Ashwini K. Rao; Occupational Therapy in Neurological Disorders: Looking Ahead to the American Occupational Therapy Association’s Centennial Vision. Am J Occup Ther 2012;66(6):e119-e130. doi: 10.5014/ajot.2012.005280.
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© 2017 American Occupational Therapy Association
The Centennial Vision articulated by the American Occupational Therapy Association includes moving the profession to being science driven and evidence based. The American Journal of Occupational Therapy contributes to this vision by publishing high-quality research. I reviewed research in the practice area of neurological rehabilitation published between May 2010 and October 2011. In particular, I reviewed effectiveness and efficacy studies, instrument development and testing, and basic research studies. Concerns emerging from the review were (1) few studies in neurological rehabilitation; (2) many disorders not represented; (3) exclusive use of impairment-level outcomes in some studies; and (4) high preponderance of case series designs in effectiveness studies. To achieve the Centennial Vision, the field needs to improve the volume and diversity of research in neurological rehabilitation. It is also important to modify academic and clinical practice to enable occupational therapists to spend more time in producing high-quality evidence to support the crucial role they play in neurological rehabilitation.
Improve the journal’s access to a wider audience nationally and internationally by making AJOT an online publication (Gutman, 2010b).
Improve the journal’s impact factor through timely publication of high-quality studies, particularly those that examine the effectiveness of occupational therapy intervention in specific practice areas (Gutman, 2010b).
Contribute to the development of occupational therapy as a science-driven and evidence-based profession by publishing larger numbers of high-quality intervention studies (Gutman, 2010a).
Improve the quality of published intervention studies by starting the Research Scholars Initiative, a special program in AJOT in which established and productive research groups in occupational therapy are invited to publish effectiveness or efficacy studies (Gutman, 2010c).
Level I includes systematic reviews, meta-analyses, and randomized controlled trials with low bias;
Level II includes randomized controlled trials with high bias (small sample size) and two-group nonrandomized trials (cohort or case-control studies);
Level III includes single-group nonrandomized studies (pretest–posttest design);
Level IV includes single-subject designs and case series; and
Level V includes expert opinion without critical appraisal.
A stratified randomized trial demonstrated that modified constraint-induced therapy was not different from bilateral therapy of equal intensity on motor function and occupational performance in people with subacute stroke (Hayner et al., 2010).
A nonrandomized cohort study demonstrated that improvements seen as a result of modified constraint-induced therapy were not retained 3 mo after the end of intervention (Page et al., 2011).
Lehman, Woodbury, et al. (2011) examined the factor structure of the DASH through secondary analysis in a large sample of people with orthopedic or neurological problems. The study confirmed previous results that a single factor (relating to whole-arm movements) explained most of the variance, indicating that using the total score of the DASH was appropriate, rather than creating scores for whole-arm movements, fine hand movements, and symptoms.
Lehman, Sindhu, et al. (2011) examined whether using subscales of the DASH (whole-arm movements, fine hand movements, and symptoms) would be useful for clinical practice. As with the preceding study, the authors conducted a secondary retrospective analysis of a large sample. Although the division of the DASH into three subscales was not supported statistically, the authors suggested that each subscale may be useful for setting therapeutic goals.
Classen, Witter, et al. (2011) presented a framework for using clinical assessments to predict driving performance in people with Parkinson’s disease. The study highlighted the importance of a simple test such as the Visual Field of View as a predictor of driving performance. Given the importance of predicting driving performance, this study is highly relevant to clinical practice.
Doig et al. (2010) examined the combined use of the Canadian Occupational Performance Measure and Goal Attainment Scaling in people with TBI. Combined use of the two instruments improved sensitivity to change and provided goals that were client centered, both important factors in choosing assessment tools.
Fear of falls was correlated with anxiety, depression, and lower quality of life among people with stroke (Schmid et al., 2011) . This relationship highlights the importance of assessing and reducing fear of falls among people with stroke.
Chronometry (time taken to complete a task) was not valid for mental practice because no clear agreement was found between the time it took to complete physical practice of a task and the time it took to complete mental practice of a task (Wu et al., 2010). Although mental practice is important in therapeutic practice, Wu et al. (2010) recommended against the use of chronometry.
Combat veterans with TBI commit more driving errors, which increases the risk of road traffic accidents. Occupational therapists working with people with TBI, and with combat veterans in particular, should assess driving performance during the process of community reintegration (Classen, Levy, et al., 2011).
People with TBI learn and retain functional skills better when the learning process is self-generated, highlighting the importance of patients’ active involvement in the learning process (Goverover et al., 2010).
Number of articles on neurological rehabilitation: During the review period (May 2010–October 2011), only 18% of 116 published articles were related to neurological rehabilitation. Given that neurological rehabilitation is a prominent area of practice and research in occupational therapy, it is imperative to have more high-quality studies published in AJOT.
Diversity of practice areas: Most of the articles published during the review period were related to stroke rehabilitation. No articles on Parkinson’s disease, spinal cord injury, Huntington’s disease, and amyotrophic lateral sclerosis were published. It is important for published research to reflect the diversity of practice areas in occupational therapy.
Quality of effectiveness research: The majority of published effectiveness and efficacy studies were single-case designs, which are often seen in the early stages of development of knowledge in specific practice areas (Law & MacDermid, 2008). To achieve the Centennial Vision of producing evidence for clinical practice, it is important to improve the quality of research designs for use in randomized controlled trials.
Choice of outcome measures: During the publication period, several effectiveness studies used impairment-, activity-, and participation-level outcomes. However, some studies used only impairment-level measures. In the future, studies need to include activity- and participation-level measures because they are a major focus of occupational therapy practice.
Increase the volume and diversity of research in neurological rehabilitation: The limitations in number of studies and lack of diversity in populations are, in part, explained by the fact that occupational therapists and their collaborators publish studies in area-specific journals outside occupational therapy. It is important that researchers publish their findings in AJOT so as to reach a larger number of occupational therapists. The publication of special issues and the Research Scholars Initiative will help to increase the volume and diversity of published research.
Improve quality of research: The need for improvement in the quality of effectiveness research is clear, including using more rigorous research designs such as randomized controlled trials. In addition, researchers need to routinely include outcome measures at the activity and participation level. The journal can help in this process by publishing editorial updates on research designs and appropriate use of statistical procedures.
Structurally improve both the volume and quality of research: Although AOTA (2009) has clarified the importance of scholarship and research in occupational therapy education, unified standards for teaching research methods in occupational therapy education are needed. Such uniform standards will ensure that occupational therapists are better trained in best practices for research methodology. An equally important issue concerns the time occupational therapists spend engaging in research activities. A recently published survey by AOTA (2010) reported that occupational therapy faculty members (N = 519) spent 10% of their time, on average, on research-related activities. The survey highlighted that time spent in research decreases with increasing years of experience. In the first 5 yr, faculty members spend 27% of their time on research. Faculty members with >5 yr of experience spend ≤10% time on research. Experienced faculty members should be encouraged to spend more time on research (either directly or through mentoring of junior faculty) so that academic centers maintain productivity. Clinicians (N = 9,305) spent <2% of their time on research activities (AOTA, 2010). Changes in health care have necessitated that clinicians work with larger numbers of patients, leaving little to no time for research activities. The profession needs to design creative ways to integrate research within clinical practice. For instance, using uniform standardized assessment tools and uniform effective interventions in groups of patients can lead to significant progress in examining effectiveness of occupational therapy interventions. To achieve the Centennial Vision, academicians and clinicians need to be enabled to spend greater time on effectiveness and efficacy research (Gutman, 2010a).
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