Occupational therapy for adults with problems in activities of daily living after stroke

Article Reviews
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Read Full Text: Occupational therapy for adults with problems in activities of daily living after stroke
Journal: Cochrane Database of Systematic Reviews
Year Published: 2017
Ranked 43rd on our 2017-2021 list of the 100 Most Influential OT Journal Articles

Cochrane systematic reviews are considered the pinnacle of health research. So, when they release a review that’s clearly relevant to occupational therapy, we should pay attention.

This week, we’re looking at a Cochrane review of OT’s role in addressing ADL deficits post-stroke.

The review is promising. The authors concluded that when OT focuses on improving ADL function post-stroke, a clear difference can be seen. That said, there is a lot of nuance to their findings, which we’ll discuss. I also took note of a major red flag, so don’t miss my takeaways! :slight_smile:

Let’s dive in.

What background did the authors provide regarding OT and stroke?

I LOVE it when really smart non-OTs describe our profession. And this is exactly what you will find in the opening section.

The authors really emphasize that OT for stroke is a partnership between the therapist and client. This partnership requires working together to identify the main concerns, then using shared decision-making to determine a program plan. (I know you all know this—but it is still a fun section to read!)

Why was this review done?

Mortality rates from stroke continue to improve, which thankfully means we have increasing numbers of stroke survivors. Yet, many of these survivors have marked limitations in their ability to perform ADLs.

Hence, the authors sought to assess the impact of occupational therapy. Specifically, how ADL-related interventions affect the functional ability of adults following stroke.

(For our purposes, it is important to note that this is an update from a 2006 Cochrane review on the same topic.)

What types of studies were included in this review?

For this review, the authors sought out randomized controlled trials (RCTs) that compared OT to no intervention or standard care.

To be included, the participants in the study had to be adults (ages 18 or over) whose medical histories met the clinical definition of stroke.

The intervention in the study had to be an OT intervention related to ADLs—and this had to be reflected in a primary outcome measure. The intervention had to fall under one of the following treatment focuses:

  • Remediating impaired capacity or ability, such as activity-based supports
  • The use of adaptive equipment
  • The use of assistive technology
  • Environmental adaptation

Trials were excluded if:

  • OT was delivered in a nursing home setting, as that was covered in this separate Cochrane review
  • The study included OT as part of a multidisciplinary team approach
  • OT intervention was combined with other interventions (for example OT and brain stimulation)
  • The study was examining specific treatment approaches (for example, cognitive training)

How did they analyze the data?

This is really where you can tell that Cochrane is next level, because they do such a thorough job of data analysis. Not only were the primary outcomes analyzed, along with lots of secondary outcomes, they also dive into the quality of each study.

What were the results?

The authors included 9 studies with 994 participants in their update. (What was super interesting/worrisome was that 8 of them were published prior to 2006.)

What assessments did the studies utilize?

In the 9 studies, a variety of assessments were utilized to track ADL status. The authors also found and tracked multiple secondary outcomes measures in the areas of:

  • Caregiver mood and quality of life
  • Extended ADLs
  • Health-related quality of life
  • Patient mood or distress

Here’s a full list of the assessments, so you can check them out in the OT Potential Assessment Search:

Assessments from ongoing studies:

See all Stroke Assessments

Did OT influence the primary outcomes (ADL status and poor outcomes)?

YES! Participants who received post-stroke occupational therapy were more independent in their ADLs than those who received standard care or no care at all—and they were less likely to experience poor outcomes.

Did OT influence the secondary outcomes?

Participants who received OT were more independent in extended ADLs.

OT did NOT influence mortality rate or their combined metric of death/dependency. It also did not influence patient mood or distress.

Data on both health-related quality of life and caregiver outcomes was insufficient.

What was the quality of the evidence?

Cochrane has very high standards for evidence quality. And, their grade of the evidence in this review was “LOW,” which is not uncommon for rehab studies. Part of the problem was insufficient data reporting. But, the other part is the high risk of bias when the therapist and client are not “blinded” to whether they are delivering/receiving treatment—which, honestly, is just hard to do in rehab.

What did the authors conclude?

The authors concluded that OT does appear to improve performance in ADLs, and it seems to reduce the odds of those abilities deteriorating.

The current data does support the provision of OT—but, due to the low quality of evidence, it is possible that this could be overturned by future research.

They concluded that more high-quality, large, multiple-therapist, RCTs that compare OT to no intervention or standardized care are required. Only by doing this can we firmly establish the clinical effectiveness and cost effectiveness of OT post stroke.

Takeaways for OT Practitioners

(Please note: These are my personal takeaways. They are not mentioned specifically in the article.)

1. You gain what you train.

I LOVE the maxim “you gain what you train” when it comes to stroke rehab. I learned the saying in a past stroke article, and it keeps holding up!

This review showed us again that when OTs provide ADL-specific training, clients make gains in these areas.

And the flip side of this is also true: you cannot expect your therapy to naturally spill over into other areas of clients’ lives, even when the areas seem closely related. For example, this article showed that OT did not influence clients’ moods.

Overall, I think OTs should feel fortified by this article—and inspired to continue forward with our focus on function.

2. It is a major red flag to me that no recent studies qualified for this review!

While this article made me feel edified in our treatment approach, it made me feel worried about the state of OT research.

If ADLs are our bread and butter—and stroke is one of the most common conditions we treat—shouldn’t there be more studies on this? AND, if Cochrane is doing numerous reviews on this topic, can’t we focus some energy on running studies that meet their very clear criteria?

I’m looking forward to digging into big-picture questions like this, as well as practical takeaways for your stroke care, in the comments below!

Here’s the full APA citation for this article:
Legg, L. A., Lewis, S. R., Schofield-Robinson, O. J., Drummond, A., &; Langhorne, P. (2017). Occupational therapy for adults with problems in activities of daily living after stroke. Stroke, 48(11).

What questions/thoughts does this article raise for you?

(Be sure to “like” comments you find helpful below! The person with the most popular comment on 2/20 will win $100! AND, if you give out 50 “likes” this year, YOU will be entered to win $500!)

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This article was was informative, and I appreciated the list of assessments. I agree the lack of no recent studies is a red flag. Finding a therapist to continue treatment after discharge has been a problem in our state.

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I found it interesting that many studies find that they really only tested the effectiveness of one OTP. It would be an interesting to see a study on the effectiveness of a team of OTPs.

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My initial reaction when reading this article is… DUH! We as OTs know that what we do works. It’s all part of motor learning in which specific practice leads to specific results. I wonder if this is why there aren’t many recent studies on this topic. Perhaps because we know this works, we’re not taking the time to study it?

It also makes me wonder, too, if the reason the evidence is rated so low has to do with the exclusion criteria for the study. For example, studies were excluded if OT was completed as part of a multidisciplinary approach, and we rarely treat patients without the help of other disciplines. So when you take out studies like that, it doesn’t leave us many studies to analyze.

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Reading this article, I feel like this is a call to action for myself (a new OTR) and my peer group of new graduates. This article highlights for me just how important research, and keeping an open mind about my potential role in that research, is for the future of our profession. I have wondered if the push to OTD is in part to support research.

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I’m so glad you liked the assessment list- gathering assessments for our Assessment Search is a passion project of ours!

That is so interesting/worrisome to hear about the shortage of neuro OTs in your state. Is it largely a shortage in outpatient therapists? Steve and I touch on this in our podcast episode for next week. It worries me that there are not enough OT to treat one of the most common conditions!

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Yes!!! I also took this article as a major call to action!!

I think your point about the OTD is interesting, because I think the aim is to have more OTs prepared to conduct and integrate research- but based on this review, we haven’t seen the fruition of that yet! I’m certainly not an expert in this area- and would be curious to hear other people’s thoughts…

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Ha! I liked this reaction! We do know this works because we see it everyday! But on the other hand, we are also totally prone to bias- and I think our patients and fellow healthcare providers deserve to see solid evidence behind our mainstay treatments. I keep wondering who I can reach out to this week to better understand the lack of evidence here. Maybe you are right @amanda32 - it is taken for granted and not studied? Wondering if @satvika or any other members have any insight or have a connection I could talk to?

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Two thoughts come into my mind after reading this article-
The first is a bit of disappointment that there wasn’t a positive impact on the secondary outcome of increased mood… I would have loved to see that as clients improve in their ADL/self-care independence that they would then have an increase in positive mood…plus our emphasis on holistic care/treating the whole person/therapeutic use of self, and hopefully identifying what was meaningful to the client and incorporating that into treatment should also ideally have an impact on positive outcomes on mood. Perhaps the strong incidence toward depression following CVA may blunt the positive effects??
My second thought is an ongoing concern for me and it is- How can we better connect front-line OT’s working in the field with academic institutions to produce high-quality research. This is so true across all of our practice settings. I would love to see increased partnerships between OT educational programs and clinical practitioners coming together to work on creating a substantial research base for the future of our profession! Stepping off my soapbox now, LOL!

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Unfortunately as long as research standards continue to be identified by the current structure we will continue to be biased/“weak” research. There needs to be a way to isolate and randomize what we assess….which are usually intangible/subjective. The “stronger” research is tangible like research related to physical body, etc.

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I also wonder why patient mood or distress factor did not see a positive change with functional gains? May be it has to do with remediation of function or if the improvement was a result of compensatory training?

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This is SUCH a good point, @krystina! Clearly the traditional research standards favor interventions like medication- where you can truly blind people to whether they are receiving a placebo. (Related: I get so frustrated when rehab is referred to “alternative” or “non-pharmacological” interventions, which again centralizes and favors medications.)

I’d love to have someone on the podcast to talk about what types of research are better suited for interventions like ours. And, how we can help change the “rules of the game” so that therapy interventions have more of an equal playing field in research.

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Agree with all that you stated. Thanks

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Very well identified and stated. So so true. More research has to be done on ‘research tools’ I guess to be able to address research on non physical entities, the not so tangible areas of OT intervention.

Thank you

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@Pollywallace “How can we better connect front-line OT’s working in the field with academic institutions to produce high-quality research”?
This has been such a frustrating situation for me. As a clinician, I used to partner with our local OT program for student research projects. But now as a faculty, it is extremely difficult to get all the front-line clinicians onboard for research projects. The current situation and busy schedules make it extremely difficult to obtain answers/surveys back from area clinicians. There is definitely a disconnect between academia and clinical work. I wish we could work together to produce quality research on important OT topics.
@rashmi It could be the deep depression many stroke victims suffer from that does not allow them to experience any positive changes. We had seen this finding in another article we discussed in the OT Potential club.
@amanda32 I agree with you that we rarely treat patients without the help of other disciplines. And that is what makes it more difficult to tease out if the patient improved due to OT or other approaches. It is a tough situation.

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Could you reach out to Glen Gillen? He is an authority on stroke and has many published articles/books.

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