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Research Article  |   July 2011
Rehabilitation, Disability, and Participation Research: Are Occupational Therapy Researchers Addressing Cognitive Rehabilitation After Stroke?
Author Affiliations
  • Timothy J. Wolf, OTD, MSCI, OTR/L, is Assistant Professor, Program in Occupational Therapy and Department of Neurology, Washington University School of Medicine, St. Louis, MO 63108; wolft@wustl.edu
Article Information
Neurologic Conditions / Rehabilitation, Participation, and Disability / Stroke / Departments / Centennial Vision
Research Article   |   July 2011
Rehabilitation, Disability, and Participation Research: Are Occupational Therapy Researchers Addressing Cognitive Rehabilitation After Stroke?
American Journal of Occupational Therapy, July/August 2011, Vol. 65, e46-e59. doi:10.5014/ajot.2011.002089
American Journal of Occupational Therapy, July/August 2011, Vol. 65, e46-e59. doi:10.5014/ajot.2011.002089
Abstract

I reviewed articles published in the American Journal of Occupational Therapy (AJOT) in 2009 and 2010 to assess (1) whether research was published in the practice area of rehabilitation, disability, and participation and (2) the evidence being produced in an underdeveloped subcategory of this practice area: cognitive rehabilitation after stroke. The review revealed one intervention effectiveness study that addressed cognitive rehabilitation poststroke published in the 2-year period. Further analysis of outside repositories of evidence in this area revealed that although some evidence supports rehabilitation approaches for people with cognitive dysfunction after a stroke, little research has been devoted to this practice area. The poststroke cognitive intervention approaches in use have been shown to have little or no effect on improving everyday life activity. Occupational therapy has a key research and practice role with the poststroke population, and occupational therapists should be at the forefront in developing the science to support the effectiveness of their services.

Akey component of the American Occupational Therapy Association’s (AOTA’s) Centennial Vision is the desire to be an “evidence-based profession” by 2017 (AOTA, 2007). This desire is not unique to occupational therapy and is, in fact, a major focus of the national health care community. The U.S. Congress asked the Institute of Medicine to establish a list of comparative effectiveness research questions that need to be answered to improve health care quality for all Americans (Committee on Comparative Effectiveness Research Prioritization, Board on Health Care Services, 2009). If, as a profession, occupational therapy is to meet the goal of being evidence based, the occupational therapy scientific community must place a concentrated effort on conducting comparative effectiveness studies to produce evidence to support practice. Although most of this work falls on the occupational therapy scientific community, success in achieving the goal to be evidence based will also require each occupational therapy practitioner to contribute his or her part. The production of evidence to support occupational therapy services is only truly effective when practitioners integrate evidence into their practice. The role that the American Journal of Occupational Therapy (AJOT) plays in this process is the evaluation of the quality of evidence produced in all areas of occupational therapy practice and the dissemination of this evidence in an effective manner to practitioners.
As part of the development process related to the Centennial Vision, occupational therapy practice was categorized into six broad areas of practice: (1) children and youth; (2) health and wellness; (3) mental health; (4) productive aging; (5) work and industry; and (6) rehabilitation, disability, and participation. The rehabilitation, disability, and participation category arguably represents the largest area of occupational therapy practice; it is focused on helping people with any illness, injury, or deficit in occupational performance that is not specified in the other practice areas improve their participation in everyday life activities. This practice area includes people with Alzheimer’s disease, traumatic brain injury (TBI), chronic pain, multiple sclerosis, spinal cord injury, Parkinson’s disease, and stroke; it also encompasses driving and community mobility for older adults. This short list involves some of the largest populations with which occupational therapists and occupational therapy assistants work, and it by no means encompasses all conditions addressed in this area of practice. The breadth of this practice area makes it critical to evaluate the research evidence produced to determine which populations and practice methods are adequately addressed and which require more attention. Therefore, the purpose of the review described in this article was twofold: (1) to summarize and evaluate the rehabilitation, disability, and participation research published AJOT in 2009 and 2010 and (2) to synthesize and review the evidence being produced in an underdeveloped subcategory of rehabilitation, disability, and participation practice: cognitive rehabilitation poststroke.
Rehabilitation, Disability, and Participation Research Published in AJOT: 2009 and 2010
In 2009 and 2010, AJOT published 58 articles that addressed the practice area of rehabilitation, disability, and participation: 20 studies (34.5%) were effectiveness studies that evaluated some form of intervention; 5 studies (8.6%) were efficiency studies evaluating aspects of practice other than effectiveness (e.g., cost and time efficiency, patient satisfaction, adherence); 16 studies (27.6%) were basic research examining a specific clinical phenomenon; 15 studies (25.9%) described instrument development and testing; and 2 studies (3.4%) examined the link between occupational engagement and health. The fact that effectiveness studies represented the largest percentage of the rehabilitation, disability, and participation literature published in AJOT in 2009 and 2010 is a positive sign that occupational therapy researchers are addressing the goal of being evidence based, given that effectiveness studies are the most critical for developing evidence.
AJOT uses the following system to classify effectiveness studies into levels of evidence (Lieberman & Scheer, 2002): Level I—systematic reviews, meta-analyses, and randomized controlled trials; Level II—two-group, nonrandomized studies (e.g., case control); Level III—one-group, nonrandomized studies (e.g., pretest–posttest design); Level IV—descriptive studies (e.g., case series design); and Level V—case reports and expert opinion. Level I is considered the highest level of evidence in this classification. The 20 effectiveness studies reviewed for this article are summarized in Table 1.
Table 1.
Summary of Effectiveness Studies Addressing Rehabilitation, Disability, and Participation Published in the American Journal of Occupational Therapy, 2009 and 2010
Summary of Effectiveness Studies Addressing Rehabilitation, Disability, and Participation Published in the American Journal of Occupational Therapy, 2009 and 2010×
Author/YearLevel of EvidenceContent AreaSampleMethodsOutcomes
Carver (2009) V
  • TBI
  • Intermittent self-catheterization (ISC)
  • Treatment with assistive technology
Inpatient rehabilitation patient with TBI (n = 1)
  • Case study
  • Goal was to improve independence with ISC through construction and use of splint.
  • Function
  • Improved independence with ISC
Earley, Herlache, & Skelton (2010) V
  • Stroke
  • Upper-extremity dysfunction
  • mCIMT
Chronic stroke patient 4 years post-CVA (n = 1)
  • Case study with pre–post assessment
  • Patient received mCIMT with home exercise program (4 weeks).
  • Impairment
  • Improved ROM, MMT, pinch/grip
  • Function
  • Improved self-rating of IADL performance
Fong & Howie (2009) II
  • ABI
  • Cognitive dysfunction
  • Problem-solving treatment
Outpatient rehabilitation patients in Hong Kong with moderate ABI (n = 33)
  • RCT with matched pairs (2 groups)
  • Both groups received cognitive training program.
  • Treatment group (n = 16) received additional problem-solving training.
  • Impairment
  • Improved total score and score on one subtest of metacomponents and executive function
  • Function
  • No significant differences
Giuffrida, Demery, Reyes, Lebowitz, & Hanlon (2009) II
  • TBI
  • Cognitive dysfunction
  • Effect of different practice schedules on improving function
Patients with chronic cognitive impairment after TBI (n = 6)
  • Case control
  • All participants completed 3 tasks: touch typing, 5- to 6-digit sequence typing, and subway schedule task.
  • Patients were assigned to random practice (n = 3) or blocked ordered practice (n = 3).
  • Impairment
  • Improvements in all groups from baseline performance, retained over 2 weeks
  • Transfer of learning to another task demonstrated by random practice group
Goverover, Arango-Lasprilla, Hilary, Chiaravalloti, & DeLuca (2009) II
  • TBI
  • Cognitive dysfunction
  • Use of spacing effect to improve learning and memory
Patients with TBI documented by CT or MRI (n =10) and healthy controls (n = 15)
  • Case control
  • All groups completed both a paragraph and a route-learning task.
  • Within groups, patients were split into either spaced or massed learning groups.
  • Impairment
  • In both groups, better results from spaced learning than from massed practice
  • No significant difference between TBI and control group
Goverover, Chiaravalloti, & DeLuca (2010) II
  • TBI
  • Cognitive dysfunction
  • Use of self-generated vs. directed strategies
Patients with TBI documented by CT or MRI (n = 10) and healthy controls (n = 15)
  • Case control
  • All groups completed 2 meal preparation tasks and 2 financial management tasks. One task for each condition was completed using provided instructions, and the other task was completed using self-generated instructions.
  • Impairment
  • In both groups, better results from self-generated learning than from directed learning
  • No significant difference between TBI and control groups
Hall, Lee, Page, Rosenwax, & Lee (2010) I
  • Hand injury
  • Extensor tendon repair (ETR)
  • Comparison of 3 postoperative treatment protocols
Hospital-based outpatient hand clinic patients with ETR (n = 18) with 24 total injured fingers
  • RCT (3 groups)
  • All participants were assessed 3, 6, and 12 wk posttreatment.
  • Patients were assigned to immobilization (n = 4), early passive motion (n = 5), or early active motion (n = 9) treatment groups.
  • Impairment
  • Across all time points, improvement in all groups
  • Greatest treatment effect with early active motion protocol
Hardy et al. (2010) IV
  • Stroke
  • UE spasticity
  • Treatment study combining 2 existing protocols
Outpatient clinic patients (n = 2) with chronic stroke (>6 months post-CVA) and documented UE spasticity
  • Case study with pre–post assessment
  • Treatment combined UE bracing with electrical stimulation in a functional training program.
  • Impairment
  • Decreased spasticity
  • Function
  • Improved motor function
  • Improvements retained at 3 mo posttreatment
Hayner, Gibson, & Giles (2010) I
  • Stroke
  • Upper extremity dysfunction
  • CIMT
Community-dwelling people with chronic stroke symptoms (>6 months post-CVA; n = 12)
  • RCT (2 groups)
  • Groups were stratified by more or less impaired.
  • Treatment group (n = 6) received CIMT protocol.
  • Control group (n = 6) received bilateral treatment protocol.
  • Function
  • Improved self-rating of performance and satisfaction in both groups
  • Therapeutic improvement a factor of treatment intensity and not related to protocol followed
Hermann et al. (2010) V
  • Stroke
  • ADL limitations
  • Telerehabilitation and task-specific training
Community-dwelling patient with chronic stroke (>3 years post-CVA; n = 1)
  • Case study with pre–post assessment
  • Patients were treated with telerehabilitation protocol to improve ADLs (4 weeks).
  • Impairment
  • Improved UE movement
  • Function
  • Improved motor function
  • Improved self-rating of performance and satisfaction
Jack & Estes (2010) IV
  • Arthritis
  • Lupus related
  • Evaluation of a different intervention approach
Orthopedic outpatient clinic patient with lupus-related arthritis (n = 1)
  • Case study with pre–post assessment
  • Patients received treatment using the occupational adaptation model.
  • Function
  • Improved performance on all functional tasks addressed in treatment
Kim & Colantonio (2010) I
  • TBI
  • Postacute rehabilitation intervention
  • Improvement in community reintegration outcomes
10 research articles from 1990 to 2007 related to improving community reintegration post-TBI
  • Systematic review
  • Goal was to identify evidence to support postacute rehabilitation intervention approaches that address community reintegration.
  • Seven articles provided this evidence.
  • Benefits of postacute TBI rehabilitation programs to improve community reintegration supported by 7 of 10 articles
  • Occupational therapy or occupational therapy interventions involved in all studies
McClure, McClure, Day, & Brufsky (2010) I
  • Breast cancer–related lymphedema (BCRL)
  • Evaluation of a recovery program to improve physical and emotional symptoms
Community-setting patients with BCRL recruited from local hospitals, clinics, and events (n = 32)
  • RCT (2 groups)
  • Treatment group (n = 16) was treated with breast cancer recovery program emphasizing exercise and relaxation. Control group (n = 16) received standard care.
  • Impairment
  • Significantly improved bioimpedance, flexibility, mood, and weight loss in treatment group compared with controls
  • Function
  • Significantly improved quality of life in treatment group compared with controls
Nilsen, Gillen, & Gordon (2010) I
  • Stroke
  • UE dysfunction
  • Use of mental practice to improve recovery
15 research articles published between 1985 and 2009 focused on using mental practice as part of a stroke rehabilitation intervention
  • Systematic review
  • Goal was to determine whether using mental practice is effective in improving UE recovery poststroke.
  • Impairment
  • Support by most articles for mental practice as effective in reducing impairment and improving function of affected UE
  • Generalizability of findings limited by the mostly heterogeneous study populations
Preissner (2010) V
  • Stroke
  • Cognitive dysfunction
  • Use of the task-oriented approach to improve ADL function
Inpatient rehabilitation setting stroke patient with motor and cognitive dysfunction (n = 1)
  • Case study with pre–post assessment
  • Patients were treated with the task-oriented approach.
  • Function
  • Improved self-care performance after treatment
Rand, Weiss, & Katz (2009) III
  • Stroke
  • Cognitive dysfunction
  • Evaluation of a multitasking intervention protocol
Community-dwelling people poststroke with executive function deficits (n = 4)
  • Pre–post assessment
  • Patients were treated using VMall, a virtual supermarket, to improve multitasking.
  • Impairment
  • Improvements on performance-based assessment of executive function
Rowe, Blanton, & Wolf (2009) IV
  • Stroke
  • UE dysfunction
  • Constraint-induced movement therapy
Community-dwelling person with chronic stroke (5 yr post-CVA; n = 1)
  • Case study with pre–post and longitudinal assessment
  • Patients received 2 wk of CIMT treatment.
  • Impairment
  • Improved motor performance
  • Function
  • Improved self-reported function
  • Improvement retained at 5 years
Stapanian, Stapanian, & Staley (2010) V
  • Hand injury
  • Bilateral amputation of all fingers
  • Evaluation of treatment methods used
Community-dwelling person with all fingers amputated secondary to frostbite (n = 1)
  • Case study with pre–post and longitudinal assessment
  • Outcomes were evaluated after index finger residual transfer to thumb.
  • Impairment
  • Improved ROM of thumb MP joint posttreatment and at follow-up 17 years posttreatment
Thorne, Sauve, Yacoub, & Guitard (2009) II
  • Acute care
  • Pressure sores
  • Evaluation of gel pads used to decrease pressure sores
Heterogeneous sample of acute care patients at high risk to develop pressure sores (n = 60)
  • Two-group, nonrandomized crossover
  • Interface pressure was evaluated with and without use of gel pad in supine position.
  • Impairment
  • No significant difference in pressure with or without use of the gel pad
Zlotnik, Sachs, Rosenblum, Shpasser, & Josman (2009) V
  • TBI
  • Adolescents
  • Evaluation of the Dynamic Interaction Model (DIM) intervention approach
Inpatient rehabilitation patients post-TBI (n = 2)
  • Case study with pre–post assessment
  • Patients were treated using the DIM to improve function post-TBI.
  • Function
  • Improved writing, mobility, and independence in self-care posttreatment
Table Footer NoteNote. ABI = acquired brain injury; ADL = activity of daily living; CIMT = constraint-induced movement therapy; CT = computed tomography; CVA = cerebrovascular accident; IADL = instrumental activity of daily living; mCIMT = modified constraint-induced movement therapy; MMT = manual muscle test; MP = metacarpophalangeal; MRI = magnetic resonance imaging; RCT = randomized controlled trial; ROM = range of motion; TBI = traumatic brain injury; UE = upper extremity.
Note. ABI = acquired brain injury; ADL = activity of daily living; CIMT = constraint-induced movement therapy; CT = computed tomography; CVA = cerebrovascular accident; IADL = instrumental activity of daily living; mCIMT = modified constraint-induced movement therapy; MMT = manual muscle test; MP = metacarpophalangeal; MRI = magnetic resonance imaging; RCT = randomized controlled trial; ROM = range of motion; TBI = traumatic brain injury; UE = upper extremity.×
Table 1.
Summary of Effectiveness Studies Addressing Rehabilitation, Disability, and Participation Published in the American Journal of Occupational Therapy, 2009 and 2010
Summary of Effectiveness Studies Addressing Rehabilitation, Disability, and Participation Published in the American Journal of Occupational Therapy, 2009 and 2010×
Author/YearLevel of EvidenceContent AreaSampleMethodsOutcomes
Carver (2009) V
  • TBI
  • Intermittent self-catheterization (ISC)
  • Treatment with assistive technology
Inpatient rehabilitation patient with TBI (n = 1)
  • Case study
  • Goal was to improve independence with ISC through construction and use of splint.
  • Function
  • Improved independence with ISC
Earley, Herlache, & Skelton (2010) V
  • Stroke
  • Upper-extremity dysfunction
  • mCIMT
Chronic stroke patient 4 years post-CVA (n = 1)
  • Case study with pre–post assessment
  • Patient received mCIMT with home exercise program (4 weeks).
  • Impairment
  • Improved ROM, MMT, pinch/grip
  • Function
  • Improved self-rating of IADL performance
Fong & Howie (2009) II
  • ABI
  • Cognitive dysfunction
  • Problem-solving treatment
Outpatient rehabilitation patients in Hong Kong with moderate ABI (n = 33)
  • RCT with matched pairs (2 groups)
  • Both groups received cognitive training program.
  • Treatment group (n = 16) received additional problem-solving training.
  • Impairment
  • Improved total score and score on one subtest of metacomponents and executive function
  • Function
  • No significant differences
Giuffrida, Demery, Reyes, Lebowitz, & Hanlon (2009) II
  • TBI
  • Cognitive dysfunction
  • Effect of different practice schedules on improving function
Patients with chronic cognitive impairment after TBI (n = 6)
  • Case control
  • All participants completed 3 tasks: touch typing, 5- to 6-digit sequence typing, and subway schedule task.
  • Patients were assigned to random practice (n = 3) or blocked ordered practice (n = 3).
  • Impairment
  • Improvements in all groups from baseline performance, retained over 2 weeks
  • Transfer of learning to another task demonstrated by random practice group
Goverover, Arango-Lasprilla, Hilary, Chiaravalloti, & DeLuca (2009) II
  • TBI
  • Cognitive dysfunction
  • Use of spacing effect to improve learning and memory
Patients with TBI documented by CT or MRI (n =10) and healthy controls (n = 15)
  • Case control
  • All groups completed both a paragraph and a route-learning task.
  • Within groups, patients were split into either spaced or massed learning groups.
  • Impairment
  • In both groups, better results from spaced learning than from massed practice
  • No significant difference between TBI and control group
Goverover, Chiaravalloti, & DeLuca (2010) II
  • TBI
  • Cognitive dysfunction
  • Use of self-generated vs. directed strategies
Patients with TBI documented by CT or MRI (n = 10) and healthy controls (n = 15)
  • Case control
  • All groups completed 2 meal preparation tasks and 2 financial management tasks. One task for each condition was completed using provided instructions, and the other task was completed using self-generated instructions.
  • Impairment
  • In both groups, better results from self-generated learning than from directed learning
  • No significant difference between TBI and control groups
Hall, Lee, Page, Rosenwax, & Lee (2010) I
  • Hand injury
  • Extensor tendon repair (ETR)
  • Comparison of 3 postoperative treatment protocols
Hospital-based outpatient hand clinic patients with ETR (n = 18) with 24 total injured fingers
  • RCT (3 groups)
  • All participants were assessed 3, 6, and 12 wk posttreatment.
  • Patients were assigned to immobilization (n = 4), early passive motion (n = 5), or early active motion (n = 9) treatment groups.
  • Impairment
  • Across all time points, improvement in all groups
  • Greatest treatment effect with early active motion protocol
Hardy et al. (2010) IV
  • Stroke
  • UE spasticity
  • Treatment study combining 2 existing protocols
Outpatient clinic patients (n = 2) with chronic stroke (>6 months post-CVA) and documented UE spasticity
  • Case study with pre–post assessment
  • Treatment combined UE bracing with electrical stimulation in a functional training program.
  • Impairment
  • Decreased spasticity
  • Function
  • Improved motor function
  • Improvements retained at 3 mo posttreatment
Hayner, Gibson, & Giles (2010) I
  • Stroke
  • Upper extremity dysfunction
  • CIMT
Community-dwelling people with chronic stroke symptoms (>6 months post-CVA; n = 12)
  • RCT (2 groups)
  • Groups were stratified by more or less impaired.
  • Treatment group (n = 6) received CIMT protocol.
  • Control group (n = 6) received bilateral treatment protocol.
  • Function
  • Improved self-rating of performance and satisfaction in both groups
  • Therapeutic improvement a factor of treatment intensity and not related to protocol followed
Hermann et al. (2010) V
  • Stroke
  • ADL limitations
  • Telerehabilitation and task-specific training
Community-dwelling patient with chronic stroke (>3 years post-CVA; n = 1)
  • Case study with pre–post assessment
  • Patients were treated with telerehabilitation protocol to improve ADLs (4 weeks).
  • Impairment
  • Improved UE movement
  • Function
  • Improved motor function
  • Improved self-rating of performance and satisfaction
Jack & Estes (2010) IV
  • Arthritis
  • Lupus related
  • Evaluation of a different intervention approach
Orthopedic outpatient clinic patient with lupus-related arthritis (n = 1)
  • Case study with pre–post assessment
  • Patients received treatment using the occupational adaptation model.
  • Function
  • Improved performance on all functional tasks addressed in treatment
Kim & Colantonio (2010) I
  • TBI
  • Postacute rehabilitation intervention
  • Improvement in community reintegration outcomes
10 research articles from 1990 to 2007 related to improving community reintegration post-TBI
  • Systematic review
  • Goal was to identify evidence to support postacute rehabilitation intervention approaches that address community reintegration.
  • Seven articles provided this evidence.
  • Benefits of postacute TBI rehabilitation programs to improve community reintegration supported by 7 of 10 articles
  • Occupational therapy or occupational therapy interventions involved in all studies
McClure, McClure, Day, & Brufsky (2010) I
  • Breast cancer–related lymphedema (BCRL)
  • Evaluation of a recovery program to improve physical and emotional symptoms
Community-setting patients with BCRL recruited from local hospitals, clinics, and events (n = 32)
  • RCT (2 groups)
  • Treatment group (n = 16) was treated with breast cancer recovery program emphasizing exercise and relaxation. Control group (n = 16) received standard care.
  • Impairment
  • Significantly improved bioimpedance, flexibility, mood, and weight loss in treatment group compared with controls
  • Function
  • Significantly improved quality of life in treatment group compared with controls
Nilsen, Gillen, & Gordon (2010) I
  • Stroke
  • UE dysfunction
  • Use of mental practice to improve recovery
15 research articles published between 1985 and 2009 focused on using mental practice as part of a stroke rehabilitation intervention
  • Systematic review
  • Goal was to determine whether using mental practice is effective in improving UE recovery poststroke.
  • Impairment
  • Support by most articles for mental practice as effective in reducing impairment and improving function of affected UE
  • Generalizability of findings limited by the mostly heterogeneous study populations
Preissner (2010) V
  • Stroke
  • Cognitive dysfunction
  • Use of the task-oriented approach to improve ADL function
Inpatient rehabilitation setting stroke patient with motor and cognitive dysfunction (n = 1)
  • Case study with pre–post assessment
  • Patients were treated with the task-oriented approach.
  • Function
  • Improved self-care performance after treatment
Rand, Weiss, & Katz (2009) III
  • Stroke
  • Cognitive dysfunction
  • Evaluation of a multitasking intervention protocol
Community-dwelling people poststroke with executive function deficits (n = 4)
  • Pre–post assessment
  • Patients were treated using VMall, a virtual supermarket, to improve multitasking.
  • Impairment
  • Improvements on performance-based assessment of executive function
Rowe, Blanton, & Wolf (2009) IV
  • Stroke
  • UE dysfunction
  • Constraint-induced movement therapy
Community-dwelling person with chronic stroke (5 yr post-CVA; n = 1)
  • Case study with pre–post and longitudinal assessment
  • Patients received 2 wk of CIMT treatment.
  • Impairment
  • Improved motor performance
  • Function
  • Improved self-reported function
  • Improvement retained at 5 years
Stapanian, Stapanian, & Staley (2010) V
  • Hand injury
  • Bilateral amputation of all fingers
  • Evaluation of treatment methods used
Community-dwelling person with all fingers amputated secondary to frostbite (n = 1)
  • Case study with pre–post and longitudinal assessment
  • Outcomes were evaluated after index finger residual transfer to thumb.
  • Impairment
  • Improved ROM of thumb MP joint posttreatment and at follow-up 17 years posttreatment
Thorne, Sauve, Yacoub, & Guitard (2009) II
  • Acute care
  • Pressure sores
  • Evaluation of gel pads used to decrease pressure sores
Heterogeneous sample of acute care patients at high risk to develop pressure sores (n = 60)
  • Two-group, nonrandomized crossover
  • Interface pressure was evaluated with and without use of gel pad in supine position.
  • Impairment
  • No significant difference in pressure with or without use of the gel pad
Zlotnik, Sachs, Rosenblum, Shpasser, & Josman (2009) V
  • TBI
  • Adolescents
  • Evaluation of the Dynamic Interaction Model (DIM) intervention approach
Inpatient rehabilitation patients post-TBI (n = 2)
  • Case study with pre–post assessment
  • Patients were treated using the DIM to improve function post-TBI.
  • Function
  • Improved writing, mobility, and independence in self-care posttreatment
Table Footer NoteNote. ABI = acquired brain injury; ADL = activity of daily living; CIMT = constraint-induced movement therapy; CT = computed tomography; CVA = cerebrovascular accident; IADL = instrumental activity of daily living; mCIMT = modified constraint-induced movement therapy; MMT = manual muscle test; MP = metacarpophalangeal; MRI = magnetic resonance imaging; RCT = randomized controlled trial; ROM = range of motion; TBI = traumatic brain injury; UE = upper extremity.
Note. ABI = acquired brain injury; ADL = activity of daily living; CIMT = constraint-induced movement therapy; CT = computed tomography; CVA = cerebrovascular accident; IADL = instrumental activity of daily living; mCIMT = modified constraint-induced movement therapy; MMT = manual muscle test; MP = metacarpophalangeal; MRI = magnetic resonance imaging; RCT = randomized controlled trial; ROM = range of motion; TBI = traumatic brain injury; UE = upper extremity.×
×
Fifteen of the 20 effectiveness studies were related to either stroke or traumatic brain injury (TBI). Those related to TBI (n = 7) examined a broad spectrum of treatment approaches targeting both impairment-level and participation-level outcomes, including intermittent self-catheterization (Carver, 2009); problem-solving strategies (Fong & Howie, 2009); improvement of learning or memory (Giuffrida, Demery, Reyes, Lebowitz, & Hanlon, 2009; Goverover, Arango-Lasprilla, Hillary, Chiaravalloti, & DeLuca, 2009; Goverover, Chiaravalloti, & DeLuca, 2010); community reintegration (Kim & Colantonio, 2010); and improvement of self-care abilities (Zlotnik, Sachs, Rosenblum, Shpasser, & Josman, 2009). The effectiveness studies related to stroke (n = 8) were much narrower in focus and targeted primarily upper-extremity dysfunction or motor impairment (Earley, Herlache, & Skelton, 2010; Hardy et al., 2010; Hayner, Gibson, & Giles, 2010; Nilsen, Gillen, & Gordon, 2010; Rowe, Blanton, & Wolf, 2009) and self-care and activities of daily living (ADLs; Hermann et al., 2010; Preissner, 2010). The 2 stroke self-care studies, although focused on participation (ADLs), also addressed primarily people with upper-extremity dysfunction or motor dysfunction poststroke. Only 1 stroke effectiveness study specifically addressed a different area of impairment poststroke—cognitive dysfunction (Rand, Weiss, & Katz, 2009). The remaining effectiveness studies (n = 5) involved hand injury (Hall, Lee, Page, Rosenwax, & Lee, 2010; Stapanian, Stapanian, & Staley, 2010), arthritis (Jack & Estes, 2010), lymphedema (McClure, McClure, Day, & Brufsky, 2010), and acute care rehabilitation (Thorne, Sauve, Yacoub, & Guitard, 2009). Although collectively, the studies related to rehabilitation, disability, and participation published in AJOT during this period demonstrate that occupational therapy researchers are producing evidence, some concerns need to be addressed related to becoming evidence based in this practice area.
Concerns in Rehabilitation, Disability, and Participation Research
Research That Does Not Produce Evidence for the Profession
Most of the research related to rehabilitation, disability, and participation did not produce evidence for the profession. Of the 58 rehabilitation, disability, and participation studies published in AJOT in 2009 and 2010, 38 were efficiency studies, basic research studies, instrument development and testing studies, or studies that explored the link between occupational engagement and health. All four of these areas serve a key role in the continuum of research and are ultimately necessary for the development of evidence to support the profession. For example, efficiency studies are necessary to determine whether a certain intervention can affect an outcome. It is crucial to conduct a study of this nature to determine whether an effectiveness study is warranted. For example, Walker and colleagues (2010)  developed a community mobility skills course for people using mobility devices. The authors were able to determine that some skills gained through a community mobility skills course can transfer to use in a real-world environment; this finding can now be translated into clinical guidelines that can be evaluated in effectiveness studies.
The review of the AJOT literature reported in this article highlights the fact that most research in this area of practice is in an early phase of development (e.g., basic science and efficiency studies) and has not progressed to the level of effectiveness studies. This concern is notable for the profession because effectiveness studies are the only studies that truly produce evidence. If the occupational therapy profession is to meet the goal of being evidence based in this practice area, the research community must give special consideration to developing lines of research inquiry along the research continuum, culminating in effectiveness studies.
Poor Representation of Several Populations
Several populations may be poorly represented in the work being produced in rehabilitation, disability, and participation. Stroke and TBI were overrepresented in the effectiveness studies reviewed for this article; however, several considerations must be noted. First, the results are skewed by the fact that many of the studies were published in a 2009 special issue of AJOT focused on stroke and TBI. Second, although stroke and TBI affect two of the largest populations with which occupational therapists work, thereby warranting a special issue to highlight related work being produced, in the past 2 years the focus on stroke and TBI created a void that left several other major populations underrepresented in AJOT. For example, spinal cord injury (SCI) affects a large population with which occupational therapy practitioners work in a variety of rehabilitation settings. AJOT published no effectiveness studies in 2009 and 2010 related to the SCI population. AJOT should give special consideration to the production of special issues highlighting research related to other populations with whom practitioners work in rehabilitation, disability, and participation.
Preponderance of Case Studies and Studies With Small Sample Sizes
Most effectiveness studies related to rehabilitation, disability, and participation are case studies or have a small sample size, which limits the generalizability of the findings. Of the 20 effectiveness studies published by AJOT in 2009 and 2010 related to rehabilitation, disability, and participation, nearly half (n = 9) were case studies (Carver, 2009; Earley et al., 2010; Hardy et al., 2010; Hermann et al., 2010; Jack & Estes, 2010; Preissner, 2010; Rowe et al., 2009; Stapanian et al., 2010; Zlotnik et al., 2009). Moreover, 4 studies had <10 participants per intervention group evaluated (Giuffrida et al., 2009; Hall et al., 2010; Hayner et al., 2010; Rand et al., 2009). This review suggests that the evidence being published is not at the strongest levels to support practice. This finding speaks to a larger issue in occupational therapy research: Sufficiently powered randomized controlled studies (Level 1 evidence) require many resources to conduct, and few occupational therapy scientists have the research infrastructure and resources necessary to conduct such trials. In addition, the trials that are being conducted are being reported in venues other than AJOT. For these reasons, it is critical that the Level I evidence being produced make its way back to the occupational therapy community. AJOT should make the Level I evidence in this practice area accessible to the occupational therapy community through systematic reviews or other avenues such as the AOTA Evidence-Based Practice and Research resources.
Outcome Measures at the Impairment Level
More than half of the rehabilitation, disability, and participation effectiveness studies reported in AJOT in 2009 and 2010 (n = 11) used impairment-level measures as their primary outcome measures (Earley et al., 2010; Fong & Howie, 2009; Giuffrida et al., 2009; Goverover et al., 2009, 2010; Hall et al., 2010; McClure et al., 2010; Nilsen et al., 2010; Rand et al., 2009; Stapanian et al., 2010; Thorne et al., 2009). Impairment associated with any disorder, disease, or condition must be addressed in some capacity during rehabilitation to improve participation; however, the unique contribution of occupational therapy practitioners to the health care community is their focus on everyday life participation. Occupational therapy researchers must highlight this unique contribution to the health care community by including measures of participation in studies that demonstrate occupational therapy’s effectiveness.
Need to Address Poststroke Cognitive Dysfunction
A significant need exists for occupational therapy practitioners in rehabilitation, disability, and participation to expand their focus to address poststroke cognitive dysfunction. Among the many areas that arguably need to be addressed in producing evidence to support occupational therapy practice in this area, one of the most critical is cognitive dysfunction after a stroke. The AOTA Research Advisory Panel (2009)  identified people with cognitive impairments, specifically after stroke, as a priority population in the Occupational Therapy Research Agenda. The review undertaken for this article highlighted that although evidence is being produced related to stroke, most of this work is focused on motor recovery and self-care. The remainder of this article addresses the unique needs of people with cognitive dysfunction poststroke, the reasons poststroke cognitive rehabilitation should be a priority for occupational therapy practitioners, and the evidence being produced to support practice in this area.
Cognitive Dysfunction After Stroke
People with stroke are one of the largest groups that occupational therapists serve. Stroke syndromes are complex and include a wide variety of symptoms; however, studies have shown that the functional scales used to guide intervention after stroke (e.g., FIM™, Barthel Index are biased toward physical disability, given their high correlation with measures of motor performance (Hajek, Gagnon, & Ruderman, 1997). The health care community’s overfocus on physical disability and ADL performance has led to an underappreciation of other deficits after stroke that affect everyday life, particularly cognitive impairment. Cognitive impairment poststroke is prevalent: As many as 65% of stroke survivors exhibit some sort of cognitive dysfunction (Donovan et al., 2008; Edwards, Hahn, Baum, & Dromerick, 2006; Rochette et al., 2007; Wolf, Baum, & Connor, 2009). Even people with mild neurological impairment after a stroke who are independent in ADLs and have limited or no physical impairment can exhibit debilitating cognitive impairment that lowers their ability to return to complex activities such as work, community roles, and driving (Edwards et al., 2006; Rochette et al., 2007; Wolf et al., 2009).
In 2009 and 2010, AJOT published only 1 effectiveness study that specifically addressed cognitive dysfunction poststroke. Rand and colleagues (2009)  evaluated use of a virtual supermarket to train clients in multitasking after stroke (Level III evidence). Even though this area of practice was underrepresented in AJOT, my review of outside repositories of stroke research demonstrated that in general, insufficient evidence exists to support this area of practice.
Existing Knowledge of Cognitive Rehabilitation After Stroke
The second purpose of this review was to synthesize and review the evidence produced in an underdeveloped subcategory of rehabilitation, disability, and participation practice: poststroke cognitive rehabilitation. Two of the leading publicly available repositories of evidence-based reviews are the Cochrane Reviews (www2.cochrane.org/reviews) and the Evidence-Based Review of Stroke Rehabilitation (EBRSR; www.ebrsr.com). The EBRSR is an excellent resource for evidence to support stroke rehabilitation, but a major limitation exists in its clinical utility related to addressing cognitive dysfunction poststroke: Most of the evidence reported in the EBRSR comes from studies of TBI, not stroke. Although the clinical presentation of cognitive dysfunction can sometimes be similar, the populations are sufficiently different to warrant further study using the methodologies reported in the EBRSR to confirm whether findings can be replicated with a stroke population. For this reason, I did not review the EBRSR information related to cognitive dysfunction. To examine available evidence to support cognitive rehabilitation poststroke, I examined the information reported in the Cochrane Reviews.
Cochrane Reviews
The Cochrane Collaboration is a network of scholars focused on helping stakeholders in health care (e.g., policymakers, health care providers, consumers, caregivers) make well-informed health care decisions (Mavergames et al., 2010) by systematically reviewing and assessing all available evidence for specific interventions and populations. Cochrane Reviews are continuously updated to ensure that reviews provide the most current information. Three Cochrane Reviews addressed poststroke cognitive rehabilitation for (1) attention deficits (Lincoln, Majid, & Weyman, 2000), (2) memory deficits (das Nair & Lincoln, 2007), and (3) spatial neglect (Bowen & Lincoln, 2007). Each group completed a comprehensive review of electronic databases and hand searches of journals related to the specific topic. All three coordinated with the Cochrane Stroke Group, and details of their search criteria can be found in their references or on the Stroke Group’s Web page (Editorial Team, Cochrane Stroke Group, 2010). Of particular note, the Stroke Group used strict inclusion criteria, and only controlled trials and systematic reviews were included (AJOT Level I only). Table 2 summarizes the studies identified by the Cochrane Reviews to support cognitive rehabilitation for attention, memory, and spatial neglect poststroke.
Table 2.
Studies Identified by the Cochrane Reviews to Support Cognitive Rehabilitation for Attention, Memory, and Spatial Neglect Poststroke
Studies Identified by the Cochrane Reviews to Support Cognitive Rehabilitation for Attention, Memory, and Spatial Neglect Poststroke×
TitleProfessionPopulationInterventionOutcomesConclusions
“Cognitive rehabilitation for attention deficits following stroke” (Lincoln, Majid, & Weyman, 2000)NeuropsychologyStroke patients (n = 29)RCT—Treatment group (n = 16) received attentional training program; control group (n = 13) received standard care.
  • Impairment
  • Improved sustained attention
  • Function
  • No effect on ADL
Intervention was effective in improving attentional impairment, but improvement did not generalize to improved ADL performance.
“Rehabilitation von Aufmerksamkeits storungen nach einem Schlagenfall—Effectivitat eines verhaltensmedizinisch–neuropsychologischen Aufmerksamkeitstrainings” (Schöttke, 1997)
“Efficacy of a reaction training on various attentional and cognitive functions in stroke patients” (Sturm & Willmes, 1991)NeuropsychologyLeft hemisphere stroke patients (n = 27)RCT crossover design—computer-assisted reaction training program
  • Impairment
  • • Improved alertness
  • • Improved sustained attention
Intervention was effective in improving attentional impairment, but improvement did not generalize to other cognitive functions.
“Cognitive rehabilitation for memory deficits following stroke” (das Nair & Lincoln, 2007)NeuropsychologyStroke patients (n = 12)RCT—Treatment group (n = 6) received a memory training program that combined 6 different strategies; control group (n = 6) received repetitive practice of memory tasks.
  • Impairment
  • • Improved performance on trained memory tasks
  • • No transfer to untrained tasks
  • Function
  • • No effect on everyday memory functions
Only trained task performance improved in the treatment group compared with the control group, and this improvement did not transfer to global memory function or everyday memory.
“Cognitive training for memory deficits in stroke patients” (Doornhein & deHaan, 1998)
“Imagery mnemonics for the rehabilitation of memory: A randomised group controlled trial” (Kaschel et al., 2002)NeuropsychologyMixed etiology sample (n = 21) that included stroke patients (n = 6)RCT—Treatment group (n = 3) received an experimental imagery mnemonic program; control group (n = 3) received a pragmatic memory rehabilitation program.
  • Impairment
  • In the stroke group, no significant differences between groups
The entire group showed improvement in delayed and immediate recall; however, in the stroke groups, there was no difference between groups.
“Cognitive rehabilitation for spatial neglect following stroke” (Bowen & Lincoln, 2007)Speech language pathology, physical medicine and rehabilitationPatients with right hemisphere stroke and evidence of neglect (n = 4)Efficacy study—Treatment 1 (n = 2) received an intervention of repetitive practice during a reading task; Treatment 2 (n = 2) received an intervention targeting impairment of attention during visual scanning.No clear efficacy of either approach determinedNo objective data were obtained to support or refute either approach.
“Two approaches to treating unilateral neglect after right hemisphere stroke: A preliminary investigation” (Cherney, Halper, & Papachronis, 2003)
“A comparison of two approaches in the treatment of perceptual problems after stroke” (Edmans, Webster, & Lincoln, 2000)Occupational therapyPatients in an inpatient rehabilitation hospital with neglect secondary to stroke (n = 80)RCT—Group 1 (n = 40) received a transfer of training approach; Group 2 (n = 40) received the functional approach for perceptual treatment.
  • Impairment
  • • No significant differences between groups in perceptual impairment
  • • Overall improvements in both groups
  • Function
  • • No difference between groups in ADL performance.
  • • Overall improvements in both groups
Results provided no clear indication that one treatment approach was better than the other; however, both groups improved on measures of perception and self-care. The time frame of the intervention, however, could indicate that findings were attributable to spontaneous recovery.
“The treatment of visual neglect using feedback of eye movements: A pilot study” (Fanthome, Lincoln, Drummond, & Walker, 1995)PsychologyPatients in an inpatient rehabilitation hospital with neglect secondary to stroke (n = 12)RCT—Treatment group (n = 9) received an eye movement feedback treatment; control group (n = 3) received no treatment.
  • Impairment
  • • No significant differences between groups in neglect or eye movements over time
Feedback from eye movements had no significant effect on eye movements or neglect symptoms poststroke.
“The influence of visual neglect on stroke rehabilitation” (Kalra, Perez, Gupta, & Wittink, 1997)MedicinePatients with neglect secondary to stroke (n =12)RCT—Treatment group (n = 9) received spatiomotor cueing with an early emphasis on function; control group (n = 3) received standard care.
  • Function
  • • Significantly lower median days in hospital for treatment group compared with controls
  • • No significant difference in ADL function
Although the results of this study showed that the treatment group trended toward improved ADL performance, the results were not significant.
“Microcomputer-based rehabilitation for unilateral left visual neglect: A randomised controlled trial” (Robertson, Gray, Pentland, & Waite, 1990)PsychologyPatients in an inpatient rehabilitation hospital setting with neglect secondary to stroke (n = 36)RCT—Treatment group (n = 20) received computer scanning and attention training; control group (n = 16) received recreational computing.
  • Impairment
  • No significant differences between groups in neglect at 6 months
The use of computer training is not supported as a method to improve neglect.
“Rehabilitation by limb activation training reduces left-sided motor impairment in unilateral neglect patients: a single-blind randomised control trial” (Robertson, McMillan, MacLeod, Edgeworth, & Brock, 2002)NeuropsychologyPatients with neglect secondary to stroke (n = 36)RCT—Treatment group received limb activation training plus perceptual training (n = 17); control group (n = 19) received perceptual training only.
  • Impairment
  • Significant improvement in left side motor function for treatment group compared with controls
Limb activation training can improve impairment in left side motor function; impact on everyday life function was not assessed.
“Fresnel prisms improve visual perception in stroke patients with homonymous hemianopia or unilateral visual neglect” (Rossi, Kheyfets, & Reding, 1990)Physical medicine and rehabilitationPatients with neglect secondary to stroke or hemianopsia (n = 39)RCT—Treatment group (n = 18) received 15-diopter Fresnel prism glasses; control group (n = 21) received standard care.
  • Impairment
  • Significant improvement in perception, neglect, and visual field sight for treatment group compared with controls
  • Function
  • No difference between groups in ADL performance
Fresnel prisms were shown to improve impairment associated with neglect or hemianopsia; however, there was no difference between groups in function.
“Different cognitive trainings in the rehabilitation of visuo-spatial neglect” (Rusconi, Meineke, Sbrissa, & Bernardini, 2002)PsychologyPatients with neglect secondary to stroke (n = 20)RCT (4 groups)—Group 1 (n = 5) received Training 1 (visuospatial and visuoconstructive tasks); Group 2 (n = 5) received Training 1 plus TENS; Group 3 (n = 5) received Training 2 (cueing and feedback); Group 4 (n = 5) received Training 2 plus TENS.
  • Impairment
  • Improvement in neglect symptoms for all groups; treatment effect greater in Training 1
The use of TENS associated with any treatment for neglect is not supported to improve symptoms. The impact of intervention on functional outcomes was not assessed.
“Visual scanning training effect on reading-related tasks in acquired right brain damage” (Weinberg et al., 1977)PsychologyPatients with neglect secondary to stroke (n = 57)RCT—Treatment group (n = 25) received visual scanning training; control group (n = 32) received standard care.
  • Impairment
  • Significantly greater improvement in scanning for treatment group compared with controls
Visual scanning training for neglect can improve scanning abilities; however, the impact on function was not assessed.
“Unilateral neglect syndrome rehabilitation by trunk rotation and scanning training” (Wiart et al., 1997)Physical medicine and rehabilitationPatients with neglect secondary to stroke (n = 22)RCT—Treatment group (n = 11) received Bon Saint Come’s device (voluntary trunk rotation); control group (n = 11) received standard care.
  • Impairment
  • Significant improvement in neglect for treatment group compared with controls
  • Function
  • Significant improvement in ADL for treatment group compared with controls
The Bon Saint Come’s device was shown to improve impairment in neglect and improve ADL function. Further study was recommended.
“Viewing less to see better” (Zeloni, Farne, & Baccini, 2002)NeuropsychologyPatients with neglect secondary to stroke (n = 11)RCT—Treatment group (n = 5) received scanning task with hemiblinding goggles; control group (n = 6) received just scanning task.
  • Impairment
  • Significant improvement in neglect for treatment group compared with controls immediately and 1 wk posttreatment
Hemiblinding goggles were shown to improve neglect; however, the impact of this treatment on function was not assessed.
Table Footer NoteNote. ADL = activity of daily living; RCT = randomized controlled trial; TENS = transcutaneous electrical nerve stimulation.
Note. ADL = activity of daily living; RCT = randomized controlled trial; TENS = transcutaneous electrical nerve stimulation.×
Table 2.
Studies Identified by the Cochrane Reviews to Support Cognitive Rehabilitation for Attention, Memory, and Spatial Neglect Poststroke
Studies Identified by the Cochrane Reviews to Support Cognitive Rehabilitation for Attention, Memory, and Spatial Neglect Poststroke×
TitleProfessionPopulationInterventionOutcomesConclusions
“Cognitive rehabilitation for attention deficits following stroke” (Lincoln, Majid, & Weyman, 2000)NeuropsychologyStroke patients (n = 29)RCT—Treatment group (n = 16) received attentional training program; control group (n = 13) received standard care.
  • Impairment
  • Improved sustained attention
  • Function
  • No effect on ADL
Intervention was effective in improving attentional impairment, but improvement did not generalize to improved ADL performance.
“Rehabilitation von Aufmerksamkeits storungen nach einem Schlagenfall—Effectivitat eines verhaltensmedizinisch–neuropsychologischen Aufmerksamkeitstrainings” (Schöttke, 1997)
“Efficacy of a reaction training on various attentional and cognitive functions in stroke patients” (Sturm & Willmes, 1991)NeuropsychologyLeft hemisphere stroke patients (n = 27)RCT crossover design—computer-assisted reaction training program
  • Impairment
  • • Improved alertness
  • • Improved sustained attention
Intervention was effective in improving attentional impairment, but improvement did not generalize to other cognitive functions.
“Cognitive rehabilitation for memory deficits following stroke” (das Nair & Lincoln, 2007)NeuropsychologyStroke patients (n = 12)RCT—Treatment group (n = 6) received a memory training program that combined 6 different strategies; control group (n = 6) received repetitive practice of memory tasks.
  • Impairment
  • • Improved performance on trained memory tasks
  • • No transfer to untrained tasks
  • Function
  • • No effect on everyday memory functions
Only trained task performance improved in the treatment group compared with the control group, and this improvement did not transfer to global memory function or everyday memory.
“Cognitive training for memory deficits in stroke patients” (Doornhein & deHaan, 1998)
“Imagery mnemonics for the rehabilitation of memory: A randomised group controlled trial” (Kaschel et al., 2002)NeuropsychologyMixed etiology sample (n = 21) that included stroke patients (n = 6)RCT—Treatment group (n = 3) received an experimental imagery mnemonic program; control group (n = 3) received a pragmatic memory rehabilitation program.
  • Impairment
  • In the stroke group, no significant differences between groups
The entire group showed improvement in delayed and immediate recall; however, in the stroke groups, there was no difference between groups.
“Cognitive rehabilitation for spatial neglect following stroke” (Bowen & Lincoln, 2007)Speech language pathology, physical medicine and rehabilitationPatients with right hemisphere stroke and evidence of neglect (n = 4)Efficacy study—Treatment 1 (n = 2) received an intervention of repetitive practice during a reading task; Treatment 2 (n = 2) received an intervention targeting impairment of attention during visual scanning.No clear efficacy of either approach determinedNo objective data were obtained to support or refute either approach.
“Two approaches to treating unilateral neglect after right hemisphere stroke: A preliminary investigation” (Cherney, Halper, & Papachronis, 2003)
“A comparison of two approaches in the treatment of perceptual problems after stroke” (Edmans, Webster, & Lincoln, 2000)Occupational therapyPatients in an inpatient rehabilitation hospital with neglect secondary to stroke (n = 80)RCT—Group 1 (n = 40) received a transfer of training approach; Group 2 (n = 40) received the functional approach for perceptual treatment.
  • Impairment
  • • No significant differences between groups in perceptual impairment
  • • Overall improvements in both groups
  • Function
  • • No difference between groups in ADL performance.
  • • Overall improvements in both groups
Results provided no clear indication that one treatment approach was better than the other; however, both groups improved on measures of perception and self-care. The time frame of the intervention, however, could indicate that findings were attributable to spontaneous recovery.
“The treatment of visual neglect using feedback of eye movements: A pilot study” (Fanthome, Lincoln, Drummond, & Walker, 1995)PsychologyPatients in an inpatient rehabilitation hospital with neglect secondary to stroke (n = 12)RCT—Treatment group (n = 9) received an eye movement feedback treatment; control group (n = 3) received no treatment.
  • Impairment
  • • No significant differences between groups in neglect or eye movements over time
Feedback from eye movements had no significant effect on eye movements or neglect symptoms poststroke.
“The influence of visual neglect on stroke rehabilitation” (Kalra, Perez, Gupta, & Wittink, 1997)MedicinePatients with neglect secondary to stroke (n =12)RCT—Treatment group (n = 9) received spatiomotor cueing with an early emphasis on function; control group (n = 3) received standard care.
  • Function
  • • Significantly lower median days in hospital for treatment group compared with controls
  • • No significant difference in ADL function
Although the results of this study showed that the treatment group trended toward improved ADL performance, the results were not significant.
“Microcomputer-based rehabilitation for unilateral left visual neglect: A randomised controlled trial” (Robertson, Gray, Pentland, & Waite, 1990)PsychologyPatients in an inpatient rehabilitation hospital setting with neglect secondary to stroke (n = 36)RCT—Treatment group (n = 20) received computer scanning and attention training; control group (n = 16) received recreational computing.
  • Impairment
  • No significant differences between groups in neglect at 6 months
The use of computer training is not supported as a method to improve neglect.
“Rehabilitation by limb activation training reduces left-sided motor impairment in unilateral neglect patients: a single-blind randomised control trial” (Robertson, McMillan, MacLeod, Edgeworth, & Brock, 2002)NeuropsychologyPatients with neglect secondary to stroke (n = 36)RCT—Treatment group received limb activation training plus perceptual training (n = 17); control group (n = 19) received perceptual training only.
  • Impairment
  • Significant improvement in left side motor function for treatment group compared with controls
Limb activation training can improve impairment in left side motor function; impact on everyday life function was not assessed.
“Fresnel prisms improve visual perception in stroke patients with homonymous hemianopia or unilateral visual neglect” (Rossi, Kheyfets, & Reding, 1990)Physical medicine and rehabilitationPatients with neglect secondary to stroke or hemianopsia (n = 39)RCT—Treatment group (n = 18) received 15-diopter Fresnel prism glasses; control group (n = 21) received standard care.
  • Impairment
  • Significant improvement in perception, neglect, and visual field sight for treatment group compared with controls
  • Function
  • No difference between groups in ADL performance
Fresnel prisms were shown to improve impairment associated with neglect or hemianopsia; however, there was no difference between groups in function.
“Different cognitive trainings in the rehabilitation of visuo-spatial neglect” (Rusconi, Meineke, Sbrissa, & Bernardini, 2002)PsychologyPatients with neglect secondary to stroke (n = 20)RCT (4 groups)—Group 1 (n = 5) received Training 1 (visuospatial and visuoconstructive tasks); Group 2 (n = 5) received Training 1 plus TENS; Group 3 (n = 5) received Training 2 (cueing and feedback); Group 4 (n = 5) received Training 2 plus TENS.
  • Impairment
  • Improvement in neglect symptoms for all groups; treatment effect greater in Training 1
The use of TENS associated with any treatment for neglect is not supported to improve symptoms. The impact of intervention on functional outcomes was not assessed.
“Visual scanning training effect on reading-related tasks in acquired right brain damage” (Weinberg et al., 1977)PsychologyPatients with neglect secondary to stroke (n = 57)RCT—Treatment group (n = 25) received visual scanning training; control group (n = 32) received standard care.
  • Impairment
  • Significantly greater improvement in scanning for treatment group compared with controls
Visual scanning training for neglect can improve scanning abilities; however, the impact on function was not assessed.
“Unilateral neglect syndrome rehabilitation by trunk rotation and scanning training” (Wiart et al., 1997)Physical medicine and rehabilitationPatients with neglect secondary to stroke (n = 22)RCT—Treatment group (n = 11) received Bon Saint Come’s device (voluntary trunk rotation); control group (n = 11) received standard care.
  • Impairment
  • Significant improvement in neglect for treatment group compared with controls
  • Function
  • Significant improvement in ADL for treatment group compared with controls
The Bon Saint Come’s device was shown to improve impairment in neglect and improve ADL function. Further study was recommended.
“Viewing less to see better” (Zeloni, Farne, & Baccini, 2002)NeuropsychologyPatients with neglect secondary to stroke (n = 11)RCT—Treatment group (n = 5) received scanning task with hemiblinding goggles; control group (n = 6) received just scanning task.
  • Impairment
  • Significant improvement in neglect for treatment group compared with controls immediately and 1 wk posttreatment
Hemiblinding goggles were shown to improve neglect; however, the impact of this treatment on function was not assessed.
Table Footer NoteNote. ADL = activity of daily living; RCT = randomized controlled trial; TENS = transcutaneous electrical nerve stimulation.
Note. ADL = activity of daily living; RCT = randomized controlled trial; TENS = transcutaneous electrical nerve stimulation.×
×
In the Cochrane Review that examined cognitive rehabilitation for attention deficits after stroke, two trials were identified (Schöttke, 1997; Sturm & Willmes, 1991). The authors of the review concluded that evidence supports the use of cognitive training to improve alertness and sustained attention; however, no evidence has indicated that such improvements translate to improvement in everyday life activities (Lincoln et al., 2000).
In the review that examined memory deficits, two studies were also identified (see Table 2; Doornhein & deHaan, 1998; Kaschel et al., 2002). Neither study demonstrated any significant effect of memory rehabilitation on impairment-level assessments, and the review group therefore concluded that no evidence either supports or refutes the effectiveness of memory rehabilitation on functional outcomes (das Nair & Lincoln, 2007).
Finally, the group that examined spatial neglect identified 11 studies that evaluated the effectiveness of various interventions (see Table 2; Cherney, Halper, & Papachronis, 2003; Edmans, Webster, & Lincoln, 2000; Fanthome, Lincoln, Drummond, & Walker, 1995; Kalra, Perez, Gupta, & Wittink, 1997; Robertson, Gray, Pentland, & Waite, 1990; Robertson, McMillan, MacLeod, Edgeworth, & Brock, 2002; Rossi, Kheyfets, & Reding, 1990; Rusconi, Meinecke, Sbrissa, & Bernardini, 2002; Weinberg et al., 1977; Wiart et al., 1997; Zeloni, Farne, & Baccini, 2002). Again, the group concluded that although some evidence has supported the effectiveness of the interventions in improving performance on impairment-level testing, insufficient evidence exists to support or refute the effectiveness of any of the intervention approaches in reducing disability and improving independence in everyday life activities (Bowen & Lincoln, 2007).
The available data from the Cochrane Reviews clearly indicate that insufficient knowledge and evidence are being produced by occupational therapy—or any other health care profession—to support or refute the effectiveness of cognitive rehabilitation approaches poststroke. Moreover, none of the studies in the three reviews demonstrated that any of the intervention approaches translated to improvement in everyday life activities—a clinical objective within occupational therapy’s domain. Note that a Cochrane Review protocol was published indicating intent to produce a review related to occupational therapy’s effectiveness in improving function in people with cognitive impairment poststroke (Hoffmann, Bennett, Koh, & McKenna, 2007).
The Cochrane Reviews demonstrate that limited evidence is being produced anywhere by any health care profession to support specific cognitive intervention approaches that can improve everyday life performance after a stroke. This situation is disconcerting for clients but presents a unique opportunity for occupational therapy to contribute to this body of knowledge. Cognitive rehabilitation approaches are largely impairment focused and often give little consideration to the environmental context in which clients with cognitive dysfunction have difficulty (Bowen & Lincoln, 2007; das Nair & Lincoln, 2007; Lincoln et al., 2000). Although transferability and generalization are critical to every intervention approach used in rehabilitation, it can be argued that they are most important in the area of cognitive rehabilitation. Occupational therapists are trained to collectively evaluate the person, the environment, and the occupation to improve client participation in everyday life (Christiansen, Baum, & Bass Haugen, 2005). Intervention approaches for cognitive rehabilitation that independently address the person, the environment, or the occupation have been shown not to lead to improvement in participation. All three contexts must be taken into account, and occupational therapists have established intervention approaches that do just that. For example, the Cognitive Orientation to daily Occupational Performance model (CO–OP; McEwen, Polatajko, Huijbregts, & Ryan, 2009, 2010; Polatajko, McEwen, Ryan, & Baum, 2009) was originally designed for children but has recently been adapted for use with people with poststroke cognitive dysfunction. The CO–OP model uses cognitive strategy training to help people compensate for cognitive loss, and in preliminary studies it has been shown to improve participation even in untrained tasks. However, researchers have not conducted the studies necessary to demonstrate that intervention approaches such as CO–OP are effective in helping people with cognitive dysfunction participate in their daily life activities. Conducting effectiveness studies needs to be at the forefront of occupational therapy’s research agenda to enable the profession to achieve the goal of being evidence based.
Conclusion and Future Directions
This article has highlighted the pressing need to conduct effectiveness research to support occupational therapy’s role in rehabilitation, disability, and participation. The profession’s goal of being evidence based is not only necessary to achieve the Centennial Vision but also critical for the future success and growth of the profession. One of the most pressing populations needing to be addressed is people with poststroke cognitive dysfunction, a population identified as a priority by the AOTA Research Advisory Panel (2009) . As a whole, evidence is lacking to support occupational therapy practice with this population. The state of the evidence in this area, reviewed in this article, indicates that future research should take into account the following recommendations:
  1. Intervention approaches addressing cognitive dysfunction poststroke should include participation in everyday life activities as an outcome measure. Past research and available evidence have shown that interventions in common use have a limited impact on changing everyday life outcomes for this client population.

  2. Future intervention development should include methodologies to improve performance in everyday life for people with cognitive dysfunction poststroke. Generalization and transfer of cognitive intervention approaches are problematic and need to be addressed at the onset of intervention development. Intervention approaches that do not take into account the context in which an activity will be performed will not produce changes in everyday life participation.

  3. The development and testing of cognitive intervention approaches should be carried out by a multidisciplinary team. Cognition is an overarching factor in all areas of function, and different professions have different expertise in addressing cognitive dysfunction. Physical therapists understand how cognition affects motor performance, speech therapists understand how cognition affects language, neuropsychologists understand how to capture cognitive dysfunction through standardized assessments, and occupational therapists understand how cognition supports performance in everyday life. Collaboration on multidisciplinary teams will enable occupational therapists to best contribute to the development of the science to support their role in this practice area.

Acknowledgments
I thank the Cognitive Rehabilitation Research Group in the Program in Occupational Therapy at Washington University and, in particular, Colleen Fowler for their support with this article.
References
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*Zlotnik, S., Sachs, D., Rosenblum, S., Shpasser, R., & Josman, N. (2009). Use of the dynamic interactional model in self-care and motor intervention after traumatic brain injury: Explanatory case studies. American Journal of Occupational Therapy, 63, 549–558. doi: 10.5014/ajot.63.5.549 [Article] [PubMed]
*Zlotnik, S., Sachs, D., Rosenblum, S., Shpasser, R., & Josman, N. (2009). Use of the dynamic interactional model in self-care and motor intervention after traumatic brain injury: Explanatory case studies. American Journal of Occupational Therapy, 63, 549–558. doi: 10.5014/ajot.63.5.549 [Article] [PubMed]×
*Studies reviewed for this article.
Studies reviewed for this article.×
Table 1.
Summary of Effectiveness Studies Addressing Rehabilitation, Disability, and Participation Published in the American Journal of Occupational Therapy, 2009 and 2010
Summary of Effectiveness Studies Addressing Rehabilitation, Disability, and Participation Published in the American Journal of Occupational Therapy, 2009 and 2010×
Author/YearLevel of EvidenceContent AreaSampleMethodsOutcomes
Carver (2009) V
  • TBI
  • Intermittent self-catheterization (ISC)
  • Treatment with assistive technology
Inpatient rehabilitation patient with TBI (n = 1)
  • Case study
  • Goal was to improve independence with ISC through construction and use of splint.
  • Function
  • Improved independence with ISC
Earley, Herlache, & Skelton (2010) V
  • Stroke
  • Upper-extremity dysfunction
  • mCIMT
Chronic stroke patient 4 years post-CVA (n = 1)
  • Case study with pre–post assessment
  • Patient received mCIMT with home exercise program (4 weeks).
  • Impairment
  • Improved ROM, MMT, pinch/grip
  • Function
  • Improved self-rating of IADL performance
Fong & Howie (2009) II
  • ABI
  • Cognitive dysfunction
  • Problem-solving treatment
Outpatient rehabilitation patients in Hong Kong with moderate ABI (n = 33)
  • RCT with matched pairs (2 groups)
  • Both groups received cognitive training program.
  • Treatment group (n = 16) received additional problem-solving training.
  • Impairment
  • Improved total score and score on one subtest of metacomponents and executive function
  • Function
  • No significant differences
Giuffrida, Demery, Reyes, Lebowitz, & Hanlon (2009) II
  • TBI
  • Cognitive dysfunction
  • Effect of different practice schedules on improving function
Patients with chronic cognitive impairment after TBI (n = 6)
  • Case control
  • All participants completed 3 tasks: touch typing, 5- to 6-digit sequence typing, and subway schedule task.
  • Patients were assigned to random practice (n = 3) or blocked ordered practice (n = 3).
  • Impairment
  • Improvements in all groups from baseline performance, retained over 2 weeks
  • Transfer of learning to another task demonstrated by random practice group
Goverover, Arango-Lasprilla, Hilary, Chiaravalloti, & DeLuca (2009) II
  • TBI
  • Cognitive dysfunction
  • Use of spacing effect to improve learning and memory
Patients with TBI documented by CT or MRI (n =10) and healthy controls (n = 15)
  • Case control
  • All groups completed both a paragraph and a route-learning task.
  • Within groups, patients were split into either spaced or massed learning groups.
  • Impairment
  • In both groups, better results from spaced learning than from massed practice
  • No significant difference between TBI and control group
Goverover, Chiaravalloti, & DeLuca (2010) II
  • TBI
  • Cognitive dysfunction
  • Use of self-generated vs. directed strategies
Patients with TBI documented by CT or MRI (n = 10) and healthy controls (n = 15)
  • Case control
  • All groups completed 2 meal preparation tasks and 2 financial management tasks. One task for each condition was completed using provided instructions, and the other task was completed using self-generated instructions.
  • Impairment
  • In both groups, better results from self-generated learning than from directed learning
  • No significant difference between TBI and control groups
Hall, Lee, Page, Rosenwax, & Lee (2010) I
  • Hand injury
  • Extensor tendon repair (ETR)
  • Comparison of 3 postoperative treatment protocols
Hospital-based outpatient hand clinic patients with ETR (n = 18) with 24 total injured fingers
  • RCT (3 groups)
  • All participants were assessed 3, 6, and 12 wk posttreatment.
  • Patients were assigned to immobilization (n = 4), early passive motion (n = 5), or early active motion (n = 9) treatment groups.
  • Impairment
  • Across all time points, improvement in all groups
  • Greatest treatment effect with early active motion protocol
Hardy et al. (2010) IV
  • Stroke
  • UE spasticity
  • Treatment study combining 2 existing protocols
Outpatient clinic patients (n = 2) with chronic stroke (>6 months post-CVA) and documented UE spasticity
  • Case study with pre–post assessment
  • Treatment combined UE bracing with electrical stimulation in a functional training program.
  • Impairment
  • Decreased spasticity
  • Function
  • Improved motor function
  • Improvements retained at 3 mo posttreatment
Hayner, Gibson, & Giles (2010) I
  • Stroke
  • Upper extremity dysfunction
  • CIMT
Community-dwelling people with chronic stroke symptoms (>6 months post-CVA; n = 12)
  • RCT (2 groups)
  • Groups were stratified by more or less impaired.
  • Treatment group (n = 6) received CIMT protocol.
  • Control group (n = 6) received bilateral treatment protocol.
  • Function
  • Improved self-rating of performance and satisfaction in both groups
  • Therapeutic improvement a factor of treatment intensity and not related to protocol followed
Hermann et al. (2010) V
  • Stroke
  • ADL limitations
  • Telerehabilitation and task-specific training
Community-dwelling patient with chronic stroke (>3 years post-CVA; n = 1)
  • Case study with pre–post assessment
  • Patients were treated with telerehabilitation protocol to improve ADLs (4 weeks).
  • Impairment
  • Improved UE movement
  • Function
  • Improved motor function
  • Improved self-rating of performance and satisfaction
Jack & Estes (2010) IV
  • Arthritis
  • Lupus related
  • Evaluation of a different intervention approach
Orthopedic outpatient clinic patient with lupus-related arthritis (n = 1)
  • Case study with pre–post assessment
  • Patients received treatment using the occupational adaptation model.
  • Function
  • Improved performance on all functional tasks addressed in treatment
Kim & Colantonio (2010) I
  • TBI
  • Postacute rehabilitation intervention
  • Improvement in community reintegration outcomes
10 research articles from 1990 to 2007 related to improving community reintegration post-TBI
  • Systematic review
  • Goal was to identify evidence to support postacute rehabilitation intervention approaches that address community reintegration.
  • Seven articles provided this evidence.
  • Benefits of postacute TBI rehabilitation programs to improve community reintegration supported by 7 of 10 articles
  • Occupational therapy or occupational therapy interventions involved in all studies
McClure, McClure, Day, & Brufsky (2010) I
  • Breast cancer–related lymphedema (BCRL)
  • Evaluation of a recovery program to improve physical and emotional symptoms
Community-setting patients with BCRL recruited from local hospitals, clinics, and events (n = 32)
  • RCT (2 groups)
  • Treatment group (n = 16) was treated with breast cancer recovery program emphasizing exercise and relaxation. Control group (n = 16) received standard care.
  • Impairment
  • Significantly improved bioimpedance, flexibility, mood, and weight loss in treatment group compared with controls
  • Function
  • Significantly improved quality of life in treatment group compared with controls
Nilsen, Gillen, & Gordon (2010) I
  • Stroke
  • UE dysfunction
  • Use of mental practice to improve recovery
15 research articles published between 1985 and 2009 focused on using mental practice as part of a stroke rehabilitation intervention
  • Systematic review
  • Goal was to determine whether using mental practice is effective in improving UE recovery poststroke.
  • Impairment
  • Support by most articles for mental practice as effective in reducing impairment and improving function of affected UE
  • Generalizability of findings limited by the mostly heterogeneous study populations
Preissner (2010) V
  • Stroke
  • Cognitive dysfunction
  • Use of the task-oriented approach to improve ADL function
Inpatient rehabilitation setting stroke patient with motor and cognitive dysfunction (n = 1)
  • Case study with pre–post assessment
  • Patients were treated with the task-oriented approach.
  • Function
  • Improved self-care performance after treatment
Rand, Weiss, & Katz (2009) III
  • Stroke
  • Cognitive dysfunction
  • Evaluation of a multitasking intervention protocol
Community-dwelling people poststroke with executive function deficits (n = 4)
  • Pre–post assessment
  • Patients were treated using VMall, a virtual supermarket, to improve multitasking.
  • Impairment
  • Improvements on performance-based assessment of executive function
Rowe, Blanton, & Wolf (2009) IV
  • Stroke
  • UE dysfunction
  • Constraint-induced movement therapy
Community-dwelling person with chronic stroke (5 yr post-CVA; n = 1)
  • Case study with pre–post and longitudinal assessment
  • Patients received 2 wk of CIMT treatment.
  • Impairment
  • Improved motor performance
  • Function
  • Improved self-reported function
  • Improvement retained at 5 years
Stapanian, Stapanian, & Staley (2010) V
  • Hand injury
  • Bilateral amputation of all fingers
  • Evaluation of treatment methods used
Community-dwelling person with all fingers amputated secondary to frostbite (n = 1)
  • Case study with pre–post and longitudinal assessment
  • Outcomes were evaluated after index finger residual transfer to thumb.
  • Impairment
  • Improved ROM of thumb MP joint posttreatment and at follow-up 17 years posttreatment
Thorne, Sauve, Yacoub, & Guitard (2009) II
  • Acute care
  • Pressure sores
  • Evaluation of gel pads used to decrease pressure sores
Heterogeneous sample of acute care patients at high risk to develop pressure sores (n = 60)
  • Two-group, nonrandomized crossover
  • Interface pressure was evaluated with and without use of gel pad in supine position.
  • Impairment
  • No significant difference in pressure with or without use of the gel pad
Zlotnik, Sachs, Rosenblum, Shpasser, & Josman (2009) V
  • TBI
  • Adolescents
  • Evaluation of the Dynamic Interaction Model (DIM) intervention approach
Inpatient rehabilitation patients post-TBI (n = 2)
  • Case study with pre–post assessment
  • Patients were treated using the DIM to improve function post-TBI.
  • Function
  • Improved writing, mobility, and independence in self-care posttreatment
Table Footer NoteNote. ABI = acquired brain injury; ADL = activity of daily living; CIMT = constraint-induced movement therapy; CT = computed tomography; CVA = cerebrovascular accident; IADL = instrumental activity of daily living; mCIMT = modified constraint-induced movement therapy; MMT = manual muscle test; MP = metacarpophalangeal; MRI = magnetic resonance imaging; RCT = randomized controlled trial; ROM = range of motion; TBI = traumatic brain injury; UE = upper extremity.
Note. ABI = acquired brain injury; ADL = activity of daily living; CIMT = constraint-induced movement therapy; CT = computed tomography; CVA = cerebrovascular accident; IADL = instrumental activity of daily living; mCIMT = modified constraint-induced movement therapy; MMT = manual muscle test; MP = metacarpophalangeal; MRI = magnetic resonance imaging; RCT = randomized controlled trial; ROM = range of motion; TBI = traumatic brain injury; UE = upper extremity.×
Table 1.
Summary of Effectiveness Studies Addressing Rehabilitation, Disability, and Participation Published in the American Journal of Occupational Therapy, 2009 and 2010
Summary of Effectiveness Studies Addressing Rehabilitation, Disability, and Participation Published in the American Journal of Occupational Therapy, 2009 and 2010×
Author/YearLevel of EvidenceContent AreaSampleMethodsOutcomes
Carver (2009) V
  • TBI
  • Intermittent self-catheterization (ISC)
  • Treatment with assistive technology
Inpatient rehabilitation patient with TBI (n = 1)
  • Case study
  • Goal was to improve independence with ISC through construction and use of splint.
  • Function
  • Improved independence with ISC
Earley, Herlache, & Skelton (2010) V
  • Stroke
  • Upper-extremity dysfunction
  • mCIMT
Chronic stroke patient 4 years post-CVA (n = 1)
  • Case study with pre–post assessment
  • Patient received mCIMT with home exercise program (4 weeks).
  • Impairment
  • Improved ROM, MMT, pinch/grip
  • Function
  • Improved self-rating of IADL performance
Fong & Howie (2009) II
  • ABI
  • Cognitive dysfunction
  • Problem-solving treatment
Outpatient rehabilitation patients in Hong Kong with moderate ABI (n = 33)
  • RCT with matched pairs (2 groups)
  • Both groups received cognitive training program.
  • Treatment group (n = 16) received additional problem-solving training.
  • Impairment
  • Improved total score and score on one subtest of metacomponents and executive function
  • Function
  • No significant differences
Giuffrida, Demery, Reyes, Lebowitz, & Hanlon (2009) II
  • TBI
  • Cognitive dysfunction
  • Effect of different practice schedules on improving function
Patients with chronic cognitive impairment after TBI (n = 6)
  • Case control
  • All participants completed 3 tasks: touch typing, 5- to 6-digit sequence typing, and subway schedule task.
  • Patients were assigned to random practice (n = 3) or blocked ordered practice (n = 3).
  • Impairment
  • Improvements in all groups from baseline performance, retained over 2 weeks
  • Transfer of learning to another task demonstrated by random practice group
Goverover, Arango-Lasprilla, Hilary, Chiaravalloti, & DeLuca (2009) II
  • TBI
  • Cognitive dysfunction
  • Use of spacing effect to improve learning and memory
Patients with TBI documented by CT or MRI (n =10) and healthy controls (n = 15)
  • Case control
  • All groups completed both a paragraph and a route-learning task.
  • Within groups, patients were split into either spaced or massed learning groups.
  • Impairment
  • In both groups, better results from spaced learning than from massed practice
  • No significant difference between TBI and control group
Goverover, Chiaravalloti, & DeLuca (2010) II
  • TBI
  • Cognitive dysfunction
  • Use of self-generated vs. directed strategies
Patients with TBI documented by CT or MRI (n = 10) and healthy controls (n = 15)
  • Case control
  • All groups completed 2 meal preparation tasks and 2 financial management tasks. One task for each condition was completed using provided instructions, and the other task was completed using self-generated instructions.
  • Impairment
  • In both groups, better results from self-generated learning than from directed learning
  • No significant difference between TBI and control groups
Hall, Lee, Page, Rosenwax, & Lee (2010) I
  • Hand injury
  • Extensor tendon repair (ETR)
  • Comparison of 3 postoperative treatment protocols
Hospital-based outpatient hand clinic patients with ETR (n = 18) with 24 total injured fingers
  • RCT (3 groups)
  • All participants were assessed 3, 6, and 12 wk posttreatment.
  • Patients were assigned to immobilization (n = 4), early passive motion (n = 5), or early active motion (n = 9) treatment groups.
  • Impairment
  • Across all time points, improvement in all groups
  • Greatest treatment effect with early active motion protocol
Hardy et al. (2010) IV
  • Stroke
  • UE spasticity
  • Treatment study combining 2 existing protocols
Outpatient clinic patients (n = 2) with chronic stroke (>6 months post-CVA) and documented UE spasticity
  • Case study with pre–post assessment
  • Treatment combined UE bracing with electrical stimulation in a functional training program.
  • Impairment
  • Decreased spasticity
  • Function
  • Improved motor function
  • Improvements retained at 3 mo posttreatment
Hayner, Gibson, & Giles (2010) I
  • Stroke
  • Upper extremity dysfunction
  • CIMT
Community-dwelling people with chronic stroke symptoms (>6 months post-CVA; n = 12)
  • RCT (2 groups)
  • Groups were stratified by more or less impaired.
  • Treatment group (n = 6) received CIMT protocol.
  • Control group (n = 6) received bilateral treatment protocol.
  • Function
  • Improved self-rating of performance and satisfaction in both groups
  • Therapeutic improvement a factor of treatment intensity and not related to protocol followed
Hermann et al. (2010) V
  • Stroke
  • ADL limitations
  • Telerehabilitation and task-specific training
Community-dwelling patient with chronic stroke (>3 years post-CVA; n = 1)
  • Case study with pre–post assessment
  • Patients were treated with telerehabilitation protocol to improve ADLs (4 weeks).
  • Impairment
  • Improved UE movement
  • Function
  • Improved motor function
  • Improved self-rating of performance and satisfaction
Jack & Estes (2010) IV
  • Arthritis
  • Lupus related
  • Evaluation of a different intervention approach
Orthopedic outpatient clinic patient with lupus-related arthritis (n = 1)
  • Case study with pre–post assessment
  • Patients received treatment using the occupational adaptation model.
  • Function
  • Improved performance on all functional tasks addressed in treatment
Kim & Colantonio (2010) I
  • TBI
  • Postacute rehabilitation intervention
  • Improvement in community reintegration outcomes
10 research articles from 1990 to 2007 related to improving community reintegration post-TBI
  • Systematic review
  • Goal was to identify evidence to support postacute rehabilitation intervention approaches that address community reintegration.
  • Seven articles provided this evidence.
  • Benefits of postacute TBI rehabilitation programs to improve community reintegration supported by 7 of 10 articles
  • Occupational therapy or occupational therapy interventions involved in all studies
McClure, McClure, Day, & Brufsky (2010) I
  • Breast cancer–related lymphedema (BCRL)
  • Evaluation of a recovery program to improve physical and emotional symptoms
Community-setting patients with BCRL recruited from local hospitals, clinics, and events (n = 32)
  • RCT (2 groups)
  • Treatment group (n = 16) was treated with breast cancer recovery program emphasizing exercise and relaxation. Control group (n = 16) received standard care.
  • Impairment
  • Significantly improved bioimpedance, flexibility, mood, and weight loss in treatment group compared with controls
  • Function
  • Significantly improved quality of life in treatment group compared with controls
Nilsen, Gillen, & Gordon (2010) I
  • Stroke
  • UE dysfunction
  • Use of mental practice to improve recovery
15 research articles published between 1985 and 2009 focused on using mental practice as part of a stroke rehabilitation intervention
  • Systematic review
  • Goal was to determine whether using mental practice is effective in improving UE recovery poststroke.
  • Impairment
  • Support by most articles for mental practice as effective in reducing impairment and improving function of affected UE
  • Generalizability of findings limited by the mostly heterogeneous study populations
Preissner (2010) V
  • Stroke
  • Cognitive dysfunction
  • Use of the task-oriented approach to improve ADL function
Inpatient rehabilitation setting stroke patient with motor and cognitive dysfunction (n = 1)
  • Case study with pre–post assessment
  • Patients were treated with the task-oriented approach.
  • Function
  • Improved self-care performance after treatment
Rand, Weiss, & Katz (2009) III
  • Stroke
  • Cognitive dysfunction
  • Evaluation of a multitasking intervention protocol
Community-dwelling people poststroke with executive function deficits (n = 4)
  • Pre–post assessment
  • Patients were treated using VMall, a virtual supermarket, to improve multitasking.
  • Impairment
  • Improvements on performance-based assessment of executive function
Rowe, Blanton, & Wolf (2009) IV
  • Stroke
  • UE dysfunction
  • Constraint-induced movement therapy
Community-dwelling person with chronic stroke (5 yr post-CVA; n = 1)
  • Case study with pre–post and longitudinal assessment
  • Patients received 2 wk of CIMT treatment.
  • Impairment
  • Improved motor performance
  • Function
  • Improved self-reported function
  • Improvement retained at 5 years
Stapanian, Stapanian, & Staley (2010) V
  • Hand injury
  • Bilateral amputation of all fingers
  • Evaluation of treatment methods used
Community-dwelling person with all fingers amputated secondary to frostbite (n = 1)
  • Case study with pre–post and longitudinal assessment
  • Outcomes were evaluated after index finger residual transfer to thumb.
  • Impairment
  • Improved ROM of thumb MP joint posttreatment and at follow-up 17 years posttreatment
Thorne, Sauve, Yacoub, & Guitard (2009) II
  • Acute care
  • Pressure sores
  • Evaluation of gel pads used to decrease pressure sores
Heterogeneous sample of acute care patients at high risk to develop pressure sores (n = 60)
  • Two-group, nonrandomized crossover
  • Interface pressure was evaluated with and without use of gel pad in supine position.
  • Impairment
  • No significant difference in pressure with or without use of the gel pad
Zlotnik, Sachs, Rosenblum, Shpasser, & Josman (2009) V
  • TBI
  • Adolescents
  • Evaluation of the Dynamic Interaction Model (DIM) intervention approach
Inpatient rehabilitation patients post-TBI (n = 2)
  • Case study with pre–post assessment
  • Patients were treated using the DIM to improve function post-TBI.
  • Function
  • Improved writing, mobility, and independence in self-care posttreatment
Table Footer NoteNote. ABI = acquired brain injury; ADL = activity of daily living; CIMT = constraint-induced movement therapy; CT = computed tomography; CVA = cerebrovascular accident; IADL = instrumental activity of daily living; mCIMT = modified constraint-induced movement therapy; MMT = manual muscle test; MP = metacarpophalangeal; MRI = magnetic resonance imaging; RCT = randomized controlled trial; ROM = range of motion; TBI = traumatic brain injury; UE = upper extremity.
Note. ABI = acquired brain injury; ADL = activity of daily living; CIMT = constraint-induced movement therapy; CT = computed tomography; CVA = cerebrovascular accident; IADL = instrumental activity of daily living; mCIMT = modified constraint-induced movement therapy; MMT = manual muscle test; MP = metacarpophalangeal; MRI = magnetic resonance imaging; RCT = randomized controlled trial; ROM = range of motion; TBI = traumatic brain injury; UE = upper extremity.×
×
Table 2.
Studies Identified by the Cochrane Reviews to Support Cognitive Rehabilitation for Attention, Memory, and Spatial Neglect Poststroke
Studies Identified by the Cochrane Reviews to Support Cognitive Rehabilitation for Attention, Memory, and Spatial Neglect Poststroke×
TitleProfessionPopulationInterventionOutcomesConclusions
“Cognitive rehabilitation for attention deficits following stroke” (Lincoln, Majid, & Weyman, 2000)NeuropsychologyStroke patients (n = 29)RCT—Treatment group (n = 16) received attentional training program; control group (n = 13) received standard care.
  • Impairment
  • Improved sustained attention
  • Function
  • No effect on ADL
Intervention was effective in improving attentional impairment, but improvement did not generalize to improved ADL performance.
“Rehabilitation von Aufmerksamkeits storungen nach einem Schlagenfall—Effectivitat eines verhaltensmedizinisch–neuropsychologischen Aufmerksamkeitstrainings” (Schöttke, 1997)
“Efficacy of a reaction training on various attentional and cognitive functions in stroke patients” (Sturm & Willmes, 1991)NeuropsychologyLeft hemisphere stroke patients (n = 27)RCT crossover design—computer-assisted reaction training program
  • Impairment
  • • Improved alertness
  • • Improved sustained attention
Intervention was effective in improving attentional impairment, but improvement did not generalize to other cognitive functions.
“Cognitive rehabilitation for memory deficits following stroke” (das Nair & Lincoln, 2007)NeuropsychologyStroke patients (n = 12)RCT—Treatment group (n = 6) received a memory training program that combined 6 different strategies; control group (n = 6) received repetitive practice of memory tasks.
  • Impairment
  • • Improved performance on trained memory tasks
  • • No transfer to untrained tasks
  • Function
  • • No effect on everyday memory functions
Only trained task performance improved in the treatment group compared with the control group, and this improvement did not transfer to global memory function or everyday memory.
“Cognitive training for memory deficits in stroke patients” (Doornhein & deHaan, 1998)
“Imagery mnemonics for the rehabilitation of memory: A randomised group controlled trial” (Kaschel et al., 2002)NeuropsychologyMixed etiology sample (n = 21) that included stroke patients (n = 6)RCT—Treatment group (n = 3) received an experimental imagery mnemonic program; control group (n = 3) received a pragmatic memory rehabilitation program.
  • Impairment
  • In the stroke group, no significant differences between groups
The entire group showed improvement in delayed and immediate recall; however, in the stroke groups, there was no difference between groups.
“Cognitive rehabilitation for spatial neglect following stroke” (Bowen & Lincoln, 2007)Speech language pathology, physical medicine and rehabilitationPatients with right hemisphere stroke and evidence of neglect (n = 4)Efficacy study—Treatment 1 (n = 2) received an intervention of repetitive practice during a reading task; Treatment 2 (n = 2) received an intervention targeting impairment of attention during visual scanning.No clear efficacy of either approach determinedNo objective data were obtained to support or refute either approach.
“Two approaches to treating unilateral neglect after right hemisphere stroke: A preliminary investigation” (Cherney, Halper, & Papachronis, 2003)
“A comparison of two approaches in the treatment of perceptual problems after stroke” (Edmans, Webster, & Lincoln, 2000)Occupational therapyPatients in an inpatient rehabilitation hospital with neglect secondary to stroke (n = 80)RCT—Group 1 (n = 40) received a transfer of training approach; Group 2 (n = 40) received the functional approach for perceptual treatment.
  • Impairment
  • • No significant differences between groups in perceptual impairment
  • • Overall improvements in both groups
  • Function
  • • No difference between groups in ADL performance.
  • • Overall improvements in both groups
Results provided no clear indication that one treatment approach was better than the other; however, both groups improved on measures of perception and self-care. The time frame of the intervention, however, could indicate that findings were attributable to spontaneous recovery.
“The treatment of visual neglect using feedback of eye movements: A pilot study” (Fanthome, Lincoln, Drummond, & Walker, 1995)PsychologyPatients in an inpatient rehabilitation hospital with neglect secondary to stroke (n = 12)RCT—Treatment group (n = 9) received an eye movement feedback treatment; control group (n = 3) received no treatment.
  • Impairment
  • • No significant differences between groups in neglect or eye movements over time
Feedback from eye movements had no significant effect on eye movements or neglect symptoms poststroke.
“The influence of visual neglect on stroke rehabilitation” (Kalra, Perez, Gupta, & Wittink, 1997)MedicinePatients with neglect secondary to stroke (n =12)RCT—Treatment group (n = 9) received spatiomotor cueing with an early emphasis on function; control group (n = 3) received standard care.
  • Function
  • • Significantly lower median days in hospital for treatment group compared with controls
  • • No significant difference in ADL function
Although the results of this study showed that the treatment group trended toward improved ADL performance, the results were not significant.
“Microcomputer-based rehabilitation for unilateral left visual neglect: A randomised controlled trial” (Robertson, Gray, Pentland, & Waite, 1990)PsychologyPatients in an inpatient rehabilitation hospital setting with neglect secondary to stroke (n = 36)RCT—Treatment group (n = 20) received computer scanning and attention training; control group (n = 16) received recreational computing.
  • Impairment
  • No significant differences between groups in neglect at 6 months
The use of computer training is not supported as a method to improve neglect.
“Rehabilitation by limb activation training reduces left-sided motor impairment in unilateral neglect patients: a single-blind randomised control trial” (Robertson, McMillan, MacLeod, Edgeworth, & Brock, 2002)NeuropsychologyPatients with neglect secondary to stroke (n = 36)RCT—Treatment group received limb activation training plus perceptual training (n = 17); control group (n = 19) received perceptual training only.
  • Impairment
  • Significant improvement in left side motor function for treatment group compared with controls
Limb activation training can improve impairment in left side motor function; impact on everyday life function was not assessed.
“Fresnel prisms improve visual perception in stroke patients with homonymous hemianopia or unilateral visual neglect” (Rossi, Kheyfets, & Reding, 1990)Physical medicine and rehabilitationPatients with neglect secondary to stroke or hemianopsia (n = 39)RCT—Treatment group (n = 18) received 15-diopter Fresnel prism glasses; control group (n = 21) received standard care.
  • Impairment
  • Significant improvement in perception, neglect, and visual field sight for treatment group compared with controls
  • Function
  • No difference between groups in ADL performance
Fresnel prisms were shown to improve impairment associated with neglect or hemianopsia; however, there was no difference between groups in function.
“Different cognitive trainings in the rehabilitation of visuo-spatial neglect” (Rusconi, Meineke, Sbrissa, & Bernardini, 2002)PsychologyPatients with neglect secondary to stroke (n = 20)RCT (4 groups)—Group 1 (n = 5) received Training 1 (visuospatial and visuoconstructive tasks); Group 2 (n = 5) received Training 1 plus TENS; Group 3 (n = 5) received Training 2 (cueing and feedback); Group 4 (n = 5) received Training 2 plus TENS.
  • Impairment
  • Improvement in neglect symptoms for all groups; treatment effect greater in Training 1
The use of TENS associated with any treatment for neglect is not supported to improve symptoms. The impact of intervention on functional outcomes was not assessed.
“Visual scanning training effect on reading-related tasks in acquired right brain damage” (Weinberg et al., 1977)PsychologyPatients with neglect secondary to stroke (n = 57)RCT—Treatment group (n = 25) received visual scanning training; control group (n = 32) received standard care.
  • Impairment
  • Significantly greater improvement in scanning for treatment group compared with controls
Visual scanning training for neglect can improve scanning abilities; however, the impact on function was not assessed.
“Unilateral neglect syndrome rehabilitation by trunk rotation and scanning training” (Wiart et al., 1997)Physical medicine and rehabilitationPatients with neglect secondary to stroke (n = 22)RCT—Treatment group (n = 11) received Bon Saint Come’s device (voluntary trunk rotation); control group (n = 11) received standard care.
  • Impairment
  • Significant improvement in neglect for treatment group compared with controls
  • Function
  • Significant improvement in ADL for treatment group compared with controls
The Bon Saint Come’s device was shown to improve impairment in neglect and improve ADL function. Further study was recommended.
“Viewing less to see better” (Zeloni, Farne, & Baccini, 2002)NeuropsychologyPatients with neglect secondary to stroke (n = 11)RCT—Treatment group (n = 5) received scanning task with hemiblinding goggles; control group (n = 6) received just scanning task.
  • Impairment
  • Significant improvement in neglect for treatment group compared with controls immediately and 1 wk posttreatment
Hemiblinding goggles were shown to improve neglect; however, the impact of this treatment on function was not assessed.
Table Footer NoteNote. ADL = activity of daily living; RCT = randomized controlled trial; TENS = transcutaneous electrical nerve stimulation.
Note. ADL = activity of daily living; RCT = randomized controlled trial; TENS = transcutaneous electrical nerve stimulation.×
Table 2.
Studies Identified by the Cochrane Reviews to Support Cognitive Rehabilitation for Attention, Memory, and Spatial Neglect Poststroke
Studies Identified by the Cochrane Reviews to Support Cognitive Rehabilitation for Attention, Memory, and Spatial Neglect Poststroke×
TitleProfessionPopulationInterventionOutcomesConclusions
“Cognitive rehabilitation for attention deficits following stroke” (Lincoln, Majid, & Weyman, 2000)NeuropsychologyStroke patients (n = 29)RCT—Treatment group (n = 16) received attentional training program; control group (n = 13) received standard care.
  • Impairment
  • Improved sustained attention
  • Function
  • No effect on ADL
Intervention was effective in improving attentional impairment, but improvement did not generalize to improved ADL performance.
“Rehabilitation von Aufmerksamkeits storungen nach einem Schlagenfall—Effectivitat eines verhaltensmedizinisch–neuropsychologischen Aufmerksamkeitstrainings” (Schöttke, 1997)
“Efficacy of a reaction training on various attentional and cognitive functions in stroke patients” (Sturm & Willmes, 1991)NeuropsychologyLeft hemisphere stroke patients (n = 27)RCT crossover design—computer-assisted reaction training program
  • Impairment
  • • Improved alertness
  • • Improved sustained attention
Intervention was effective in improving attentional impairment, but improvement did not generalize to other cognitive functions.
“Cognitive rehabilitation for memory deficits following stroke” (das Nair & Lincoln, 2007)NeuropsychologyStroke patients (n = 12)RCT—Treatment group (n = 6) received a memory training program that combined 6 different strategies; control group (n = 6) received repetitive practice of memory tasks.
  • Impairment
  • • Improved performance on trained memory tasks
  • • No transfer to untrained tasks
  • Function
  • • No effect on everyday memory functions
Only trained task performance improved in the treatment group compared with the control group, and this improvement did not transfer to global memory function or everyday memory.
“Cognitive training for memory deficits in stroke patients” (Doornhein & deHaan, 1998)
“Imagery mnemonics for the rehabilitation of memory: A randomised group controlled trial” (Kaschel et al., 2002)NeuropsychologyMixed etiology sample (n = 21) that included stroke patients (n = 6)RCT—Treatment group (n = 3) received an experimental imagery mnemonic program; control group (n = 3) received a pragmatic memory rehabilitation program.
  • Impairment
  • In the stroke group, no significant differences between groups
The entire group showed improvement in delayed and immediate recall; however, in the stroke groups, there was no difference between groups.
“Cognitive rehabilitation for spatial neglect following stroke” (Bowen & Lincoln, 2007)Speech language pathology, physical medicine and rehabilitationPatients with right hemisphere stroke and evidence of neglect (n = 4)Efficacy study—Treatment 1 (n = 2) received an intervention of repetitive practice during a reading task; Treatment 2 (n = 2) received an intervention targeting impairment of attention during visual scanning.No clear efficacy of either approach determinedNo objective data were obtained to support or refute either approach.
“Two approaches to treating unilateral neglect after right hemisphere stroke: A preliminary investigation” (Cherney, Halper, & Papachronis, 2003)
“A comparison of two approaches in the treatment of perceptual problems after stroke” (Edmans, Webster, & Lincoln, 2000)Occupational therapyPatients in an inpatient rehabilitation hospital with neglect secondary to stroke (n = 80)RCT—Group 1 (n = 40) received a transfer of training approach; Group 2 (n = 40) received the functional approach for perceptual treatment.
  • Impairment
  • • No significant differences between groups in perceptual impairment
  • • Overall improvements in both groups
  • Function
  • • No difference between groups in ADL performance.
  • • Overall improvements in both groups
Results provided no clear indication that one treatment approach was better than the other; however, both groups improved on measures of perception and self-care. The time frame of the intervention, however, could indicate that findings were attributable to spontaneous recovery.
“The treatment of visual neglect using feedback of eye movements: A pilot study” (Fanthome, Lincoln, Drummond, & Walker, 1995)PsychologyPatients in an inpatient rehabilitation hospital with neglect secondary to stroke (n = 12)RCT—Treatment group (n = 9) received an eye movement feedback treatment; control group (n = 3) received no treatment.
  • Impairment
  • • No significant differences between groups in neglect or eye movements over time
Feedback from eye movements had no significant effect on eye movements or neglect symptoms poststroke.
“The influence of visual neglect on stroke rehabilitation” (Kalra, Perez, Gupta, & Wittink, 1997)MedicinePatients with neglect secondary to stroke (n =12)RCT—Treatment group (n = 9) received spatiomotor cueing with an early emphasis on function; control group (n = 3) received standard care.
  • Function
  • • Significantly lower median days in hospital for treatment group compared with controls
  • • No significant difference in ADL function
Although the results of this study showed that the treatment group trended toward improved ADL performance, the results were not significant.
“Microcomputer-based rehabilitation for unilateral left visual neglect: A randomised controlled trial” (Robertson, Gray, Pentland, & Waite, 1990)PsychologyPatients in an inpatient rehabilitation hospital setting with neglect secondary to stroke (n = 36)RCT—Treatment group (n = 20) received computer scanning and attention training; control group (n = 16) received recreational computing.
  • Impairment
  • No significant differences between groups in neglect at 6 months
The use of computer training is not supported as a method to improve neglect.
“Rehabilitation by limb activation training reduces left-sided motor impairment in unilateral neglect patients: a single-blind randomised control trial” (Robertson, McMillan, MacLeod, Edgeworth, & Brock, 2002)NeuropsychologyPatients with neglect secondary to stroke (n = 36)RCT—Treatment group received limb activation training plus perceptual training (n = 17); control group (n = 19) received perceptual training only.
  • Impairment
  • Significant improvement in left side motor function for treatment group compared with controls
Limb activation training can improve impairment in left side motor function; impact on everyday life function was not assessed.
“Fresnel prisms improve visual perception in stroke patients with homonymous hemianopia or unilateral visual neglect” (Rossi, Kheyfets, & Reding, 1990)Physical medicine and rehabilitationPatients with neglect secondary to stroke or hemianopsia (n = 39)RCT—Treatment group (n = 18) received 15-diopter Fresnel prism glasses; control group (n = 21) received standard care.
  • Impairment
  • Significant improvement in perception, neglect, and visual field sight for treatment group compared with controls
  • Function
  • No difference between groups in ADL performance
Fresnel prisms were shown to improve impairment associated with neglect or hemianopsia; however, there was no difference between groups in function.
“Different cognitive trainings in the rehabilitation of visuo-spatial neglect” (Rusconi, Meineke, Sbrissa, & Bernardini, 2002)PsychologyPatients with neglect secondary to stroke (n = 20)RCT (4 groups)—Group 1 (n = 5) received Training 1 (visuospatial and visuoconstructive tasks); Group 2 (n = 5) received Training 1 plus TENS; Group 3 (n = 5) received Training 2 (cueing and feedback); Group 4 (n = 5) received Training 2 plus TENS.
  • Impairment
  • Improvement in neglect symptoms for all groups; treatment effect greater in Training 1
The use of TENS associated with any treatment for neglect is not supported to improve symptoms. The impact of intervention on functional outcomes was not assessed.
“Visual scanning training effect on reading-related tasks in acquired right brain damage” (Weinberg et al., 1977)PsychologyPatients with neglect secondary to stroke (n = 57)RCT—Treatment group (n = 25) received visual scanning training; control group (n = 32) received standard care.
  • Impairment
  • Significantly greater improvement in scanning for treatment group compared with controls
Visual scanning training for neglect can improve scanning abilities; however, the impact on function was not assessed.
“Unilateral neglect syndrome rehabilitation by trunk rotation and scanning training” (Wiart et al., 1997)Physical medicine and rehabilitationPatients with neglect secondary to stroke (n = 22)RCT—Treatment group (n = 11) received Bon Saint Come’s device (voluntary trunk rotation); control group (n = 11) received standard care.
  • Impairment
  • Significant improvement in neglect for treatment group compared with controls
  • Function
  • Significant improvement in ADL for treatment group compared with controls
The Bon Saint Come’s device was shown to improve impairment in neglect and improve ADL function. Further study was recommended.
“Viewing less to see better” (Zeloni, Farne, & Baccini, 2002)NeuropsychologyPatients with neglect secondary to stroke (n = 11)RCT—Treatment group (n = 5) received scanning task with hemiblinding goggles; control group (n = 6) received just scanning task.
  • Impairment
  • Significant improvement in neglect for treatment group compared with controls immediately and 1 wk posttreatment
Hemiblinding goggles were shown to improve neglect; however, the impact of this treatment on function was not assessed.
Table Footer NoteNote. ADL = activity of daily living; RCT = randomized controlled trial; TENS = transcutaneous electrical nerve stimulation.
Note. ADL = activity of daily living; RCT = randomized controlled trial; TENS = transcutaneous electrical nerve stimulation.×
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