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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

*Studies reviewed for this article.