occupational therapists, 33% by occupational therapy assistants
or aides, and 7% by students. The vast majority of the sessions (91%) were provided one-on-one by an occupational
therapy provider. Only 5% of sessions consisted of cotreatment with another discipline, and in only 11% of sessions
Episodes
N = 954
18.8
10.3
175
11.8
7.2
153
1.6
0.4
13
0.64
0.19
0.021.0
22.9
14.2
10.8
9.0
7.1
6.2
6.1
4.6
4.5
3.2
2.8
2.6
2.0
1.9
0.8
0.8
did a group session occur (i.e., more than one client was
treated by a single provider). See Table 3.
More than 94% of clients had some form of examination or evaluation time recorded, and approximately 7% of
sessions included only examination or evaluation. Table 2
gives the percentage time clients spent in each occupational therapy activity. Upper-extremity control (22.9% of total
treatment time) and dressing activities (14.2% of total treatment time) were the most frequently used activities, with
examination or evaluation (10.8%) and pre-functional
activities (9%), the third and fourth most common activities (see Table 3). Upper-extremity control activities were
defined as the training or facilitation of normal movement,
strength, range of movement, or alignment in the upper
extremity. Dressing activities were defined as selecting
appropriate clothing and accessories, obtaining clothing
from storage area, dressing and undressing in a sequential
fashion, and fastening and adjusting clothing, shoes, or personal devices. Pre-functional activities were described as
activities that were related to or provided preparation for
functional activities.
Table 4 provides data on the types of interventions that
occupational therapy providers used in each therapeutic
activity with their patients. Of a total of 24 types of direct
interventions from which providers could choose, 19 interventions were used during at least 5% of the sessions for one
or more of the therapeutic activities. All seven educational
or equipment provision interventions were used during 5%
of sessions for any activity. A wheelchair was the only device
used during at least 5% of sessions for any activity. Only
6.5% of patients used a wheelchair during at least one session and it was used primarily in transfer and wheelchair
management activities.
Sessions
N = 18,359
39.4
16.9
5240
10.8 (1,992)
5
70
32
7
9
(1,006)
(12,943)
(5,838)
(1,234)
(1,629)
5.6
33.3
16.1
5.5
2.3
373
Bathing
Dressing
Grooming
Toileting
Eating
Transfers
Bed Mobility
Functional Mobility
Home Management
Community Integration
Leisure Performance
Upper-Extremity
Control
Wheelchair
Management
Sitting Balance
Neuromuscular
Balance training
Postural awareness
Motor learning
PNF
NDT
Constraint induced therapy
37.6
41.0
42.0
2.6
16.1
1.8
60.5
64.0
43.7
5.7
19.3
3.6
66.1
64.5
54.3
5.4
18.5
3.2
62.0
67.9
56.8
7.4
24.6
3.3
66.6
64.7
49.6
4.4
22.7
3.8
27.5
48.3
45.5
5.9
14.3
1.6
76.7
71.2
51.4
1.6
26.5
2.5
73.5
73.9
57.1
1.6
28.6
2.2
74.8
61.4
45.3
2.3
19.2
3.1
49.0
43.4
37.5
1.9
15.0
2.7
27.8
27.2
24.1
0.8
9.8
1.8
52.4
43.9
39.8
0.3
27.5
1.7
38.7
42.3
51.4
5.4
31.7
4.1
49.7
52.6
55.0
3.3
43.6
2.9
68.9
87.0
46.8
11.8
47.3
2.9
44.5
44.7
42.6
3.6
19.1
2.7
Adaptive/Compensatory
One-handed skills
Energy conservation
Environmental adaptation
Adaptive equipment
17.1
4.7
5.7
6.9
37.2
16.3
28.1
28.2
48.8
11.2
14.5
16.7
47.4
12.7
11.3
11.7
28.9
12.8
28.6
27.2
40.8
10.0
12.7
12.5
29.7
5.5
15.8
18.7
40.7
7.1
16.1
16.8
16.2
8.5
13.7
12.3
13.6
17.7
18.2
13.0
7.5
9.3
13.1
6.1
14.6
4.7
10.3
10.0
17.8
4.4
7.1
8.3
30.7
6.7
20.5
29.2
30.0
5.6
4.8
6.0
23.6
7.0
10.5
10.6
Musculoskeletal
Strengthening
Mobilization/Manual therapy
Passive Range of Motion (ROM)
Edema control
Aerobic exercise
30.5
9.4
23.8
3.1
3.9
17.3
3.2
6.4
1.1
2.7
22.9
4.6
9.4
1.1
2.5
18.8
4.9
9.6
1.4
3.0
22.2
9.7
12.5
3.5
2.6
14.3
3.8
7.4
1.0
1.8
36.6
12.4
22.9
5.5
3.0
37.9
9.4
24.2
4.2
3.4
45.6
9.3
18.6
2.4
5.1
28.0
4.5
8.2
1.5
3.5
12.1
2.3
5.0
0.4
2.4
47.9
5.3
29.8
1.2
3.2
53.7
16.5
42.5
7.5
3.7
35.7
20.1
27.0
8.7
7.4
47.2
12.6
32.7
3.5
3.4
31.5
7.7
19.4
3.3
2.8
Cognitive/Perceptual/Sensory
Cognitive therapy
Perceptual training
Visual training
Sensory training
47.7
34.8
24.7
8.0
44.6
23.4
8.4
3.1
44.5
29.1
11.3
5.1
49.3
34.2
14.9
5.5
43.1
27.0
11.6
4.4
63.0
40.6
19.6
7.2
30.8
23.7
9.6
5.4
35.7
22.7
13.0
4.6
34.3
21.8
11.4
4.8
43.6
21.7
12.0
3.8
38.8
24.0
14.3
3.4
45.6
25.6
14.6
2.9
27.5
18.8
10.2
8.0
42.1
34.5
15.1
8.7
37.4
24.1
10.6
5.0
34.9
22.5
11.1
5.6
4.0
2.3
2.4
1.3
3.3
1.1
1.6
0.7
0.7
1.2
0.8
0.3
0.6
1.2
1.2
0.3
2.8
1.5
2.5
1.0
0.6
2.8
1.6
0
2.5
1.3
2.5
0.3
1.4
0.8
2.4
0
1.6
0.8
1.5
0.6
1.0
0.7
1.5
0.4
1.0
0.9
2.0
0.4
0
0
2.0
0
1.5
1.7
2.1
0.5
2.4
2.4
4.9
1.3
0.8
1.0
1.3
0.1
1.6
1.2
1.5
0.4
34.0
10.6
0.9
30.7
12.7
0.4
27.3 27.7
4.9
4.5
0.26 0.3
34.0
14.0
0.6
25.8
8.0
2.1
44.2
12.8
0.5
42.6
9.5
0.8
40.6
8.3
0.3
43.7
10.8
0.4
60.4
19.2
0.5
43.1
4.7
0.2
34.9
7.6
0.2
60.4
11.1
1.6
36.1
4.1
0.1
30.8
7.9
0.4
3.2
7.0
9.1
1.6
16.5
16.1
6.4
2.1
2.9
2.7
4.5
26.7
2.4
4.6
Activity
Pre-Functional
Interventions
Equipment
Prescription
Application
Fabrication
Ordering
Educational
Client education
Caregiver education
Staff education
Devices Used
Wheelchair
6.6
5.8
Sessions include more than one activity. bPercentages <5% not reported. Note. PNF = proprioceptive neuromuscular facilitation; NDT = neurodevelopmental treatment.
(42.5% of sessions), and postural awareness (42.3% of sessions). In all the sessions that addressed dressing activities,
the interventions most frequently provided were balance
(included in 66.1% of sessions for dressing activities), postural awareness (64.5% of sessions), motor learning (54.3%
of sessions), one-handed skills (48.8% of sessions), and cognitive therapy (44.5% of sessions). These data probably
reflect the large emphasis placed on regaining sensorimotor
skills in this population.
A total of 40.2% of therapy time was spent on direct
practice of daily life activities, the majority of this time
(28.1%) in basic ADL. Clients engaged in the more complex activities of leisure performance, home management,
or community integration 12.1% of the time. During
July/August 2006, Volume 60, Number 4
Discussion
In this descriptive study of occupational therapy provided
to clients during stroke rehabilitation, about 40% of the
occupational therapy provided directly targeted life activities (i.e., ADL and IADL), whereas half of the therapy time
targeted body function and structure or motor skills that are
presumed to underlie functional limitations post-stroke.
Upper-extremity tasks and dressing were the most frequently provided activities, and accounted for almost half of
the treatment that clients received. Evaluation or examination activities also composed a significant proportion (10%)
of occupational therapy time. In 6% of patients, no evaluation or examination session was documented. It is probable
that in many of these cases the therapist did do an evaluation, but the time devoted to this was included under each
activity (i.e., a dressing evaluation was recorded under dressing instead of examination or evaluation).
When types of activities were compared, there was
clearly a greater emphasis on basic ADL, such as dressing,
grooming, eating, and toileting than on IADL, such as
home maintenance, or on community integration and
leisure performance. This focus on more basic activities
probably reflects the fact that therapy was taking place in a
hospital setting with clients who were still in the early rehabilitation phase. In addition, the average length of stay was
less than 3 weeks, which could limit the time that is available for more advanced activities. It is interesting to note
that, in the Practice Analysis, 65% of therapists reported
that dressing was the focus of intervention for more than
25% of their clients (NBCOT, 2004). This percentage was
among the five most frequent interventions listed in that
analysis, which covered all practice areas.
Occupational therapists reported using a variety of
interventions to enable each activity. The most commonly
used interventions were neuromuscular interventions, especially balance training, postural awareness, and motor learning; however, adaptive approaches, such as teaching onehanded skills for ADL tasks, were also reported frequently.
The therapists were clearly selective in the interventions
that they chose to use with each activity, because there was
variation in the interventions that were used in each activity. For example, whereas strengthening was used overall in
31.5% of sessions, it was used in more than half (53.7%) of
upper-extremity activity sessions but in less than 1/5 (17%)
The American Journal of Occupational Therapy
Conclusion
Occupational therapy provided to clients with stroke at inpatient rehabilitation facilities reflected an integration of
multiple treatment approaches to facilitate performance of
daily activities. The greatest emphasis was on increasing
upper-extremity control and improving performance of
basic ADL. Most occupational therapy was provided on an
individual basis, for an average duration of about 40 min
per session, across an average hospital stay of less than 3
weeks. A small proportion of therapy time was spent on
leisure and community integration, suggesting the need for
occupational therapy services after discharge that address
these activities.
July/August 2006, Volume 60, Number 4
Acknowledgments
Funding for this project was provided by: The National
Institute on Disability & Rehabilitation Research (NIDRR)
Grant # H133B990005 establishing the Rehabilitation
Research and Training Center on Medical Rehabilitation
Outcomes at Sargent College in Boston, Massachusetts,
with subcontracts to the Institute for Clinical Outcome
Studies in Salt Lake City, Utah; and the NRH Center for
Health & Disability Research at the National Rehabilitation Hospital and the MedStar Research Institute in
Washington, DC; the U.S. Army & Materiel Command
(Cooperative Agreement Award # DAMD17-02-2-0032)
establishing the NRH Neuroscience Research Center at the
National Rehabilitation Hospital in Washington, DC; the
Boston University Aging Research Center; and resources at
the North Florida/South Georgia VA Medical Center,
Gainesville, Florida.
The authors wish to acknowledge the role and contributions of the occupational therapists, occupational therapy
assistants, patients, and staff at each of the participating sites
in the Post Stroke Rehabilitation Outcomes Project. In particular, the authors wish to acknowledge the contributions
of: Alan Jette (Director, Health and Disability Research
Institute, Boston University); Brendan Conroy, MD (Stroke
Recovery Program, National Rehabilitation Hospital,
Washington, DC); Richard Zorowitz, MD (Department of
Rehabilitation Medicine, University of Pennsylvania
Medical Center, Philadelphia, Pennsylvania); David Ryser,
MD (Rehabilitation Department, LDS Hospital, Salt Lake
City, Utah); Jeffrey Teraoka, MD (Division of Physical
Medicine & Rehabilitation, Stanford University, Palo Alto,
California); Frank Wong, MD, and LeeAnn Sims, RN
(Rehabilitation Institute of Oregon, Legacy Health Systems,
Portland, Oregon); and Murray Brandstater, MD (Loma
Linda University Medical Center, Loma Linda, California).
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