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Research Article  |   July 2014
Moving Toward 2017: Progress in Rehabilitation Intervention Effectiveness Research
Author Affiliations
  • Barbara M. Doucet, OTR, PhD, is Assistant Professor, Louisiana State University Health Science Center, School of Allied Health Professions, Department of Occupational Therapy, 1900 Gravier Street, New Orleans, LA 70112; bdouc3@lsuhsc.edu
  • Anne Woodson, OTR, is Adjunct Faculty, University of Texas Medical Branch, Galveston
  • Monica Watford, MA, OTR, is Doctoral Candidate, University of Texas Medical Branch, Galveston
Article Information
Centennial Vision / Evidence-Based Practice / Neurologic Conditions / Rehabilitation, Participation, and Disability / Departments / Centennial Vision
Research Article   |   July 2014
Moving Toward 2017: Progress in Rehabilitation Intervention Effectiveness Research
American Journal of Occupational Therapy, July/August 2014, Vol. 68, e124-e148. doi:10.5014/ajot.2014.011874
American Journal of Occupational Therapy, July/August 2014, Vol. 68, e124-e148. doi:10.5014/ajot.2014.011874
Abstract

Halfway into the 10-yr American Occupational Therapy Association Centennial Vision initiative, occupational therapy has made notable progress in establishing itself as a science-driven profession. Through the diligent work of many talented occupational therapy scholars, 42 research studies exploring interventions used in rehabilitation research were published in the past 5 years. A variety of both novel and established intervention strategies were investigated using diverse research designs and measurement tools. A predominant number of studies were conducted with the poststroke population. Moving forward to 2017 and building on our success, we can recognize our full potential by fostering knowledge translation, expanding participant numbers, exploring less-studied populations, increasing the volume of systematic reviews published, and reporting occupation-centered outcomes, the unique and defining component of our profession.

AOTA’s Centennial Vision: “We envision that occupational therapy is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society’s occupational needs.” (AOTA, 2007, p. 613)

In 2007, the American Occupational Therapy Association (AOTA) articulated the Centennial Vision, a 10-yr strategic planning initiative that would lead to the 100th anniversary of the occupational therapy profession in 2017. Last year marked the halfway point to this vision, and as in any systematic assessment, it is incumbent on us to critically review our progress to this point, identify our accomplishments, and realistically recognize the objectives we have not yet achieved. Most important, it is imperative that we see the opportunities that lie ahead and move forward with a defined plan and the determination to fully accomplish the goals that have been articulated.
In identifying barriers to attaining the eight core elements of the vision (expanded collaborations, power to influence, membership, diverse workforce, clear public image, customer demand, evidence-based decision making, and science-fostered innovation), the primary obstacle listed was “rigid adherence to the status quo” (AOTA, 2007, p. 614). The time is now for each of us to individually reflect on how we can change the status quo in our everyday behaviors. What is critically needed are courageous occupational therapy practitioners willing to expand the profession’s knowledge base by infusing research into their daily practice and creative occupational therapy scholars exploring clinical practice questions to generate meaningful research.
We are what we do. What we do now and 5 yr from now will inform others of who we are as a profession. Since 1998, scholarly leaders in occupational therapy have made a fervent push to encourage and implement evidence-based practice in occupational therapy (Law & Baum, 1998; Tickle-Degnen, 1999). Since that time, the profession has taken major steps toward developing an evidence base for occupational therapy and has begun to produce research centered on validating the effectiveness of its interventions, strategies, tools, and approaches. In 2010, the American Journal of Occupational Therapy (AJOT) designated intervention effectiveness studies as a critical publication priority for the journal (Gutman, 2010). Still, much work remains to be accomplished for occupational therapy to become the evidence-based and science-driven profession of 2017.
Recent reviews of rehabilitation research have called on occupational therapists to increase the volume and quality of research (Rao, 2012); however, in addition to increasing the number and quality of studies conducted, a critical component will be to produce research that focuses on participation, activity, and occupations, the seminal characteristics of our practice, as past rehabilitation reviews have emphasized (Doucet, 2013; Gillen, 2010; Rao, 2012; Wolf, 2011).
The past 5 yr produced 42 intervention effectiveness studies related to rehabilitation practice. These studies represent an important move forward, but we should be challenged to produce studies with larger participant numbers, conduct work that can be directly translated into clinical practice, and design studies that validate the importance of participation, activity, and occupations for healthy living. See summaries of the included articles in Table 1.
Table 1.
Intervention Effectiveness Studies Published in the American Journal of Occupational Therapy, January 2009–June 2013
Intervention Effectiveness Studies Published in the American Journal of Occupational Therapy, January 2009–June 2013×
Author/YearStudy ObjectivesLevel/Design/ParticipantsIntervention and Outcome MeasuresStatistical MethodResultsStudy Limitations
Beckelhimer, Dalton, Richter, Hermann, & Page (2011) Would the use of an Interactive Metronome intervention improve the functionality of a hemiparetic arm in 2 stroke patients?
  • Level V
  • Pretest–postest design
  • N = 2 men (M age = 71.5 yr) with history of ischemic stroke (Participant 1, 25 yr poststroke, Participant 2, 2 yr 2 mo poststroke)
  • Intervention
  • 5 min of preparatory stretching exercises, 20 min of Interactive Metronome use and a combination of purposeful and occupation-based activities for 25 min
  • Outcome Measures
  • FMA Motor Activity Test, COPM, and SIS
Descriptive; pre- and posttestingStudy participants demonstrated a positive change from pre- to posttesting on all outcome measures.
  • Small sample size
  • Further research required to warrant study findings
Carver (2009) Would the use of a trough-shaped prop assist in the 1-handed self-catheterization of a TBI patient with a neurogenic bladder?
  • Level V
  • Single-subject case report
  • N = 1; 57-yr-old male with TBI
  • Intervention
  • Observation; successful insertion and use of catheter
  • Outcome Measures
  • Manual Muscle Testing, FIM™
DescriptiveAfter 3 treatment sessions using the novel M-shaped penile prop, the participant was able to successfully self-catheterize independently.Limited generalizability because of single-subject design
Ciro, Hershey, & Garrison (2013) What is the process and outcome of using the STOMP (Skill-building through Task-Oriented Motor Practice) intervention for a person with Lewy body dementia?
  • Level V
  • Case study
  • N = 1; 73-yr-old woman
  • Intervention
  • The STOMP intervention blended task-oriented training and motor learning principles. Intervention occurred 2–3 hr/day for 10 days.
  • Outcome Measures
  • MMSE, Cornell Scale for Depression, FIM, Caregiver Burden Scale, COPM, and goal attainment scaling
Descriptive; pre- and posttestingPatient demonstrated improvement in 2 of 3 goals that were created by patient’s spouse/caregiver. The STOMP intervention demonstrates some potential in evaluating and assisting with occupational performance deficits.
  • Limited generalizability and designation of causality because of study design
  • No follow-up conducted to determine long-term effects
Earley, Herlache, & Skelton (2010) Would using a meaningful occupation during mCIMT intervention lead to improved functionality of an involved UE?
  • Level V
  • Single-subject case report
  • N = 1; 52-yr-old female violinist, 4 yr poststroke
  • Intervention
  • Participant was involved in an mCIMT program consisting of preparatory methods, purposeful activities, and occupations custom designed to her therapeutic goals. Activities involved the repeated practice of specific skills and movements necessary to play the violin. Intervention occurred 3 hr/day for 20 days.
  • Outcome Measures
  • FMA, Sensorimotor Evaluation (modified version), Motor Functioning Assessment (MFA), Arm Improvement and Movement (AIM) checklist, and journaling
Descriptive; pre- and posttestingParticipant demonstrated improved scores on outcome measures and greater function in involved extremity after the mCIMT intervention.
  • Limited generalizability because of small sample size
  • Outcome measures used (FMA, MFA and AIM checklist) not standardized, no established reliability and validity
Finlayson, Preissner, & Cho (2012) Does age, gender, work status, or impairment level have an impact on fatigue management program outcomes for people with multiple sclerosis (MS)?
  • Level III
  • Secondary data analysis using mixed-effects model
  • N = 181 participants with MS (M age = 55 yr; 79% female)
  • Intervention
  • Participants engaged in a teleconference 1×/wk for 6 wk that emphasized rest, body mechanics, environmental modification, communication, activity analysis, and goal setting. Each session lasted 70 min and was facilitated by a licensed occupational therapist.
  • Outcome Measures
  • Fatigue Impact Scale, SF–36, Self-Efficacy for Energy Conservation Questionnaire
Descriptive, mixed-effects models with time trends and variance–covariance structures to determine best modelYounger participants experienced greater reductions in fatigue impact and greater improvements in self-efficacy. Participants with less impairment experienced greater mental health gains and were more likely to retain these gains. Women experienced greater fatigue impact benefits than men, but men experienced greater mental health benefits.
  • Cognitive issues of people with MS not considered
  • Work status not specifically defined
Fong & Howie (2009) Are there greater improvements in outpatients with acquired brain injury when problem-solving skills training includes metacomponential strategies rather than conventional cognitive methods?
  • Level I
  • RCT (matched pairs)
  • N = 33 who had sustained an acquired brain injury (M age = 33.4 yr; 18% female)
  • Intervention
  • The intervention group received functional skills training, conventional cognitive training, and explicit training in problem-solving skills with an emphasis on metacomponential strategies.
  • The control group received conventional cognitive training without the explicit problem-solving component. Training consisted of 2 sessions/wk for 22 sessions.
  • Outcome Measures
  • Behavioral Assessment of the Dysexecutive Syndrome, Social Problem Solving Video Measure, Means Ends Problem Solving Measure, Raven’s Progressive Matrices, Metacomponential Interview
Descriptive; nonparametric Mann–Whitney U test for comparison of change scoresThe intervention group showed significant advantages vs. the control group on the Metacomponential Interview, demonstrating an association with the metacomponential training method used; however, transferability of these skills to real-life problem-solving measures did not produce significant findings.
  • Small sample size and participant attrition
  • Lack of a culturally sensitive instrument to collect subjective data
  • Limited time of exposure to intervention
  • Limited extent of validation and adaptation of measures to Hong Kong Chinese population
Giuffrida, Demery, Reyes, Lebowitz, & Hanlon (2009) What are the significant differences in the acquisition, retention, and transfer of skills in participants with TBI who learned a task using random practice vs. blocked practice?
  • Level II
  • Comparative study
  • N = 6 men with TBI (M age = 28 yr)
  • Intervention
  • Random practice (30 min programmed instruction in touch typing, 10 min of learning a subway schedule, and 15 min of rapid numeric input)
  • Blocked practice (typing, subway stop, and numeric input)
  • Outcome Measures
  • WAIS–R, Wechsler Memory Scale–Revised, CVLT, Trail Making Test, Category Test, Finger Tapping Test, Grooved Pegboard Test, Wisconsin Card Sorting Test
Descriptive; ANOVAThe blocked practice and random practice groups both showed a significant increase in performance skill, acquisition, and retention; the random-practice group demonstrated greater transferability to another task.
  • Small sample size
  • Participants without TBI used as control group
  • Lack of functionally relevant tasks
Glasgow, Fleming, Tooth, & Peters (2012) Will participants who are using dynamic Capener splints 12–16 hr/day make greater progress in contracture resolution than those who use splints 6–12 hr/day over 8 wk of treatment?
  • Level I
  • RCT
  • N = 18 participants with extensor deficits of the proximal interphalangeal joint as a result of hand injury (for 6–12-hr group, M age = 41.0 yr; for 12–16-hr group, M age = 35.3 yr)
  • Intervention
  • Dynamic Capener splints were fabricated with mobilizing force set to 200–250 g; each participant was randomly allocated to either a 6–12-hr or a 12–16-hr wearing regimen. Participants were also required to attend therapy every 1–2 wk for 8 wk.
  • Outcome Measures Finger goniometry for ROM, tension gauge to measure torque
Descriptive; nonparametrics for group differences; linear regression analysisNo significant differences in extension ROM were noted between the 2 groups.
  • Small sample size
  • 78% of participants from the 12–16-hr group used their splints <12 hr/day.
  • Static extension splints were used in addition to Capener splint for participants with flexion and extension deficits.
Goverover, Arango-Lasprilla, Hillary, Chiaravalloti, & DeLuca (2009) Does spaced learning enhance the memory of functional tasks in people with TBI?
  • Level III
  • Within-subject
  • N = 25; 10 TBI patients (M age = 42.5 yr) and 15 healthy control participants (M age = 43.3 yr)
  • Intervention
  • Participants were required to complete paragraph learning and rote learning tasks. Trials were presented in massed and spaced conditions.
  • Outcome Measures
  • Digit Span subtest (WAIS–R), SDMT Oral version, CVLT, D–KEFS subtest
Descriptive; ANOVAsParticipants in the spaced learning condition were better able to recall material than those in the massed learning condition.
  • Small sample size
  • Severity of type of brain injury not accounted for
  • Only 2 functional activities assessed
  • Unclear whether this technique would work for more complex tasks
  • Not known whether effects of spaced learning would maintain over a longer follow-up period
Goverover, Chiaravalloti, & DeLuca (2010) Does using the self-generation method improve recall and performance of everyday functional tasks?
  • Level II
  • Within-group
  • N = 25; 10 TBI patients (M age = 42.5 yr) and 15 healthy control participants (M age = 43.3 yr)
  • Intervention
  • Participants were divided into 2 task-learning groups: generated and provided. Generated group generated the key word in each step of the task. Provided group members were provided directions for each task.
  • Outcome Measures
  • WAIS–R, SDMT, CVLT, D–KEFS
Descriptive; ANOVAsInformation learned using the generated procedure was recalled better than information learned using the provided procedure.
  • Small sample size
  • Severity of type of brain injury not accounted for
  • Only 2 functional activities assessed
  • Unclear whether this technique would work for more complex tasks
Guidetti, Asaba, & Tham (2009) What role does context play in recapturing self-care skills after a stroke or SCI?
  • Level III
  • Survey
  • N = 11; 5 participants with stroke and 6 participants with SCI (9 men, 2 women; M age = 52 yr)
  • Intervention
  • Participants were interviewed 1–3 mo after onset of the stroke or SCI to gather information regarding recapturing self-care skills.
  • Outcome Measure
  • Open-ended survey questions
Descriptive; empirical, phenomenological, and psychological method; qualitative analysisSix characteristics were identified that describe the role of context in recapturing self-care: (1) an air of expectation, (2) support from others, (3) new daily structure, (4) extended time, (5) gradual change in challenge, and (6) therapeutic relationship as enabling possibility.
  • Risk of bias in the analysis of interviews
  • Small sample size
  • Variability in self-care training among participants
Hall et al. (2013) Does a conservative treatment program for carpal tunnel syndrome improve symptoms and reduce the desire to seek surgical interventions?
  • Level I
  • RCT
  • N = 54 (50% men; intervention group, M age = 53.8 yr; control group, M age = 54.9 yr)
  • Intervention
  • Participants were separated into a conservative group or a control group. The conservative group received an 8-wk treatment program with a skilled occupational therapist that included wrist splint and education sessions.
  • The control group received no intervention and was only observed for the same period.
  • Outcome Measures
  • Boston Carpal Tunnel Questionnaire, VAS, dynamometer, Purdue Pegboard, Semmes-Weinstein monofilament testing, Phalen’s test, satisfaction questionnaire
Descriptive; paired and independent t tests, χ2 testsParticipants in the conservative group reported greater symptom relief and improved functional outcomes than the control group.
  • Electrodiagnostic testing not used as an outcome measure
  • Differing skill levels of therapists
  • Participant attrition
  • Interventionists not blinded to study purpose or group assignment
Hall, Lee, Page, Rosenwax, & Lee (2010) Do the 3 rehabilitation protocols to repair acute extensor tendon in Zones V and VI have differing treatment effects on patients?
  • Level III
  • Quasi-experimental
  • N = 27 (17 men, 10 women; M age = 30.4 yr)
  • Intervention
  • Participants were divided into 3 groups: IM (resting splint immobilized), EPM (dorsal dynamic extension splint), and EAM (palmar blocking splint). The IM group was immobilized for the 1st 3 wk and performed graded mobilization from Wk 3–6. EPM group began passive motion on Days 1–5 and exercised in the splint during Wk 1–3. EAM group had early active motion on Days 1–5 and exercised in the splint Wk 1–3. A graded mobilization program began in Wk 5–6 for both the EPM and the EAM groups.
  • Outcome Measures
  • ROM, dynamometer, VAS, goniometer, extension lag testing
Descriptive; ANOVAsAll patient groups showed improvement, but EAM group participants recovered ROM more rapidly.
  • Small sample size in the 3 groups
  • High attrition
  • Limited generalizability to other tendon zone injuries
Hand, Law, & McColl (2011) What is the effectiveness of community-based OT interventions for improving occupational outcomes in adults with chronic conditions?
  • Level IV
  • Literature review
  • N = 16 articles; scoping review methodology used. Conditions discussed include rheumatoid arthritis, chronic obstructive pulmonary disease, congestive heart failure, depression, and multiple conditions.
Studies were grouped by occupations: work, physical function, social function, psychological health, and overall health or quality of life.DescriptiveTen studies found significant differences between intervention group participants and control group in ≥1 outcome related to function in ADL, quality of life or health, self-efficacy, social or work function, and psychological health. OT interventions may improve occupational performance outcomes in adults with chronic conditions.
  • Search strategy may have excluded articles.
  • Scope of the articles was limited to select chronic conditions; other conditions may have benefited from OT interventions as well.
Hardy et al. (2010) Does the combined effect of functional training, UE bracing, and electrical stimulation reduce spasticity and improve functional ability in chronic stroke patients?
  • Level V
  • Case series
  • N = 2 women; M age = 72.5
  • Intervention
  • Participants received both clinic- and home-based treatment sessions over 5 wk that included wearing brace with stimulation followed by repetitive, task-specific purposeful activities.
  • Outcome Measures
  • Modified Ashworth Scale (MAS), MMSE, FMA, B&B, AMAT
Descriptive; pre- and posttest scoresAt the end of intervention, participants demonstrated a 1-point reduction in MAS scores, an increase in FMA scores, and an increase in the ability to perform AMAT activities.
  • Small sample size
  • Limited generalizability to other chronic stroke patients
  • In follow-up, no retesting on the outcome measures
Hayner (2012) Does the California Tri-Pull Taping (CTPT) method reduce shoulder pain and inferior glenohumeral subluxation, improve ADL function, and increase AROM?
  • Level III
  • Time series quasi-experimental single-subject ABA design
  • N = 10 participants ranging from 1 mo to 5 yr poststroke
  • Intervention
  • Participants’ affected UE was taped to prevent subluxation using the CTPT method. The tape was removed and replaced every Monday, Wednesday, and Friday for 3 consecutive weeks.
  • Outcome Measures
  • VAS for pain, Katz ADL Scale, goniometry
Descriptive; trend analysis, Wilcoxon matched pairs signed–rank testThe CTPT method showed significant decreases in inferior subluxation from baseline through intervention phase but not through postintervention phase. Significant increases in shoulder flexion and abduction AROM and improved ADLs were evident through both phases.
  • Limited generalizability because of small sample size
  • Interventionists not blinded
  • The primary researcher who created the method collected the data.
  • Varied time since onset of stroke
Hayner, Gibson, & Giles (2010) How does effectiveness of CIMT compare with bilateral treatment of equal intensity in improving UE function in people with chronic UE dysfunction after stroke?
  • Level I
  • Randomized 2-group intervention trial
  • N = 12 participants ≥6 mo since stroke onset; stratified as having more or less UE impairment (determined by WMFT score) and randomly assigned to either CIMT or bilateral treatment group
  • Intervention
  • CIMT group participants wore padded mitt on unimpaired hand; bilateral group participants were intrusively and repetitively cued to use both UEs during all activities; 6 hr/10 days plus additional home practice.
  • Outcome Measures
  • WMFT and COPM, administered before, after, and 6 mo after treatment
Descriptive statistics; mixed model (split-plot) ANOVAs
  • Significant improvements were found in WMFT and COPM scores across time in both groups. No significant between-group differences were found on WMFT. High-intensity OT using either approach can improve UE function in those with chronic poststroke UE impairment. Treatment intensity rather than restraint may be a critical therapeutic factor.
  • Generalizability limited because of small sample size
  • Behaviors learned by the bilateral group may have been more compatible with participants' routine activities than activities of CIMT group.
  • Study design prevents elimination of nonspecific factors accounting for observed improvements.
Henshaw, Polatajko, McEwen, Ryan, & Baum (2011) How can the CO-OP, a task-specific training program, help shift the focus of OT practice from addressing impairments to improving occupational performance in adults with stroke?
  • Level IV
  • 2 single-subject case reports
  • N = 2; 1 woman age 75 yr, 10 mo poststroke, and 1 woman age 65 yr, 13 mo poststroke
  • Intervention
  • Ten intervention sessions using CO-OP approach, a performance-based, problem-solving strategy of goal–plan–do–check
  • Outcome Measures
  • COPM and Performance Quality Rating Scale used to set goals in the areas of self-care, productivity, and leisure and evaluate goal performance
Descriptive; qualitative analysis
  • Improvements were seen in performance and performance satisfaction of selected goals.
  • Findings support continued research in this area.
  • Limited generalizability and designation of causality because of case study design
  • Some scores rated by treating therapist rather than objective party
  • Lack of long-term follow-up testing to determine maintenance of treatment
Hermann et al. (2010) Does a remotely based FES program administered via a neuroprosthesis and telerehabilitation decrease UE impairment in poststroke clients?
  • Level V
  • Single-subject case report
  • N = 1; 62-yr-old man 3 yr poststroke
  • Intervention
  • Participant was educated in use of FES orthosis and provided with computer camera and software for home use. Supervised by therapist over the Internet, participant engaged in occupation-based task-specific practice of ADL using involved UE 2×/wk for 3 wk; participant also performed unsupervised tasks for 2×/day for 3 days/wk.
  • Outcome Measures
  • FMA, ARAT, and COPM, administered before and after intervention
Descriptive; comparative analysis of pre- and postintervention results
  • Scores improved on FMA, ARAT, and COPM. Participant reported increased satisfaction with task performance for all 5 COPM tasks tested and increased bilateral UE use during ADLs. Results suggest feasibility and efficacy of remotely based FES for UE rehabilitation.
  • Limited generalizability to stroke population because of small sample size
  • Reduced neuroprosthesis compliance and probable decreased monitoring of neuroprosthesis use during functional activities
  • Variation in computer competency among potential participants; limits who may benefit from this intervention
Jack & Estes (2010) Does a shift from a biomechanical to an occupational adaptation (OA) hand therapy approach in an orthopedic outpatient clinic improve patient adaptation and motivation and result in clinically significant functional progress?
  • Level V
  • Single-subject case report
  • N = 1; 51-yr-old woman with chronic lupus-related arthritis 6 days postsurgery on left hand, wrist, and forearm
  • Intervention
  • Initial evaluation and treatment based on biomechanical approach aimed at gaining or maintaining AROM and PROM and reducing edema. Treatment included splinting, modalities, massage, and therapeutic exercise. Ten weeks postsurgery, authors decided to shift to a more client-centered, OA therapeutic focus.
  • Outcome Measures
  • COPM; participant seen for 6 additional sessions with emphasis on performance of valued functional activities including compensatory techniques and adaptive equipment
DescriptiveAfter 10 wk of biomechanical-focused therapy, minimal improvements were documented. At conclusion of OA intervention, clinically important improvements were documented in all functional tasks addressed in COPM. Authors recommend combining biomechanical approach with OA approach to facilitate client adaptation and functional progress.Limited generalizability because of small sample size and complexity of participant’s diagnosis
Kim & Colantonio (2010) How effective are postacute TBI rehabilitation intervention programs that include community integration (CI) as an outcome measure? What are characteristics of effective programs, and what is OT’s involvement?
  • Level I
  • Systematic review; included RCTs (2 single-blinded, 2 unblinded), 4 controlled trials (CTs), and 2 high-quality observational studies (1 prospective cohort study, 1 case-control study)
  • N = 10 studies, including a total of 771 participants, mean age 35.4 yr, male and female, TBI severity ranging from mild to severe. Cause of TBI, length of time since injury, duration of treatment periods, and length of follow-up varied across studies.
  • Interventions
  • Treatment interventions categorized into 4 general groups: multidisciplinary rehabilitation, intensive cognitive rehabilitation, comprehensive integrated rehabilitation, and telerehabilitation. Six of 10 studies involved OT.
  • Outcome Measures
  • Community Integration Questionnaire (CIQ) and Brain Injury Community Rehabilitation Outcome–39
  • PEDro used for quality assessment of RCTs; Downs and Black checklist used for CTs and observational study designs
Because each study had different research methods, populations, measurement tools, interventions, and goals, it was not possible to pool data and synthesize results (quantitative or meta-analysis).
  • No studies were of excellent methodological quality. Each research team provided evidence to support its study’s conclusions. Of the 10 studies, 7 found that postacute TBI rehabilitation benefits CI. All effective studies involved OT or interventions occupational therapists can do.
  • Variability in research methods, sample characteristics, measurements, and interventions made analysis of evidence difficult. Limited RCTs addressed CI interventions. Some studies used CI as global outcome rather than focus of intervention.
  • High probability of ceiling effect of CIQ
  • Nonrobust findings may be result of variability among clients with TBI.
Martin, Johnston, & Sadowsky (2012) Does repetitive neuromuscular electrical stimulation (NMES)–assisted training increase strength and efficiency of the hand of patients with chronic tetraplegia during grasp-and-release functional activities?
  • Level IV
  • Prospective case series
  • N = 3 (1 woman, 2 men, 6–21 mo post–cervical SCI; median age = 18.7 yr)
  • Intervention
  • Intervention consisted of grasp training with sequential application of NMES to wrist extensors, finger flexors, and finger extensors to assist grasp and release of balls. Eight 30-min sessions were conducted over 14 days.
  • Outcome Measures
  • JTTHF, B&B; measurements taken before intervention, after 1st training session, and after final session
Descriptive; Friedman repeated-measures ANOVA on ranks; χ2 and p values generated for each comparison; qualitative data analysis on information gained during semistructured interviews at conclusion of intervention period
  • Within-participant improvements in performance were observed in all outcome measures, particularly subtests of JTTHF requiring grasp. Subjectively, participants reported reduction of spasticity and more effective grasp.
  • Small sample size limits application and generalizability.
  • Because study was conducted during regular OT sessions, it is difficult to distinguish specific individual contribution of repetitive task training vs. NMES effects.
McCall, McEwen, Colantonio, Streiner, & Dawson (2011) What are the effects of a mCIMT protocol on participation, activity, and impairment in a population of older adults with subacute stroke?
  • Level III
  • Interrupted time series
  • N = 4 (2 men, 2 women; M age = 82 yr), M time from stroke onset to start of study = 61 days
  • Intervention
  • An mCIMT protocol was individually customized to each participant on the basis of functional goals; treatment mainly shaping during functional activity with mitt worn on nonaffected UE.
  • Sessions were 2 hr/day, 5 days/wk.
  • Outcome Measures
  • COPM, FIM, Chedoke Arm and Hand Activity Inventory (CAHAI), ARAT
Descriptive analysis of mean differences and trend line analysis
  • Improvement was seen in COPM and CAHAI scores in 4 of 4 participants; improvement was seen in FIM self-report in 3 of 4 participants. Improvement was seen only on Pinch subtest of ARAT. Results suggest positive effects on participation and activity levels, with a small positive effect on impairment.
  • Small sample size
  • Nonblinded assessment of outcome measures
  • Difficult to separate treatment effects from naturally occurring recovery or placebo effect
McClure, McClure, Day, & Brufsky (2010) Does participation of clients with breast cancer–related lymphedema (BCRL) in the Breast Cancer Recovery Program (BCRP), a program of exercise and relaxation, improve physical and emotional BCRL symptoms compared with clients following standard professional recommendations?
  • Level I
  • RCT
  • N = 32 (treatment group, n = 16; control group, n = 16). Participants were female outpatients ages 21–80 yr who demonstrated Stage I or II unilateral BCRL.
  • Intervention
  • Treatment group attended 10 biweekly 1-hr sessions followed by 3 mo self-monitored home program sessions focused on relaxation techniques and low- to moderate-intensity exercise. Control group instructed to continue with lymphedema instructions from their medical team.
  • Outcome Measures
  • Lymphedema swelling (bioelectric impedence analysis and truncated cone girth measurements); patient weight (medical scale); goniometry for shoulder AROM, Beck Depression Inventory–II; SF–36 Health Survey II for quality of life; exercise adherence using self-report tool. Participants tested at entry, 2.5 wk, 5 wk, and 3 mo.
Repeated-measures mixed-model analysisTreatment group participants demonstrated significant treatment effects for improved bioimpedence, arm flexibility, quality of life, mood at 3 mo, and weight loss compared with control group. Adherence to home program was high. Results support use of BCRP as a standardized program for clients with BCRL to improve physical and emotional symptoms.
  • Small sample size
  • High percentage of participants with chronic BCRL vs. those newly diagnosed
  • Lack of experimental control of daily exercise and relaxation routine for control group participants
Nilsen, Gillen, DiRusso, & Gordon (2012) Will OT paired with mental practice (MP) reduce impairments and improve function? Would using MP as an internal (first-person) view or external (third-person) view be more effective in reducing impairment and increasing self-perception of occupational performance?
  • Level I
  • Single-blind RCT
  • N = 19 (9 men, 10 women) with unilateral subacute stroke assigned to one of three groups: control group (n = 6; M age = 66.2 yr), internal MP group (n = 6; M age = 46.6 yr), and external MP group (n = 7, M age = 62.0 yr)
  • Intervention
  • Groups received skilled OT training in functional tasks using mental imagery with either internal or external perspective, 30 min 2×/wk for 6 wk; for control group, relaxation imagery training for same duration
  • Outcome Measures
  • Vividness of Movement Imagery Questionnaire–2 to determine imagery ability and FMA, JTTHF, and COPM to assess change
Descriptive; ANOVAsBoth experimental MP groups (internal and external perspective) showed statistically similar improvements on the JTTHF and FMA at posttest. All 3 groups demonstrated improvements on the COPM. OT and MP combined may prove beneficial for UE recovery after a stroke; self-perception does not appear to be enhanced by MP.
  • Limited generalizability because of small sample size and specific population
  • Lack of blinding of interventionist
  • Randomization not stratified by side of stroke or other potential confounding variables
Nilsen, Gillen, & Gordon (2010) Does mental practice remediate impairments and improve function of the upper limb after stroke?
  • Level I
  • Systematic literature review
  • N = 15 studies; total of 140 participants with unilateral stroke, male and female, M age = 51.66. Stroke onset varied widely from acute to chronic phase. Study levels of evidence: 4 Level I, 2 Level II, 1 Level III, 6 Level IV, and 2 Level V
  • Intervention
  • Most studies combined mental and physical practice with substantial differences in protocol, intensity, and duration.
  • Outcome Measures
  • Most common outcome measures included FMA, Motricity Index, JTTHF, and ARAT.
PEDro scale used for quality assessment of internal validity of Level I and Level II studies
  • Most studies showed that mental practice, when combined with physical practice, reduces impairments and improves functional recovery of the affected upper limb.
  • Results were unclear on appropriate dosing, whether benefits are retained over time, and effect of mental practice on occupational performance.
  • Generalizations on effects difficult because of heterogeneity of studies
  • Search limited to journals published in English
  • No differentiation between large and small RCTs labeled Level I
Page, Murray, & Hermann (2011) Do people with stroke participating in mCIT retain motor benefits in the affected UE 3 mo after intervention?
  • Level III
  • Nonrandomized cohort study
  • N = 13 (9 men, 4 women; M age = 63.4 yr; M time since stroke onset = 29.5 mo)
  • Intervention
  • mCIT protocol for 30-min sessions 3×/wk for 10 wk.
  • Treatment included shaping during functional activity and restraint of unaffected arm in sling. No rehabilitative intervention was provided during 3-mo period after mCIT completion.
  • Outcome Measures
  • ARAT and FMA administered directly after mCIT intervention and 3 mo postintervention
Descriptive; t tests3 mo after intervention, 25 of 26 scores on ARAT and FMA showed nominal increases from scores taken directly after intervention. Changes during this period were not significant but indicate that participants retained previous functional level.
  • Small sample size
  • No comparison with participants not receiving mCIT
  • Only impairment level addressed by outcome measures
  • No information on activities of participants during 3-mo postintervention period
Polatajko, McEwen, Ryan, & Baum (2012) Is there a difference in performance on self-selected goals when comparing CO–OP intervention with standard occupational therapy (SOT) in adults poststroke?
  • Level I
  • RCT (pilot study)
  • N = 8 community-dwelling participants ≥ 6 mo after stroke onset with National Institutes of Health Stroke Scale score <13, IQ ≥ 80, and minimal aphasia (M age = 60.4 yr; 57.9% female); randomly assigned to receive CO-OP (n = 4) or SOT (n = 4)
  • Intervention
  • CO-OP, a 10-session, cognitive-oriented approach using client-driven, performance-based, problem-solving strategies. SOT interventions were therapist driven and combined task-specific and component-based training.
  • Outcome Measures
  • Performance Quality Rating Scale and COPM
Descriptive; Mann–Whitney U; linear regressionParticipants in the CO-OP group showed greater improvements in performance than participants receiving SOT.
  • Small sample size
  • Nonblinding of assessment administration
  • Significant withdrawal rates
  • High recruitment-to-enrollment ratio
Preissner (2010) Can the OT task-oriented approach be used to evaluate and treat a client with severe cognitive limitations poststroke? What are the benefits of this approach with this population?
  • Level V
  • Single-subject case report
  • N = 1; 83-yr-old woman with history of dementia and diagnosis of stroke seen in an inpatient rehabilitation setting
  • Intervention
  • 90 min of OT treatment 6 days/wk for 4 wk, applying selected treatment principles of OT task-oriented approach and using both compensatory and remediative strategies
  • Outcome Measures
  • Five-step evaluation framework for OT task-oriented approach, FIM, Assessment of Motor and Process Skills
Descriptive
  • FIM scores improved on all self-care items at time of discharge. Client met 7 of 9 long-term OT goals and was able to improve participation in meaningful occupations and transition to desired postdischarge setting.
Findings not generalizable to general stroke or dementia population because of small sample size
Rand, Weiss, & Katz (2009) Will clients with multitasking deficits after stroke benefit from training with a virtual supermarket running on a video-capture virtual reality system?
  • Level III
  • Pretest–posttest design
  • N = 4 community-dwelling adults poststroke (3 men, 1 woman; ages 53–70 yr; time since stroke ranged from 5 to 27 mo)
  • Intervention
  • Ten 60-min sessions over 3 wk using VMall, a virtual supermarket
  • Outcome Measures
  • Multiple Errands Test (MET)–Hospital Version, Virtual MET, IADL questionnaire
Descriptive; calculation of percentage of improvementParticipants showed improvements ranging from 20.5% to 51.2% in most mistake categories of MET in both a real shopping mall and the VMall. No significant improvement was seen in IADL scores.
  • Small sample size
  • Participants not balanced for gender or time since stroke onset
  • Stroke severity not considered
  • Limited repertoire of tasks addressed by VMall intervention
Rowe, Blanton, & Wolf (2009) Can UE gains achieved with CIT in a person with chronic stroke be maintained several years after intervention?
  • Level V
  • Case report
  • N = 1 woman (age 36 yr) enrolled in CIT training 19 mo poststroke
  • Intervention
  • CIT included mitt-wearing for 90% of waking hours over 14 days; specialized CIT sessions were provided 5.5 hr/weekday.
  • Outcome Measures
  • WMFT, Motor Activity Log (MAL), and Health-Related Quality of Life levels with Stroke Impact Scale used preintervention and immediately postintervention; 4- and 5-yr follow-up retention measures also were collected.
Descriptive analysis of results, change scores from preintervention, postintervention, and follow-upAfter intervention, participant increased speed on tasks on the WMFT; speed continued to increase at 4- and 5-yr follow-up when compared with preintervention measures. MAL amount of use score improved 2.7 points, quality of use improved 2.2 points. Overall improved quality of life was apparent on SIS.Single-subject study
Schepens, Braun, & Murphy (2012) Does a tailored approach to activity pacing improve self-perceived osteoarthritis joint stiffness to a greater degree than a general approach?
  • Level I
  • Secondary analysis of an RCT
  • N = 32 participants with symptomatic knee or hip osteoarthritis (M age = 59.5 yr for general activity-pacing group, 63.9 yr for tailored activity-pacing group)
  • Intervention
  • General approach group received generic activity-pacing educational module; tailored group received patient-specific pacing information. Both groups addressed progress and barriers in implementing pacing strategies.
  • Outcome Measures
  • Baseline data measures, Western Ontario and McMaster Universities Osteoarthritis Index, wrist accelerometer
Descriptive; ANOVA and linear mixed regression model; covariate analysisParticipants in the tailored activity-pacing group significantly improved self-perception of joint stiffness compared with the general group. The tailored activity-pacing group also demonstrated decreasing self-perceived joint stiffness over time.
  • Limited generalizability because of small sample size
  • Only a limited number of occupational therapists trained in the interventions, resulting in possible bias
Skubik-Peplaski, Carrico, Nichols, Chelette, & Sawaki (2012) Do UE motor recovery, neuroplasticity, and occupational performance change with the use of occupation-based interventions provided to a patient with chronic stroke?
  • Level V
  • Single-subject case report
  • N = 1 man (age = 55 yr) with chronic stroke (15 mo postinfarct)
  • Intervention
  • Client-centered OT provided on the basis of COPM goals and interests (meal preparation, home management tasks, playing guitar, object manipulation)
  • Outcome Measures
  • COPM, FMA, SIS, transcranial magnetic stimulation (TMS)
Descriptive; comparative analysis at baseline and postinterventionContralesional and ipsilesional cortical reorganization and expansion of motor maps were seen through TMS. Improved occupational performance and functional use of UE were also present as supported by changes on COPM.
  • Limited generalizability to stroke population because of small sample size
  • Possible confounding from ancillary techniques such as purposeful activities and preparatory methods
Sledziewski, Schaaf, & Mount (2012) Does traditional OT combined with use of the ReoGo® UE robotic trainer increase UE function after incomplete SCI?
  • Level V
  • Single-subject case report
  • N = 1 man (age 51 yr) with incomplete SCI
  • Intervention
  • Intervention combined traditional OT with ReoGo, a robotic device providing high repetitions of functionally relevant UE exercises.
  • Outcome Measures
  • Manual muscle testing, AROM and sensory testing; functional testing including FIM and Capabilities of Upper Extremity (CUE) instrument
Descriptive measures onlyParticipant demonstrated increases in AROM, independence during self-care tasks, strength, and perceived right UE function.
  • Findings not generalizable to SCI population
  • CUE completed retrospectively
  • Lack of established exercise protocols for the ReoGo
  • Goniometer measurements highly variable
Stapanian, Stapanian, & Staley (2010) Can a patient with bilateral amputations of fingers regain functional independence with creative OT interventions, adaptations, and active patient involvement?
  • Level V
  • Case report
  • N = 1 man (age 40 yr) with bilateral amputation of all 5 fingers of both hands through proximal phalanges; skin grafts and “on-top plasty” surgery performed to expand web space and extend thumb lever arm for functional pinch
Intensive OT included sensory stimulation, scar massage, stretching, exercising joints, splint construction, and functional task performance to improve dexterity. AROM measures were taken. Adaptations to clothes, automobile, home and kitchen, and exercise equipment were made to facilitate independence.DescriptiveAROM increased after OT intervention and surgeries; creative adaptations for power and woodworking tools, exercise equipment, and leisure activities were fabricated to maximize independence. An additional universal hand splint was designed to improve prehension.Single-subject study
Thorne, Sauvé, Yacoub, & Guitard (2009) Can gel pads typically used in wheelchairs be used in supine for pressure-relieving purposes and pressure ulcer management?
  • Level III
  • One-group, nonrandomized crossover design
  • N = 60 patients from acute medical floor of metropolitan hospital at low to moderate risk of skin breakdown
  • Intervention
  • Skin integrity of patient was initially assessed, followed by pressure measurement of coccygeal area in supine using a pressure-mapping system inserted between the patient’s buttocks and mattress for 20 min while measures were taken every 5 min; process was repeated after 2 hr with gel pad inserted under pressure-mapping system.
  • Outcome Measures
  • Medical history and demographics, Braden Scale score, Force Sensitive Applications pressure-mapping system
Wilcoxon signed ranks test and post hoc testing to calculate pressure differences; Spearman’s rank-order correlation to test gender, height, weight, and body mass index (BMI) relationshipsOverall, addition of gel pad did not significantly change pressure or pressure ulcer management. Pressure increased with increased weight and BMI of participants.Difficulty determining accurate height, weight, and BMI because of patients’ varied attire
Tsai et al. (2013) Does listening to classical music reduce unilateral neglect (UN) in stroke patients?
  • Level III
  • One-group, nonrandomized, within-subject, repeated-measures design
  • N = 16; convenience sample of patients with right hemisphere stroke and UN from a local medical center and 3 rehabilitation clinics
Participants sat in a quiet room and rated mood states with before and after audio exposure. Classical music, white noise, or silence was used while patients completed the Behavioral Inattention Test subtests of Star Cancellation, Line Bisection (LBT), and Picture Scanning (PST).Repeated-measures ANOVA with post hoc Bonferroni tests for pairwise comparisonsPatients performed better on LBT and PST when listening to classical music; no significant mood change occurred between conditions. Trend showed positive results for using classical music over white noise or silence to improve UN.
  • Subjectively reported mood assessments
  • Physiological responses not measured
  • Only 2 classical music excerpts used
  • Studies with larger populations needed
Unsworth, Bearup, & Rickard (2009) Can previous Upper Limb Use Scale outcomes and intervention data from the Australian Therapy Outcome Measures (AusTOMs) assessment be used as a benchmark for current OT intervention practices and AusTOMs outcomes?
  • Level II
  • Two-group nonrandomized study
  • N = 40; 20 people with stroke admitted to local subacute rehabilitation unit 4 yr earlier (benchmark sample) and 20 people with stroke currently admitted to subacute rehabilitation units (treatment sample)
Retrospective analysis of benchmark data collecting information on interventions used and outcomes on the AusTOMs Upper Limb Use Scale; these were compared with current interventions used and AusTOMs outcomes.Two-way ANOVA with post hoc testing to compare AusTOMs outcomes dataOT intervention practices were used with treatment sample similar to those used with benchmark sample; participants in both samples showed significant improvement in UE function from pre- to postintervention. No significant differences were found when benchmark scores were compared with treatment scores. AusTOMs outcomes can be used as benchmark.
  • Gains achieved may not be solely result of OT intervention
  • Samples drawn from facilities within same metropolitan area
  • Global upper-limb use outcomes assessed; more information may be needed regarding specific skills gained
Wu, Radel, & Hanna-Pladdy (2011) Can physical practice combined with mental practice improve functional performance and self-perception in a person with stroke and ideomotor apraxia (IMA)?
  • Level V
  • Case report
  • N = 1 man (age 44 yr) 7 mo post–ischemic infarct; immediately after stroke, he had received 30 days of inpatient rehabilitation including physical therapy, OT, and speech pathology
  • Intervention
  • Physical practice focused on reaching for cup and turning book pages, which were practiced for first 30 min of session, followed by 30 min of mental practice with audiotape
  • Outcome Measures
  • AMAT, COPM, and abbreviated Florida Apraxia Battery
  • Measures taken preintervention, postintervention, and 4 wk after intervention
Descriptive data and change scoresDespite persisting IMA, functional performance scores on AMAT improved; self-perception also increased as evidenced by COPM scores after intervention.
  • Single-subject study
  • Same investigator performed assessments and interventions
Wu et al. (2013) Can CIT and eye patching (EP) improve functional performance, eye movement, and trunk–arm kinematics in people with stroke and left neglect syndrome?
  • Level I
  • Single-blinded, randomized pretest–posttest control-group design
  • N = 24 patients with right-sided infarct and left neglect syndrome recruited from 8 medical centers and clinics; randomly assigned to 1 of 3 groups: CIT+EP, CIT only, or conventional therapy
  • Intervention
  • CIT+EP group wore mitt on unaffected UE for 6 hr/day for 3 wk while performing functional tasks; also wore glasses with right patch; CIT-only group received same intervention without glasses; conventional group received traditional OT matched in intensity and duration.
  • Outcome Measures
  • Catherine Bergego checklist of neglect (CBCN); kinematic data
ANCOVA to determine differences in performance between groups with Fisher’s post hoc tests; effect size calculationParticipants in the CIT+EP and CIT-only groups improved daily function as evidenced by scores on CBCN; CIT-only group showed greatest eye fixation improvement, and CIT+EP participants improved trunk–arm kinematics more than other groups.Further study needed with varying types of neglect
Yang, Lin, Chen, Wu, & Chen (2012) Will unilateral and bilateral robot-assisted training for recovery of UE movement after stroke elicit better performance than standard OT treatment? Will the 2 training methods have differential effects in outcome measures?
  • Level I
  • RCT
  • N = 21 people with stroke ≥ 6 mo but < 5 yr postonset (14 men, 7 women; M age= 51.29 yr), divided into unilateral robot-assisted training protocol (URTP), bilateral assisted robot training protocol (BRTP), and standard rehabilitation groups
  • Interview
  • Patients received 90–105 min of therapy 5 days/wk for 4 wk. Participants in the URTP and BRTP groups practiced forearm and wrist movements in a simultaneous manner with the Bi-Manu-Track robotic device. The control group received standard rehabilitation.
  • Outcome Measures
  • FMA, Medical Research Council instrument, grip strength, Modified Ashworth Scale, and Bi-Manu-Track robotic device
Descriptive; χ2 test for categorical data; ANCOVA for pre–post and group differencesURTP and BRTP showed different types of benefits for improvement in movement. URTP may be most beneficial for those needing to improve muscle power, strength at distal joints, and upper limb motor impairment, whereas BRTP might be more beneficial for those needing to improve proximal muscle power.
  • Limited generalizability and power because of small sample size
  • Motor control strategy used postintervention not assessed
  • No follow-up time point
  • Occupation-based outcome measures not included
Zlotnik, Sachs, Rosenblum, Shpasser, & Josman (2009) Can the Dynamic Interactional Model of intervention promote changes in the self-care and motor skills of adolescents with TBI?
  • Level V
  • Case studies of 2 adolescents with TBI
  • Case 1: 16-yr-old boy who sustained traumatic TBI and C7 spinal injury with right hemiparesis and Glasgow Coma Scale (GCS) score of 6–7 on admission to intensive care unit; transferred to rehabilitation 2 wk later
  • Case 2: 17-yr-old girl who sustained traumatic TBI, multiple fractures, and subarachnoid hemorrhage with speech and sensory deficits and GCS score of 14–15 on admission; transferred to rehabilitation 10 days later
  • Intervention
  • Case 1 received OT for 32 sessions (1-hr sessions 5 days/wk); Case 2 received 30 OT sessions (0.5- to 1-hr sessions 5 days/wk).
  • Outcome Measures
  • FIM, COPM, Computerized Penmanship Object Evaluation Tool, and Awareness of Mobility Deficits Questionnaire
Outcomes before, during, and after intervention were compared using visual analysis of graphic data, and qualitative results were described.Use of the Dynamic Interactional Model combined with the Extended Awareness Model was effective in meeting the special needs of the 2 adolescents with TBI. Both clients improved from partial awareness of limitations to full awareness after intervention, and both achieved desired improvement in mobility, self-care, and graphomotor functioning.
  • Research conducted in 2 separate rehabilitation settings under varying conditions
  • Treatment and assessment performed by same clinician on 1 case
Table Footer NoteNote. Effectiveness studies are classified using the system described in Lieberman and Scheer (2002) : Level I = systematic reviews, meta-analyses, and RCTs; Level II = two-group, nonrandomized studies; Level III = one-group, nonrandomized studies; Level IV = descriptive studies; and Level V = case reports and expert opinion. ADL = activities of daily living; AMAT = Arm Motor Ability Test; ANCOVA = analysis of covariance; ANOVA = analysis of variance; ARAT = Action Research Arm Test; AROM = active range of motion; B&B = Box and Block Test; CIMT = constraint-induced movement therapy; CIT = constraint-induced therapy; CO-OP = Cognitive Orientation to Daily Occupational Performance; COPM = Canadian Occupational Performance Measure; CVLT = California Verbal Learning Test; D–KEFS = Delis–Kaplan Executive Function System; FES = functional electrical stimulation; FMA = Fugl-Meyer Assessment; IADL = instrumental activities of daily living; JTTHF = Jebsen–Taylor Test of Hand Function; M = mean; mCIMT = modified constraint-induced movement therapy; mCIT = modified constraint-induced therapy; MMSE = Mini-Mental State Examination; OT = occupational therapy; PEDro = Physiotherapy Evidence Database rating scale; PROM = passive range of motion; RCT = randomized controlled trial; ROM = range of motion; SCI = spinal cord injury; SDMT = Symbol Digit Modalities Test; SF–36 = 36-Item Short Form Health Survey; SIS = Stroke Impact Scale; TBI = traumatic brain injury; UE = upper extremity; VAS = visual analog scale; WAIS–R = Wechsler Adult Intelligence Scale–Revised; WMFT = Wolf Motor Function Test.
Note. Effectiveness studies are classified using the system described in Lieberman and Scheer (2002) : Level I = systematic reviews, meta-analyses, and RCTs; Level II = two-group, nonrandomized studies; Level III = one-group, nonrandomized studies; Level IV = descriptive studies; and Level V = case reports and expert opinion. ADL = activities of daily living; AMAT = Arm Motor Ability Test; ANCOVA = analysis of covariance; ANOVA = analysis of variance; ARAT = Action Research Arm Test; AROM = active range of motion; B&B = Box and Block Test; CIMT = constraint-induced movement therapy; CIT = constraint-induced therapy; CO-OP = Cognitive Orientation to Daily Occupational Performance; COPM = Canadian Occupational Performance Measure; CVLT = California Verbal Learning Test; D–KEFS = Delis–Kaplan Executive Function System; FES = functional electrical stimulation; FMA = Fugl-Meyer Assessment; IADL = instrumental activities of daily living; JTTHF = Jebsen–Taylor Test of Hand Function; M = mean; mCIMT = modified constraint-induced movement therapy; mCIT = modified constraint-induced therapy; MMSE = Mini-Mental State Examination; OT = occupational therapy; PEDro = Physiotherapy Evidence Database rating scale; PROM = passive range of motion; RCT = randomized controlled trial; ROM = range of motion; SCI = spinal cord injury; SDMT = Symbol Digit Modalities Test; SF–36 = 36-Item Short Form Health Survey; SIS = Stroke Impact Scale; TBI = traumatic brain injury; UE = upper extremity; VAS = visual analog scale; WAIS–R = Wechsler Adult Intelligence Scale–Revised; WMFT = Wolf Motor Function Test.×
Table 1.
Intervention Effectiveness Studies Published in the American Journal of Occupational Therapy, January 2009–June 2013
Intervention Effectiveness Studies Published in the American Journal of Occupational Therapy, January 2009–June 2013×
Author/YearStudy ObjectivesLevel/Design/ParticipantsIntervention and Outcome MeasuresStatistical MethodResultsStudy Limitations
Beckelhimer, Dalton, Richter, Hermann, & Page (2011) Would the use of an Interactive Metronome intervention improve the functionality of a hemiparetic arm in 2 stroke patients?
  • Level V
  • Pretest–postest design
  • N = 2 men (M age = 71.5 yr) with history of ischemic stroke (Participant 1, 25 yr poststroke, Participant 2, 2 yr 2 mo poststroke)
  • Intervention
  • 5 min of preparatory stretching exercises, 20 min of Interactive Metronome use and a combination of purposeful and occupation-based activities for 25 min
  • Outcome Measures
  • FMA Motor Activity Test, COPM, and SIS
Descriptive; pre- and posttestingStudy participants demonstrated a positive change from pre- to posttesting on all outcome measures.
  • Small sample size
  • Further research required to warrant study findings
Carver (2009) Would the use of a trough-shaped prop assist in the 1-handed self-catheterization of a TBI patient with a neurogenic bladder?
  • Level V
  • Single-subject case report
  • N = 1; 57-yr-old male with TBI
  • Intervention
  • Observation; successful insertion and use of catheter
  • Outcome Measures
  • Manual Muscle Testing, FIM™
DescriptiveAfter 3 treatment sessions using the novel M-shaped penile prop, the participant was able to successfully self-catheterize independently.Limited generalizability because of single-subject design
Ciro, Hershey, & Garrison (2013) What is the process and outcome of using the STOMP (Skill-building through Task-Oriented Motor Practice) intervention for a person with Lewy body dementia?
  • Level V
  • Case study
  • N = 1; 73-yr-old woman
  • Intervention
  • The STOMP intervention blended task-oriented training and motor learning principles. Intervention occurred 2–3 hr/day for 10 days.
  • Outcome Measures
  • MMSE, Cornell Scale for Depression, FIM, Caregiver Burden Scale, COPM, and goal attainment scaling
Descriptive; pre- and posttestingPatient demonstrated improvement in 2 of 3 goals that were created by patient’s spouse/caregiver. The STOMP intervention demonstrates some potential in evaluating and assisting with occupational performance deficits.
  • Limited generalizability and designation of causality because of study design
  • No follow-up conducted to determine long-term effects
Earley, Herlache, & Skelton (2010) Would using a meaningful occupation during mCIMT intervention lead to improved functionality of an involved UE?
  • Level V
  • Single-subject case report
  • N = 1; 52-yr-old female violinist, 4 yr poststroke
  • Intervention
  • Participant was involved in an mCIMT program consisting of preparatory methods, purposeful activities, and occupations custom designed to her therapeutic goals. Activities involved the repeated practice of specific skills and movements necessary to play the violin. Intervention occurred 3 hr/day for 20 days.
  • Outcome Measures
  • FMA, Sensorimotor Evaluation (modified version), Motor Functioning Assessment (MFA), Arm Improvement and Movement (AIM) checklist, and journaling
Descriptive; pre- and posttestingParticipant demonstrated improved scores on outcome measures and greater function in involved extremity after the mCIMT intervention.
  • Limited generalizability because of small sample size
  • Outcome measures used (FMA, MFA and AIM checklist) not standardized, no established reliability and validity
Finlayson, Preissner, & Cho (2012) Does age, gender, work status, or impairment level have an impact on fatigue management program outcomes for people with multiple sclerosis (MS)?
  • Level III
  • Secondary data analysis using mixed-effects model
  • N = 181 participants with MS (M age = 55 yr; 79% female)
  • Intervention
  • Participants engaged in a teleconference 1×/wk for 6 wk that emphasized rest, body mechanics, environmental modification, communication, activity analysis, and goal setting. Each session lasted 70 min and was facilitated by a licensed occupational therapist.
  • Outcome Measures
  • Fatigue Impact Scale, SF–36, Self-Efficacy for Energy Conservation Questionnaire
Descriptive, mixed-effects models with time trends and variance–covariance structures to determine best modelYounger participants experienced greater reductions in fatigue impact and greater improvements in self-efficacy. Participants with less impairment experienced greater mental health gains and were more likely to retain these gains. Women experienced greater fatigue impact benefits than men, but men experienced greater mental health benefits.
  • Cognitive issues of people with MS not considered
  • Work status not specifically defined
Fong & Howie (2009) Are there greater improvements in outpatients with acquired brain injury when problem-solving skills training includes metacomponential strategies rather than conventional cognitive methods?
  • Level I
  • RCT (matched pairs)
  • N = 33 who had sustained an acquired brain injury (M age = 33.4 yr; 18% female)
  • Intervention
  • The intervention group received functional skills training, conventional cognitive training, and explicit training in problem-solving skills with an emphasis on metacomponential strategies.
  • The control group received conventional cognitive training without the explicit problem-solving component. Training consisted of 2 sessions/wk for 22 sessions.
  • Outcome Measures
  • Behavioral Assessment of the Dysexecutive Syndrome, Social Problem Solving Video Measure, Means Ends Problem Solving Measure, Raven’s Progressive Matrices, Metacomponential Interview
Descriptive; nonparametric Mann–Whitney U test for comparison of change scoresThe intervention group showed significant advantages vs. the control group on the Metacomponential Interview, demonstrating an association with the metacomponential training method used; however, transferability of these skills to real-life problem-solving measures did not produce significant findings.
  • Small sample size and participant attrition
  • Lack of a culturally sensitive instrument to collect subjective data
  • Limited time of exposure to intervention
  • Limited extent of validation and adaptation of measures to Hong Kong Chinese population
Giuffrida, Demery, Reyes, Lebowitz, & Hanlon (2009) What are the significant differences in the acquisition, retention, and transfer of skills in participants with TBI who learned a task using random practice vs. blocked practice?
  • Level II
  • Comparative study
  • N = 6 men with TBI (M age = 28 yr)
  • Intervention
  • Random practice (30 min programmed instruction in touch typing, 10 min of learning a subway schedule, and 15 min of rapid numeric input)
  • Blocked practice (typing, subway stop, and numeric input)
  • Outcome Measures
  • WAIS–R, Wechsler Memory Scale–Revised, CVLT, Trail Making Test, Category Test, Finger Tapping Test, Grooved Pegboard Test, Wisconsin Card Sorting Test
Descriptive; ANOVAThe blocked practice and random practice groups both showed a significant increase in performance skill, acquisition, and retention; the random-practice group demonstrated greater transferability to another task.
  • Small sample size
  • Participants without TBI used as control group
  • Lack of functionally relevant tasks
Glasgow, Fleming, Tooth, & Peters (2012) Will participants who are using dynamic Capener splints 12–16 hr/day make greater progress in contracture resolution than those who use splints 6–12 hr/day over 8 wk of treatment?
  • Level I
  • RCT
  • N = 18 participants with extensor deficits of the proximal interphalangeal joint as a result of hand injury (for 6–12-hr group, M age = 41.0 yr; for 12–16-hr group, M age = 35.3 yr)
  • Intervention
  • Dynamic Capener splints were fabricated with mobilizing force set to 200–250 g; each participant was randomly allocated to either a 6–12-hr or a 12–16-hr wearing regimen. Participants were also required to attend therapy every 1–2 wk for 8 wk.
  • Outcome Measures Finger goniometry for ROM, tension gauge to measure torque
Descriptive; nonparametrics for group differences; linear regression analysisNo significant differences in extension ROM were noted between the 2 groups.
  • Small sample size
  • 78% of participants from the 12–16-hr group used their splints <12 hr/day.
  • Static extension splints were used in addition to Capener splint for participants with flexion and extension deficits.
Goverover, Arango-Lasprilla, Hillary, Chiaravalloti, & DeLuca (2009) Does spaced learning enhance the memory of functional tasks in people with TBI?
  • Level III
  • Within-subject
  • N = 25; 10 TBI patients (M age = 42.5 yr) and 15 healthy control participants (M age = 43.3 yr)
  • Intervention
  • Participants were required to complete paragraph learning and rote learning tasks. Trials were presented in massed and spaced conditions.
  • Outcome Measures
  • Digit Span subtest (WAIS–R), SDMT Oral version, CVLT, D–KEFS subtest
Descriptive; ANOVAsParticipants in the spaced learning condition were better able to recall material than those in the massed learning condition.
  • Small sample size
  • Severity of type of brain injury not accounted for
  • Only 2 functional activities assessed
  • Unclear whether this technique would work for more complex tasks
  • Not known whether effects of spaced learning would maintain over a longer follow-up period
Goverover, Chiaravalloti, & DeLuca (2010) Does using the self-generation method improve recall and performance of everyday functional tasks?
  • Level II
  • Within-group
  • N = 25; 10 TBI patients (M age = 42.5 yr) and 15 healthy control participants (M age = 43.3 yr)
  • Intervention
  • Participants were divided into 2 task-learning groups: generated and provided. Generated group generated the key word in each step of the task. Provided group members were provided directions for each task.
  • Outcome Measures
  • WAIS–R, SDMT, CVLT, D–KEFS
Descriptive; ANOVAsInformation learned using the generated procedure was recalled better than information learned using the provided procedure.
  • Small sample size
  • Severity of type of brain injury not accounted for
  • Only 2 functional activities assessed
  • Unclear whether this technique would work for more complex tasks
Guidetti, Asaba, & Tham (2009) What role does context play in recapturing self-care skills after a stroke or SCI?
  • Level III
  • Survey
  • N = 11; 5 participants with stroke and 6 participants with SCI (9 men, 2 women; M age = 52 yr)
  • Intervention
  • Participants were interviewed 1–3 mo after onset of the stroke or SCI to gather information regarding recapturing self-care skills.
  • Outcome Measure
  • Open-ended survey questions
Descriptive; empirical, phenomenological, and psychological method; qualitative analysisSix characteristics were identified that describe the role of context in recapturing self-care: (1) an air of expectation, (2) support from others, (3) new daily structure, (4) extended time, (5) gradual change in challenge, and (6) therapeutic relationship as enabling possibility.
  • Risk of bias in the analysis of interviews
  • Small sample size
  • Variability in self-care training among participants
Hall et al. (2013) Does a conservative treatment program for carpal tunnel syndrome improve symptoms and reduce the desire to seek surgical interventions?
  • Level I
  • RCT
  • N = 54 (50% men; intervention group, M age = 53.8 yr; control group, M age = 54.9 yr)
  • Intervention
  • Participants were separated into a conservative group or a control group. The conservative group received an 8-wk treatment program with a skilled occupational therapist that included wrist splint and education sessions.
  • The control group received no intervention and was only observed for the same period.
  • Outcome Measures
  • Boston Carpal Tunnel Questionnaire, VAS, dynamometer, Purdue Pegboard, Semmes-Weinstein monofilament testing, Phalen’s test, satisfaction questionnaire
Descriptive; paired and independent t tests, χ2 testsParticipants in the conservative group reported greater symptom relief and improved functional outcomes than the control group.
  • Electrodiagnostic testing not used as an outcome measure
  • Differing skill levels of therapists
  • Participant attrition
  • Interventionists not blinded to study purpose or group assignment
Hall, Lee, Page, Rosenwax, & Lee (2010) Do the 3 rehabilitation protocols to repair acute extensor tendon in Zones V and VI have differing treatment effects on patients?
  • Level III
  • Quasi-experimental
  • N = 27 (17 men, 10 women; M age = 30.4 yr)
  • Intervention
  • Participants were divided into 3 groups: IM (resting splint immobilized), EPM (dorsal dynamic extension splint), and EAM (palmar blocking splint). The IM group was immobilized for the 1st 3 wk and performed graded mobilization from Wk 3–6. EPM group began passive motion on Days 1–5 and exercised in the splint during Wk 1–3. EAM group had early active motion on Days 1–5 and exercised in the splint Wk 1–3. A graded mobilization program began in Wk 5–6 for both the EPM and the EAM groups.
  • Outcome Measures
  • ROM, dynamometer, VAS, goniometer, extension lag testing
Descriptive; ANOVAsAll patient groups showed improvement, but EAM group participants recovered ROM more rapidly.
  • Small sample size in the 3 groups
  • High attrition
  • Limited generalizability to other tendon zone injuries
Hand, Law, & McColl (2011) What is the effectiveness of community-based OT interventions for improving occupational outcomes in adults with chronic conditions?
  • Level IV
  • Literature review
  • N = 16 articles; scoping review methodology used. Conditions discussed include rheumatoid arthritis, chronic obstructive pulmonary disease, congestive heart failure, depression, and multiple conditions.
Studies were grouped by occupations: work, physical function, social function, psychological health, and overall health or quality of life.DescriptiveTen studies found significant differences between intervention group participants and control group in ≥1 outcome related to function in ADL, quality of life or health, self-efficacy, social or work function, and psychological health. OT interventions may improve occupational performance outcomes in adults with chronic conditions.
  • Search strategy may have excluded articles.
  • Scope of the articles was limited to select chronic conditions; other conditions may have benefited from OT interventions as well.
Hardy et al. (2010) Does the combined effect of functional training, UE bracing, and electrical stimulation reduce spasticity and improve functional ability in chronic stroke patients?
  • Level V
  • Case series
  • N = 2 women; M age = 72.5
  • Intervention
  • Participants received both clinic- and home-based treatment sessions over 5 wk that included wearing brace with stimulation followed by repetitive, task-specific purposeful activities.
  • Outcome Measures
  • Modified Ashworth Scale (MAS), MMSE, FMA, B&B, AMAT
Descriptive; pre- and posttest scoresAt the end of intervention, participants demonstrated a 1-point reduction in MAS scores, an increase in FMA scores, and an increase in the ability to perform AMAT activities.
  • Small sample size
  • Limited generalizability to other chronic stroke patients
  • In follow-up, no retesting on the outcome measures
Hayner (2012) Does the California Tri-Pull Taping (CTPT) method reduce shoulder pain and inferior glenohumeral subluxation, improve ADL function, and increase AROM?
  • Level III
  • Time series quasi-experimental single-subject ABA design
  • N = 10 participants ranging from 1 mo to 5 yr poststroke
  • Intervention
  • Participants’ affected UE was taped to prevent subluxation using the CTPT method. The tape was removed and replaced every Monday, Wednesday, and Friday for 3 consecutive weeks.
  • Outcome Measures
  • VAS for pain, Katz ADL Scale, goniometry
Descriptive; trend analysis, Wilcoxon matched pairs signed–rank testThe CTPT method showed significant decreases in inferior subluxation from baseline through intervention phase but not through postintervention phase. Significant increases in shoulder flexion and abduction AROM and improved ADLs were evident through both phases.
  • Limited generalizability because of small sample size
  • Interventionists not blinded
  • The primary researcher who created the method collected the data.
  • Varied time since onset of stroke
Hayner, Gibson, & Giles (2010) How does effectiveness of CIMT compare with bilateral treatment of equal intensity in improving UE function in people with chronic UE dysfunction after stroke?
  • Level I
  • Randomized 2-group intervention trial
  • N = 12 participants ≥6 mo since stroke onset; stratified as having more or less UE impairment (determined by WMFT score) and randomly assigned to either CIMT or bilateral treatment group
  • Intervention
  • CIMT group participants wore padded mitt on unimpaired hand; bilateral group participants were intrusively and repetitively cued to use both UEs during all activities; 6 hr/10 days plus additional home practice.
  • Outcome Measures
  • WMFT and COPM, administered before, after, and 6 mo after treatment
Descriptive statistics; mixed model (split-plot) ANOVAs
  • Significant improvements were found in WMFT and COPM scores across time in both groups. No significant between-group differences were found on WMFT. High-intensity OT using either approach can improve UE function in those with chronic poststroke UE impairment. Treatment intensity rather than restraint may be a critical therapeutic factor.
  • Generalizability limited because of small sample size
  • Behaviors learned by the bilateral group may have been more compatible with participants' routine activities than activities of CIMT group.
  • Study design prevents elimination of nonspecific factors accounting for observed improvements.
Henshaw, Polatajko, McEwen, Ryan, & Baum (2011) How can the CO-OP, a task-specific training program, help shift the focus of OT practice from addressing impairments to improving occupational performance in adults with stroke?
  • Level IV
  • 2 single-subject case reports
  • N = 2; 1 woman age 75 yr, 10 mo poststroke, and 1 woman age 65 yr, 13 mo poststroke
  • Intervention
  • Ten intervention sessions using CO-OP approach, a performance-based, problem-solving strategy of goal–plan–do–check
  • Outcome Measures
  • COPM and Performance Quality Rating Scale used to set goals in the areas of self-care, productivity, and leisure and evaluate goal performance
Descriptive; qualitative analysis
  • Improvements were seen in performance and performance satisfaction of selected goals.
  • Findings support continued research in this area.
  • Limited generalizability and designation of causality because of case study design
  • Some scores rated by treating therapist rather than objective party
  • Lack of long-term follow-up testing to determine maintenance of treatment
Hermann et al. (2010) Does a remotely based FES program administered via a neuroprosthesis and telerehabilitation decrease UE impairment in poststroke clients?
  • Level V
  • Single-subject case report
  • N = 1; 62-yr-old man 3 yr poststroke
  • Intervention
  • Participant was educated in use of FES orthosis and provided with computer camera and software for home use. Supervised by therapist over the Internet, participant engaged in occupation-based task-specific practice of ADL using involved UE 2×/wk for 3 wk; participant also performed unsupervised tasks for 2×/day for 3 days/wk.
  • Outcome Measures
  • FMA, ARAT, and COPM, administered before and after intervention
Descriptive; comparative analysis of pre- and postintervention results
  • Scores improved on FMA, ARAT, and COPM. Participant reported increased satisfaction with task performance for all 5 COPM tasks tested and increased bilateral UE use during ADLs. Results suggest feasibility and efficacy of remotely based FES for UE rehabilitation.
  • Limited generalizability to stroke population because of small sample size
  • Reduced neuroprosthesis compliance and probable decreased monitoring of neuroprosthesis use during functional activities
  • Variation in computer competency among potential participants; limits who may benefit from this intervention
Jack & Estes (2010) Does a shift from a biomechanical to an occupational adaptation (OA) hand therapy approach in an orthopedic outpatient clinic improve patient adaptation and motivation and result in clinically significant functional progress?
  • Level V
  • Single-subject case report
  • N = 1; 51-yr-old woman with chronic lupus-related arthritis 6 days postsurgery on left hand, wrist, and forearm
  • Intervention
  • Initial evaluation and treatment based on biomechanical approach aimed at gaining or maintaining AROM and PROM and reducing edema. Treatment included splinting, modalities, massage, and therapeutic exercise. Ten weeks postsurgery, authors decided to shift to a more client-centered, OA therapeutic focus.
  • Outcome Measures
  • COPM; participant seen for 6 additional sessions with emphasis on performance of valued functional activities including compensatory techniques and adaptive equipment
DescriptiveAfter 10 wk of biomechanical-focused therapy, minimal improvements were documented. At conclusion of OA intervention, clinically important improvements were documented in all functional tasks addressed in COPM. Authors recommend combining biomechanical approach with OA approach to facilitate client adaptation and functional progress.Limited generalizability because of small sample size and complexity of participant’s diagnosis
Kim & Colantonio (2010) How effective are postacute TBI rehabilitation intervention programs that include community integration (CI) as an outcome measure? What are characteristics of effective programs, and what is OT’s involvement?
  • Level I
  • Systematic review; included RCTs (2 single-blinded, 2 unblinded), 4 controlled trials (CTs), and 2 high-quality observational studies (1 prospective cohort study, 1 case-control study)
  • N = 10 studies, including a total of 771 participants, mean age 35.4 yr, male and female, TBI severity ranging from mild to severe. Cause of TBI, length of time since injury, duration of treatment periods, and length of follow-up varied across studies.
  • Interventions
  • Treatment interventions categorized into 4 general groups: multidisciplinary rehabilitation, intensive cognitive rehabilitation, comprehensive integrated rehabilitation, and telerehabilitation. Six of 10 studies involved OT.
  • Outcome Measures
  • Community Integration Questionnaire (CIQ) and Brain Injury Community Rehabilitation Outcome–39
  • PEDro used for quality assessment of RCTs; Downs and Black checklist used for CTs and observational study designs
Because each study had different research methods, populations, measurement tools, interventions, and goals, it was not possible to pool data and synthesize results (quantitative or meta-analysis).
  • No studies were of excellent methodological quality. Each research team provided evidence to support its study’s conclusions. Of the 10 studies, 7 found that postacute TBI rehabilitation benefits CI. All effective studies involved OT or interventions occupational therapists can do.
  • Variability in research methods, sample characteristics, measurements, and interventions made analysis of evidence difficult. Limited RCTs addressed CI interventions. Some studies used CI as global outcome rather than focus of intervention.
  • High probability of ceiling effect of CIQ
  • Nonrobust findings may be result of variability among clients with TBI.
Martin, Johnston, & Sadowsky (2012) Does repetitive neuromuscular electrical stimulation (NMES)–assisted training increase strength and efficiency of the hand of patients with chronic tetraplegia during grasp-and-release functional activities?
  • Level IV
  • Prospective case series
  • N = 3 (1 woman, 2 men, 6–21 mo post–cervical SCI; median age = 18.7 yr)
  • Intervention
  • Intervention consisted of grasp training with sequential application of NMES to wrist extensors, finger flexors, and finger extensors to assist grasp and release of balls. Eight 30-min sessions were conducted over 14 days.
  • Outcome Measures
  • JTTHF, B&B; measurements taken before intervention, after 1st training session, and after final session
Descriptive; Friedman repeated-measures ANOVA on ranks; χ2 and p values generated for each comparison; qualitative data analysis on information gained during semistructured interviews at conclusion of intervention period
  • Within-participant improvements in performance were observed in all outcome measures, particularly subtests of JTTHF requiring grasp. Subjectively, participants reported reduction of spasticity and more effective grasp.
  • Small sample size limits application and generalizability.
  • Because study was conducted during regular OT sessions, it is difficult to distinguish specific individual contribution of repetitive task training vs. NMES effects.
McCall, McEwen, Colantonio, Streiner, & Dawson (2011) What are the effects of a mCIMT protocol on participation, activity, and impairment in a population of older adults with subacute stroke?
  • Level III
  • Interrupted time series
  • N = 4 (2 men, 2 women; M age = 82 yr), M time from stroke onset to start of study = 61 days
  • Intervention
  • An mCIMT protocol was individually customized to each participant on the basis of functional goals; treatment mainly shaping during functional activity with mitt worn on nonaffected UE.
  • Sessions were 2 hr/day, 5 days/wk.
  • Outcome Measures
  • COPM, FIM, Chedoke Arm and Hand Activity Inventory (CAHAI), ARAT
Descriptive analysis of mean differences and trend line analysis
  • Improvement was seen in COPM and CAHAI scores in 4 of 4 participants; improvement was seen in FIM self-report in 3 of 4 participants. Improvement was seen only on Pinch subtest of ARAT. Results suggest positive effects on participation and activity levels, with a small positive effect on impairment.
  • Small sample size
  • Nonblinded assessment of outcome measures
  • Difficult to separate treatment effects from naturally occurring recovery or placebo effect
McClure, McClure, Day, & Brufsky (2010) Does participation of clients with breast cancer–related lymphedema (BCRL) in the Breast Cancer Recovery Program (BCRP), a program of exercise and relaxation, improve physical and emotional BCRL symptoms compared with clients following standard professional recommendations?
  • Level I
  • RCT
  • N = 32 (treatment group, n = 16; control group, n = 16). Participants were female outpatients ages 21–80 yr who demonstrated Stage I or II unilateral BCRL.
  • Intervention
  • Treatment group attended 10 biweekly 1-hr sessions followed by 3 mo self-monitored home program sessions focused on relaxation techniques and low- to moderate-intensity exercise. Control group instructed to continue with lymphedema instructions from their medical team.
  • Outcome Measures
  • Lymphedema swelling (bioelectric impedence analysis and truncated cone girth measurements); patient weight (medical scale); goniometry for shoulder AROM, Beck Depression Inventory–II; SF–36 Health Survey II for quality of life; exercise adherence using self-report tool. Participants tested at entry, 2.5 wk, 5 wk, and 3 mo.
Repeated-measures mixed-model analysisTreatment group participants demonstrated significant treatment effects for improved bioimpedence, arm flexibility, quality of life, mood at 3 mo, and weight loss compared with control group. Adherence to home program was high. Results support use of BCRP as a standardized program for clients with BCRL to improve physical and emotional symptoms.
  • Small sample size
  • High percentage of participants with chronic BCRL vs. those newly diagnosed
  • Lack of experimental control of daily exercise and relaxation routine for control group participants
Nilsen, Gillen, DiRusso, & Gordon (2012) Will OT paired with mental practice (MP) reduce impairments and improve function? Would using MP as an internal (first-person) view or external (third-person) view be more effective in reducing impairment and increasing self-perception of occupational performance?
  • Level I
  • Single-blind RCT
  • N = 19 (9 men, 10 women) with unilateral subacute stroke assigned to one of three groups: control group (n = 6; M age = 66.2 yr), internal MP group (n = 6; M age = 46.6 yr), and external MP group (n = 7, M age = 62.0 yr)
  • Intervention
  • Groups received skilled OT training in functional tasks using mental imagery with either internal or external perspective, 30 min 2×/wk for 6 wk; for control group, relaxation imagery training for same duration
  • Outcome Measures
  • Vividness of Movement Imagery Questionnaire–2 to determine imagery ability and FMA, JTTHF, and COPM to assess change
Descriptive; ANOVAsBoth experimental MP groups (internal and external perspective) showed statistically similar improvements on the JTTHF and FMA at posttest. All 3 groups demonstrated improvements on the COPM. OT and MP combined may prove beneficial for UE recovery after a stroke; self-perception does not appear to be enhanced by MP.
  • Limited generalizability because of small sample size and specific population
  • Lack of blinding of interventionist
  • Randomization not stratified by side of stroke or other potential confounding variables
Nilsen, Gillen, & Gordon (2010) Does mental practice remediate impairments and improve function of the upper limb after stroke?
  • Level I
  • Systematic literature review
  • N = 15 studies; total of 140 participants with unilateral stroke, male and female, M age = 51.66. Stroke onset varied widely from acute to chronic phase. Study levels of evidence: 4 Level I, 2 Level II, 1 Level III, 6 Level IV, and 2 Level V
  • Intervention
  • Most studies combined mental and physical practice with substantial differences in protocol, intensity, and duration.
  • Outcome Measures
  • Most common outcome measures included FMA, Motricity Index, JTTHF, and ARAT.
PEDro scale used for quality assessment of internal validity of Level I and Level II studies
  • Most studies showed that mental practice, when combined with physical practice, reduces impairments and improves functional recovery of the affected upper limb.
  • Results were unclear on appropriate dosing, whether benefits are retained over time, and effect of mental practice on occupational performance.
  • Generalizations on effects difficult because of heterogeneity of studies
  • Search limited to journals published in English
  • No differentiation between large and small RCTs labeled Level I
Page, Murray, & Hermann (2011) Do people with stroke participating in mCIT retain motor benefits in the affected UE 3 mo after intervention?
  • Level III
  • Nonrandomized cohort study
  • N = 13 (9 men, 4 women; M age = 63.4 yr; M time since stroke onset = 29.5 mo)
  • Intervention
  • mCIT protocol for 30-min sessions 3×/wk for 10 wk.
  • Treatment included shaping during functional activity and restraint of unaffected arm in sling. No rehabilitative intervention was provided during 3-mo period after mCIT completion.
  • Outcome Measures
  • ARAT and FMA administered directly after mCIT intervention and 3 mo postintervention
Descriptive; t tests3 mo after intervention, 25 of 26 scores on ARAT and FMA showed nominal increases from scores taken directly after intervention. Changes during this period were not significant but indicate that participants retained previous functional level.
  • Small sample size
  • No comparison with participants not receiving mCIT
  • Only impairment level addressed by outcome measures
  • No information on activities of participants during 3-mo postintervention period
Polatajko, McEwen, Ryan, & Baum (2012) Is there a difference in performance on self-selected goals when comparing CO–OP intervention with standard occupational therapy (SOT) in adults poststroke?
  • Level I
  • RCT (pilot study)
  • N = 8 community-dwelling participants ≥ 6 mo after stroke onset with National Institutes of Health Stroke Scale score <13, IQ ≥ 80, and minimal aphasia (M age = 60.4 yr; 57.9% female); randomly assigned to receive CO-OP (n = 4) or SOT (n = 4)
  • Intervention
  • CO-OP, a 10-session, cognitive-oriented approach using client-driven, performance-based, problem-solving strategies. SOT interventions were therapist driven and combined task-specific and component-based training.
  • Outcome Measures
  • Performance Quality Rating Scale and COPM
Descriptive; Mann–Whitney U; linear regressionParticipants in the CO-OP group showed greater improvements in performance than participants receiving SOT.
  • Small sample size
  • Nonblinding of assessment administration
  • Significant withdrawal rates
  • High recruitment-to-enrollment ratio
Preissner (2010) Can the OT task-oriented approach be used to evaluate and treat a client with severe cognitive limitations poststroke? What are the benefits of this approach with this population?
  • Level V
  • Single-subject case report
  • N = 1; 83-yr-old woman with history of dementia and diagnosis of stroke seen in an inpatient rehabilitation setting
  • Intervention
  • 90 min of OT treatment 6 days/wk for 4 wk, applying selected treatment principles of OT task-oriented approach and using both compensatory and remediative strategies
  • Outcome Measures
  • Five-step evaluation framework for OT task-oriented approach, FIM, Assessment of Motor and Process Skills
Descriptive
  • FIM scores improved on all self-care items at time of discharge. Client met 7 of 9 long-term OT goals and was able to improve participation in meaningful occupations and transition to desired postdischarge setting.
Findings not generalizable to general stroke or dementia population because of small sample size
Rand, Weiss, & Katz (2009) Will clients with multitasking deficits after stroke benefit from training with a virtual supermarket running on a video-capture virtual reality system?
  • Level III
  • Pretest–posttest design
  • N = 4 community-dwelling adults poststroke (3 men, 1 woman; ages 53–70 yr; time since stroke ranged from 5 to 27 mo)
  • Intervention
  • Ten 60-min sessions over 3 wk using VMall, a virtual supermarket
  • Outcome Measures
  • Multiple Errands Test (MET)–Hospital Version, Virtual MET, IADL questionnaire
Descriptive; calculation of percentage of improvementParticipants showed improvements ranging from 20.5% to 51.2% in most mistake categories of MET in both a real shopping mall and the VMall. No significant improvement was seen in IADL scores.
  • Small sample size
  • Participants not balanced for gender or time since stroke onset
  • Stroke severity not considered
  • Limited repertoire of tasks addressed by VMall intervention
Rowe, Blanton, & Wolf (2009) Can UE gains achieved with CIT in a person with chronic stroke be maintained several years after intervention?
  • Level V
  • Case report
  • N = 1 woman (age 36 yr) enrolled in CIT training 19 mo poststroke
  • Intervention
  • CIT included mitt-wearing for 90% of waking hours over 14 days; specialized CIT sessions were provided 5.5 hr/weekday.
  • Outcome Measures
  • WMFT, Motor Activity Log (MAL), and Health-Related Quality of Life levels with Stroke Impact Scale used preintervention and immediately postintervention; 4- and 5-yr follow-up retention measures also were collected.
Descriptive analysis of results, change scores from preintervention, postintervention, and follow-upAfter intervention, participant increased speed on tasks on the WMFT; speed continued to increase at 4- and 5-yr follow-up when compared with preintervention measures. MAL amount of use score improved 2.7 points, quality of use improved 2.2 points. Overall improved quality of life was apparent on SIS.Single-subject study
Schepens, Braun, & Murphy (2012) Does a tailored approach to activity pacing improve self-perceived osteoarthritis joint stiffness to a greater degree than a general approach?
  • Level I
  • Secondary analysis of an RCT
  • N = 32 participants with symptomatic knee or hip osteoarthritis (M age = 59.5 yr for general activity-pacing group, 63.9 yr for tailored activity-pacing group)
  • Intervention
  • General approach group received generic activity-pacing educational module; tailored group received patient-specific pacing information. Both groups addressed progress and barriers in implementing pacing strategies.
  • Outcome Measures
  • Baseline data measures, Western Ontario and McMaster Universities Osteoarthritis Index, wrist accelerometer
Descriptive; ANOVA and linear mixed regression model; covariate analysisParticipants in the tailored activity-pacing group significantly improved self-perception of joint stiffness compared with the general group. The tailored activity-pacing group also demonstrated decreasing self-perceived joint stiffness over time.
  • Limited generalizability because of small sample size
  • Only a limited number of occupational therapists trained in the interventions, resulting in possible bias
Skubik-Peplaski, Carrico, Nichols, Chelette, & Sawaki (2012) Do UE motor recovery, neuroplasticity, and occupational performance change with the use of occupation-based interventions provided to a patient with chronic stroke?
  • Level V
  • Single-subject case report
  • N = 1 man (age = 55 yr) with chronic stroke (15 mo postinfarct)
  • Intervention
  • Client-centered OT provided on the basis of COPM goals and interests (meal preparation, home management tasks, playing guitar, object manipulation)
  • Outcome Measures
  • COPM, FMA, SIS, transcranial magnetic stimulation (TMS)
Descriptive; comparative analysis at baseline and postinterventionContralesional and ipsilesional cortical reorganization and expansion of motor maps were seen through TMS. Improved occupational performance and functional use of UE were also present as supported by changes on COPM.
  • Limited generalizability to stroke population because of small sample size
  • Possible confounding from ancillary techniques such as purposeful activities and preparatory methods
Sledziewski, Schaaf, & Mount (2012) Does traditional OT combined with use of the ReoGo® UE robotic trainer increase UE function after incomplete SCI?
  • Level V
  • Single-subject case report
  • N = 1 man (age 51 yr) with incomplete SCI
  • Intervention
  • Intervention combined traditional OT with ReoGo, a robotic device providing high repetitions of functionally relevant UE exercises.
  • Outcome Measures
  • Manual muscle testing, AROM and sensory testing; functional testing including FIM and Capabilities of Upper Extremity (CUE) instrument
Descriptive measures onlyParticipant demonstrated increases in AROM, independence during self-care tasks, strength, and perceived right UE function.
  • Findings not generalizable to SCI population
  • CUE completed retrospectively
  • Lack of established exercise protocols for the ReoGo
  • Goniometer measurements highly variable
Stapanian, Stapanian, & Staley (2010) Can a patient with bilateral amputations of fingers regain functional independence with creative OT interventions, adaptations, and active patient involvement?
  • Level V
  • Case report
  • N = 1 man (age 40 yr) with bilateral amputation of all 5 fingers of both hands through proximal phalanges; skin grafts and “on-top plasty” surgery performed to expand web space and extend thumb lever arm for functional pinch
Intensive OT included sensory stimulation, scar massage, stretching, exercising joints, splint construction, and functional task performance to improve dexterity. AROM measures were taken. Adaptations to clothes, automobile, home and kitchen, and exercise equipment were made to facilitate independence.DescriptiveAROM increased after OT intervention and surgeries; creative adaptations for power and woodworking tools, exercise equipment, and leisure activities were fabricated to maximize independence. An additional universal hand splint was designed to improve prehension.Single-subject study
Thorne, Sauvé, Yacoub, & Guitard (2009) Can gel pads typically used in wheelchairs be used in supine for pressure-relieving purposes and pressure ulcer management?
  • Level III
  • One-group, nonrandomized crossover design
  • N = 60 patients from acute medical floor of metropolitan hospital at low to moderate risk of skin breakdown
  • Intervention
  • Skin integrity of patient was initially assessed, followed by pressure measurement of coccygeal area in supine using a pressure-mapping system inserted between the patient’s buttocks and mattress for 20 min while measures were taken every 5 min; process was repeated after 2 hr with gel pad inserted under pressure-mapping system.
  • Outcome Measures
  • Medical history and demographics, Braden Scale score, Force Sensitive Applications pressure-mapping system
Wilcoxon signed ranks test and post hoc testing to calculate pressure differences; Spearman’s rank-order correlation to test gender, height, weight, and body mass index (BMI) relationshipsOverall, addition of gel pad did not significantly change pressure or pressure ulcer management. Pressure increased with increased weight and BMI of participants.Difficulty determining accurate height, weight, and BMI because of patients’ varied attire
Tsai et al. (2013) Does listening to classical music reduce unilateral neglect (UN) in stroke patients?
  • Level III
  • One-group, nonrandomized, within-subject, repeated-measures design
  • N = 16; convenience sample of patients with right hemisphere stroke and UN from a local medical center and 3 rehabilitation clinics
Participants sat in a quiet room and rated mood states with before and after audio exposure. Classical music, white noise, or silence was used while patients completed the Behavioral Inattention Test subtests of Star Cancellation, Line Bisection (LBT), and Picture Scanning (PST).Repeated-measures ANOVA with post hoc Bonferroni tests for pairwise comparisonsPatients performed better on LBT and PST when listening to classical music; no significant mood change occurred between conditions. Trend showed positive results for using classical music over white noise or silence to improve UN.
  • Subjectively reported mood assessments
  • Physiological responses not measured
  • Only 2 classical music excerpts used
  • Studies with larger populations needed
Unsworth, Bearup, & Rickard (2009) Can previous Upper Limb Use Scale outcomes and intervention data from the Australian Therapy Outcome Measures (AusTOMs) assessment be used as a benchmark for current OT intervention practices and AusTOMs outcomes?
  • Level II
  • Two-group nonrandomized study
  • N = 40; 20 people with stroke admitted to local subacute rehabilitation unit 4 yr earlier (benchmark sample) and 20 people with stroke currently admitted to subacute rehabilitation units (treatment sample)
Retrospective analysis of benchmark data collecting information on interventions used and outcomes on the AusTOMs Upper Limb Use Scale; these were compared with current interventions used and AusTOMs outcomes.Two-way ANOVA with post hoc testing to compare AusTOMs outcomes dataOT intervention practices were used with treatment sample similar to those used with benchmark sample; participants in both samples showed significant improvement in UE function from pre- to postintervention. No significant differences were found when benchmark scores were compared with treatment scores. AusTOMs outcomes can be used as benchmark.
  • Gains achieved may not be solely result of OT intervention
  • Samples drawn from facilities within same metropolitan area
  • Global upper-limb use outcomes assessed; more information may be needed regarding specific skills gained
Wu, Radel, & Hanna-Pladdy (2011) Can physical practice combined with mental practice improve functional performance and self-perception in a person with stroke and ideomotor apraxia (IMA)?
  • Level V
  • Case report
  • N = 1 man (age 44 yr) 7 mo post–ischemic infarct; immediately after stroke, he had received 30 days of inpatient rehabilitation including physical therapy, OT, and speech pathology
  • Intervention
  • Physical practice focused on reaching for cup and turning book pages, which were practiced for first 30 min of session, followed by 30 min of mental practice with audiotape
  • Outcome Measures
  • AMAT, COPM, and abbreviated Florida Apraxia Battery
  • Measures taken preintervention, postintervention, and 4 wk after intervention
Descriptive data and change scoresDespite persisting IMA, functional performance scores on AMAT improved; self-perception also increased as evidenced by COPM scores after intervention.
  • Single-subject study
  • Same investigator performed assessments and interventions
Wu et al. (2013) Can CIT and eye patching (EP) improve functional performance, eye movement, and trunk–arm kinematics in people with stroke and left neglect syndrome?
  • Level I
  • Single-blinded, randomized pretest–posttest control-group design
  • N = 24 patients with right-sided infarct and left neglect syndrome recruited from 8 medical centers and clinics; randomly assigned to 1 of 3 groups: CIT+EP, CIT only, or conventional therapy
  • Intervention
  • CIT+EP group wore mitt on unaffected UE for 6 hr/day for 3 wk while performing functional tasks; also wore glasses with right patch; CIT-only group received same intervention without glasses; conventional group received traditional OT matched in intensity and duration.
  • Outcome Measures
  • Catherine Bergego checklist of neglect (CBCN); kinematic data
ANCOVA to determine differences in performance between groups with Fisher’s post hoc tests; effect size calculationParticipants in the CIT+EP and CIT-only groups improved daily function as evidenced by scores on CBCN; CIT-only group showed greatest eye fixation improvement, and CIT+EP participants improved trunk–arm kinematics more than other groups.Further study needed with varying types of neglect
Yang, Lin, Chen, Wu, & Chen (2012) Will unilateral and bilateral robot-assisted training for recovery of UE movement after stroke elicit better performance than standard OT treatment? Will the 2 training methods have differential effects in outcome measures?
  • Level I
  • RCT
  • N = 21 people with stroke ≥ 6 mo but < 5 yr postonset (14 men, 7 women; M age= 51.29 yr), divided into unilateral robot-assisted training protocol (URTP), bilateral assisted robot training protocol (BRTP), and standard rehabilitation groups
  • Interview
  • Patients received 90–105 min of therapy 5 days/wk for 4 wk. Participants in the URTP and BRTP groups practiced forearm and wrist movements in a simultaneous manner with the Bi-Manu-Track robotic device. The control group received standard rehabilitation.
  • Outcome Measures
  • FMA, Medical Research Council instrument, grip strength, Modified Ashworth Scale, and Bi-Manu-Track robotic device
Descriptive; χ2 test for categorical data; ANCOVA for pre–post and group differencesURTP and BRTP showed different types of benefits for improvement in movement. URTP may be most beneficial for those needing to improve muscle power, strength at distal joints, and upper limb motor impairment, whereas BRTP might be more beneficial for those needing to improve proximal muscle power.
  • Limited generalizability and power because of small sample size
  • Motor control strategy used postintervention not assessed
  • No follow-up time point
  • Occupation-based outcome measures not included
Zlotnik, Sachs, Rosenblum, Shpasser, & Josman (2009) Can the Dynamic Interactional Model of intervention promote changes in the self-care and motor skills of adolescents with TBI?
  • Level V
  • Case studies of 2 adolescents with TBI
  • Case 1: 16-yr-old boy who sustained traumatic TBI and C7 spinal injury with right hemiparesis and Glasgow Coma Scale (GCS) score of 6–7 on admission to intensive care unit; transferred to rehabilitation 2 wk later
  • Case 2: 17-yr-old girl who sustained traumatic TBI, multiple fractures, and subarachnoid hemorrhage with speech and sensory deficits and GCS score of 14–15 on admission; transferred to rehabilitation 10 days later
  • Intervention
  • Case 1 received OT for 32 sessions (1-hr sessions 5 days/wk); Case 2 received 30 OT sessions (0.5- to 1-hr sessions 5 days/wk).
  • Outcome Measures
  • FIM, COPM, Computerized Penmanship Object Evaluation Tool, and Awareness of Mobility Deficits Questionnaire
Outcomes before, during, and after intervention were compared using visual analysis of graphic data, and qualitative results were described.Use of the Dynamic Interactional Model combined with the Extended Awareness Model was effective in meeting the special needs of the 2 adolescents with TBI. Both clients improved from partial awareness of limitations to full awareness after intervention, and both achieved desired improvement in mobility, self-care, and graphomotor functioning.
  • Research conducted in 2 separate rehabilitation settings under varying conditions
  • Treatment and assessment performed by same clinician on 1 case
Table Footer NoteNote. Effectiveness studies are classified using the system described in Lieberman and Scheer (2002) : Level I = systematic reviews, meta-analyses, and RCTs; Level II = two-group, nonrandomized studies; Level III = one-group, nonrandomized studies; Level IV = descriptive studies; and Level V = case reports and expert opinion. ADL = activities of daily living; AMAT = Arm Motor Ability Test; ANCOVA = analysis of covariance; ANOVA = analysis of variance; ARAT = Action Research Arm Test; AROM = active range of motion; B&B = Box and Block Test; CIMT = constraint-induced movement therapy; CIT = constraint-induced therapy; CO-OP = Cognitive Orientation to Daily Occupational Performance; COPM = Canadian Occupational Performance Measure; CVLT = California Verbal Learning Test; D–KEFS = Delis–Kaplan Executive Function System; FES = functional electrical stimulation; FMA = Fugl-Meyer Assessment; IADL = instrumental activities of daily living; JTTHF = Jebsen–Taylor Test of Hand Function; M = mean; mCIMT = modified constraint-induced movement therapy; mCIT = modified constraint-induced therapy; MMSE = Mini-Mental State Examination; OT = occupational therapy; PEDro = Physiotherapy Evidence Database rating scale; PROM = passive range of motion; RCT = randomized controlled trial; ROM = range of motion; SCI = spinal cord injury; SDMT = Symbol Digit Modalities Test; SF–36 = 36-Item Short Form Health Survey; SIS = Stroke Impact Scale; TBI = traumatic brain injury; UE = upper extremity; VAS = visual analog scale; WAIS–R = Wechsler Adult Intelligence Scale–Revised; WMFT = Wolf Motor Function Test.
Note. Effectiveness studies are classified using the system described in Lieberman and Scheer (2002) : Level I = systematic reviews, meta-analyses, and RCTs; Level II = two-group, nonrandomized studies; Level III = one-group, nonrandomized studies; Level IV = descriptive studies; and Level V = case reports and expert opinion. ADL = activities of daily living; AMAT = Arm Motor Ability Test; ANCOVA = analysis of covariance; ANOVA = analysis of variance; ARAT = Action Research Arm Test; AROM = active range of motion; B&B = Box and Block Test; CIMT = constraint-induced movement therapy; CIT = constraint-induced therapy; CO-OP = Cognitive Orientation to Daily Occupational Performance; COPM = Canadian Occupational Performance Measure; CVLT = California Verbal Learning Test; D–KEFS = Delis–Kaplan Executive Function System; FES = functional electrical stimulation; FMA = Fugl-Meyer Assessment; IADL = instrumental activities of daily living; JTTHF = Jebsen–Taylor Test of Hand Function; M = mean; mCIMT = modified constraint-induced movement therapy; mCIT = modified constraint-induced therapy; MMSE = Mini-Mental State Examination; OT = occupational therapy; PEDro = Physiotherapy Evidence Database rating scale; PROM = passive range of motion; RCT = randomized controlled trial; ROM = range of motion; SCI = spinal cord injury; SDMT = Symbol Digit Modalities Test; SF–36 = 36-Item Short Form Health Survey; SIS = Stroke Impact Scale; TBI = traumatic brain injury; UE = upper extremity; VAS = visual analog scale; WAIS–R = Wechsler Adult Intelligence Scale–Revised; WMFT = Wolf Motor Function Test.×
×
Populations Studied
The populations studied reflect the predominance of heart disease as a leading chronic condition in the United States (Go et al., 2013). Of the 42 studies reviewed, 22 (52%) involved the stroke population (Beckelhimer, Dalton, Richter, Hermann, & Page, 2011; Earley, Herlache, & Skelton, 2010; Guidetti, Asaba, & Tham, 2009; Hardy et al., 2010; Hayner, 2012; Hayner, Gibson, & Giles, 2010; Henshaw, Polatajko, McEwen, Ryan, & Baum, 2011; Hermann et al., 2010; McCall, McEwen, Colantonio, Streiner, & Dawson, 2011; Nilsen, Gillen, DiRusso, & Gordon, 2012; Nilsen, Gillen, & Gordon, 2010; Page, Murray, & Hermann, 2011; Polatajko, McEwen, Ryan, & Baum, 2012; Preissner, 2010; Rand, Weiss, & Katz, 2009; Rowe, Blanton, & Wolf, 2009; Skubik-Peplaski, Carrico, Nichols, Chelette, & Sawaki, 2012; Tsai et al., 2013; Unsworth, Bearup, & Rickard, 2009; Wu, Radel, & Hanna-Pladdy, 2011; Wu et al., 2013; Yang, Lin, Chen, Wu, & Chen, 2012); 7 (17%) involved people with brain injury (Carver, 2009; Fong & Howie, 2009; Giuffrida, Demery, Reyes, Lebowitz, & Hanlon, 2009; Goverover, Arango-Lasprilla, Hillary, Chiaravalloti, & Deluca, 2009; Goverover, Chiaravalloti, & DeLuca, 2010; Kim & Colantonio, 2010; Zlotnik, Sachs, Rosenblum, Shpasser, & Josman, 2009); 5 (12%) involved hand injuries (Glasgow, Fleming, Tooth, & Peters, 2012; Hall et al., 2013; Hall, Lee, Page, Rosenwax, & Lee, 2010; Jack & Estes, 2010; Stapanian, Stapanian, & Staley, 2010); 2 (5%) studied spinal injuries (Martin, Johnston, & Sadowsky, 2012; Sledziewski, Schaaf, & Mount, 2012); each of the remaining 6 single articles (14% in total) involved people with multiple sclerosis (Finlayson, Preissner, & Cho, 2012), general medical conditions (Thorne, Sauvé, Yacoub, & Guitard, 2009), dementia (Ciro, Hershey, & Garrison, 2013), chronic conditions (Hand, Law, & McColl, 2011), osteoarthritis (Schepens, Braun, & Murphy, 2012), and lymphedema (McClure, McClure, Day, & Brufsky, 2010).
Rehabilitation Interventions Investigated
A wide variety of therapeutic interventions in the area of neurorehabilitation were studied over the past 5 yr. See Tables 2 and 3, which summarize the interventions studied and the size of populations involved.
The broad categories under which most of these interventions can be subdivided are as follows: high technology, low technology, established methods, occupation-centered approaches, and cognitive-based approaches. The remaining articles covered a range of topics including adaptive equipment and the evaluation of general treatment approaches. One survey study and three literature reviews were also included.
Table 2.
Interventions Studied
Interventions Studied×
Interventions for Stroke
Problem Area Addressed or InvestigatedIntervention
Overall functionInteractive MetronomePhysical and mental practice
Self-care skillsContext survey
Upper-extremity spasticityFunctional training, bracing, and electrical stimulation
Glenohumeral subluxationCalifornia Tri-Pull Taping
Upper-extremity function
  • Modified CIMT
  • CIMT vs. bilateral training
  • Remote functional electrical stimulation and neuroprosthetic
  • Occupational therapy and mental practice
  • Mental practice
  • Modified CIMT
  • CIMT
  • Occupation-based intervention
  • CIMT and eye patching
  • Robot training
Occupational performanceCO-OP training method
ParticipationModified CIMT
CognitionOccupational therapy task-oriented approach
MultitaskingVirtual reality training
Unilateral neglectClassical music
Self-selected goalsCO–OP training method
Benchmarking occupational therapy practiceAusTOMs
Interventions for Traumatic Brain Injury
Problem Area Addressed or InvestigatedIntervention
Self-catheterizationPenile trough
Cognition
  • Metacomponential strategies
  • Spaced learning
  • Self-generation method
FunctionRandom vs. blocked practice
Self-care skillsContext survey
Outcomes
  • Traumatic brain injury rehabilitation programs incorporating community integration
  • Dynamic Interaction Model
Interventions for Hand Injuries
Problem Area Addressed or InvestigatedIntervention
Contracture managementDynamic Capener splint
Reduction in need for surgeryConservative treatment approach for carpal tunnel syndrome
Treatment effectsAcute extensor tendon repair in Zones V and VI
FunctionCreative intervention and adaptations for bilateral finger amputations
Interventions for Other Conditions
ConditionProblem Addressed or InvestigatedIntervention
Spinal injury
  • Hand strength and efficiency
  • UE function
Repetitive electrical stimulation to UE Reo-Go robotic training
DementiaSTOMP method
LymphedemaEmotional symptomsRelaxation and exercise
Multiple sclerosisFatigue management
OsteoarthritisDecreased joint stiffnessActivity pacing
General medicalCoccygeal pressure in supineGel pads
Chronic conditions
  • Occupational outcomes
  • Function
  • Community-based occupational therapy for adults with rheumatoid arthritis, chronic obstructive pulmonary disease, and congestive heart failure
  • Biomechanical vs. occupational adaptation approach for lupus
Table Footer NoteNote. AusTOMs = Australian Therapy Outcome Measures; CIMT = constraint-induced movement therapy; CO–OP = Cognitive Orientation to Daily Occupational Performance; STOMP = Skill-building through Task-Oriented Motor Practice; UE = upper extremity.
Note. AusTOMs = Australian Therapy Outcome Measures; CIMT = constraint-induced movement therapy; CO–OP = Cognitive Orientation to Daily Occupational Performance; STOMP = Skill-building through Task-Oriented Motor Practice; UE = upper extremity.×
Table 2.
Interventions Studied
Interventions Studied×
Interventions for Stroke
Problem Area Addressed or InvestigatedIntervention
Overall functionInteractive MetronomePhysical and mental practice
Self-care skillsContext survey
Upper-extremity spasticityFunctional training, bracing, and electrical stimulation
Glenohumeral subluxationCalifornia Tri-Pull Taping
Upper-extremity function
  • Modified CIMT
  • CIMT vs. bilateral training
  • Remote functional electrical stimulation and neuroprosthetic
  • Occupational therapy and mental practice
  • Mental practice
  • Modified CIMT
  • CIMT
  • Occupation-based intervention
  • CIMT and eye patching
  • Robot training
Occupational performanceCO-OP training method
ParticipationModified CIMT
CognitionOccupational therapy task-oriented approach
MultitaskingVirtual reality training
Unilateral neglectClassical music
Self-selected goalsCO–OP training method
Benchmarking occupational therapy practiceAusTOMs
Interventions for Traumatic Brain Injury
Problem Area Addressed or InvestigatedIntervention
Self-catheterizationPenile trough
Cognition
  • Metacomponential strategies
  • Spaced learning
  • Self-generation method
FunctionRandom vs. blocked practice
Self-care skillsContext survey
Outcomes
  • Traumatic brain injury rehabilitation programs incorporating community integration
  • Dynamic Interaction Model
Interventions for Hand Injuries
Problem Area Addressed or InvestigatedIntervention
Contracture managementDynamic Capener splint
Reduction in need for surgeryConservative treatment approach for carpal tunnel syndrome
Treatment effectsAcute extensor tendon repair in Zones V and VI
FunctionCreative intervention and adaptations for bilateral finger amputations
Interventions for Other Conditions
ConditionProblem Addressed or InvestigatedIntervention
Spinal injury
  • Hand strength and efficiency
  • UE function
Repetitive electrical stimulation to UE Reo-Go robotic training
DementiaSTOMP method
LymphedemaEmotional symptomsRelaxation and exercise
Multiple sclerosisFatigue management
OsteoarthritisDecreased joint stiffnessActivity pacing
General medicalCoccygeal pressure in supineGel pads
Chronic conditions
  • Occupational outcomes
  • Function
  • Community-based occupational therapy for adults with rheumatoid arthritis, chronic obstructive pulmonary disease, and congestive heart failure
  • Biomechanical vs. occupational adaptation approach for lupus
Table Footer NoteNote. AusTOMs = Australian Therapy Outcome Measures; CIMT = constraint-induced movement therapy; CO–OP = Cognitive Orientation to Daily Occupational Performance; STOMP = Skill-building through Task-Oriented Motor Practice; UE = upper extremity.
Note. AusTOMs = Australian Therapy Outcome Measures; CIMT = constraint-induced movement therapy; CO–OP = Cognitive Orientation to Daily Occupational Performance; STOMP = Skill-building through Task-Oriented Motor Practice; UE = upper extremity.×
×
High-technology devices are becoming more readily available as intervention options in occupational therapy, but research regarding the effectiveness of these devices has been limited. A recent systematic review of the use of robotics for upper-extremity (UE) motor recovery after stroke determined that equal intensity and duration of robotic therapy shows no greater effectiveness for improving activities of daily living, strength, and motor control than conventional therapy; however, when the robotic therapies were used in addition to conventional therapy, a positive additive effect for UE motor recovery occurred (Norouzi-Gheidari, Archambault, & Fung, 2012). The robotics investigated during the past 5 years included the ReoGo, used to facilitate unilateral UE motor recovery after spinal injury (Sledziewski et al., 2012) and the Bi-Manu-Track, a bimanual UE robotic trainer used to compare the effects of bilateral versus unilateral UE training after stroke (Yang et al., 2012).
Another high-technology intervention studied over the same period included the Interactive Metronome; the authors sought to determine the effect on UE hemiplegic arm function after stroke (Beckelhimer et al., 2011). Electrical stimulation (ES) was the central topic for 3 of the high-technology articles: ES was combined with bracing to reduce hemiplegic arm spasticity (Hardy et al., 2010), was embedded in a UE orthosis used to improve arm function after stroke (Hermann et al., 2010), and was part of a grasp–release training program for people with tetraplegia (Martin et al., 2012). Virtual reality was used to assess multitasking of patients poststroke through virtual grocery shopping (Rand et al., 2009), and telehealth strategies were prominent in 2 studies: 1 to manage fatigue levels in patients with multiple sclerosis (Finlayson et al., 2012) and 1 to facilitate home training in the use of the electrical stimulation orthotic mentioned previously (Hermann et al., 2010).
Despite the attractiveness of high technology, several researchers investigated basic low-technology strategies requiring little equipment or cost. Gillen (2010), in his Centennial Vision review, noted that several basic core interventions of occupational therapy still remain to be fully tested; therefore, research on low-tech, everyday occupational therapy interventions is desperately needed as we continue to justify our services and validate the tools we use. Low-tech interventions have the added incentive of being relatively easy to include as part of a treatment plan or intervention regimen.
Some of the creative low-tech approaches taken included mental practice; 1 study compared two types of mental practice (internal vs. external view) used for patients with subacute stroke to improve UE function (Nilsen et al., 2012), and the other, a case study, investigated the combined effect of mental and physical practice to ameliorate the effects of UE ideomotor apraxia in a person with stroke (Wu et al., 2011). Therapeutic taping using a unique tri-pull method to reduce glenohumeral subluxation in people poststroke was also described (Hayner, 2012).
Task-based approaches to attain client-specific goals for a patient with Lewy body dementia (Ciro et al., 2013) and to reduce severe cognitive impairment after stroke (Preissner, 2010) were also the focus of studies gauging the effectiveness of low-tech methods. Other interesting low-tech approaches studied included incorporating classical music into occupational therapy sessions to improve unilateral neglect after stroke (Tsai et al., 2013), embedding relaxation and exercise training in a recovery program for people with breast cancer–related lymphedema (McClure et al., 2010), and determining whether gel pads typically used in wheelchairs to reduce coccygeal pressure could be used for pressure reduction in medical patients when lying supine in bed (Thorne et al., 2009).
The category of established methods included interventions that have previously been studied in the occupational therapy or related-discipline literature; these approaches have an established evidence base. Often, the interventions are investigated as part of, or in addition to, conventional methods of occupational therapy; modifications or iterations of these fundamental strategies are also frequently described.
Constraint-induced movement therapy (CIMT) is a primary example of an established intervention. The strategy of constraining the nonaffected UE while actively engaging the affected hemiplegic UE in intensive task-oriented practice was the integral treatment component of the EXCITE (Extremity Constraint-Induced Therapy Evaluation) trial, the first multisite, National Institutes of Health–funded, randomized controlled clinical trial in the United States to study an UE rehabilitation method for stroke (Winstein et al., 2003).
The past 5 yr produced 6 studies investigating CIMT: Two single-subject case studies were conducted, the first using preparatory methods for playing the violin as the occupation-focused activity for CIMT (Earley et al., 2010) and the second investigating whether gains made with CIMT intervention could be maintained 4 and 5 yr after initial participation (Rowe et al., 2009). A similar assessment of CIMT retention was described in a study involving 13 chronic poststroke participants tested for maintenance of UE gains 3 mo after intervention (Page et al., 2011).
The fourth CIMT study questioned whether CIMT could produce similar outcomes when compared with intensity-matched bilateral UE treatment; interestingly, both groups made notable gains in Wolf Motor Function Test and Canadian Occupational Performance Measure (COPM) scores, but no significant group differences were found (Hayner et al., 2010). A modified CIMT protocol was implemented to assess changes in participation, activity, and UE impairment in four older people with subacute stroke (McCall et al., 2011), and the final study paired CIMT with eye patching to assess changes in functional skills, eye movement, and trunk–arm kinematics (Wu et al., 2013). Motor learning, another established area of study, was examined by Giuffrida et al. (2009) . These authors compared task learning using random versus blocked practice for people with traumatic brain injury (TBI).
Two studies focused specifically on occupation-centered approaches. Jack and Estes (2010)  described how a therapist switched from a biomechanical approach to an occupation-centered approach after 10 wk of treatment when working with a person with an orthopedic hand injury; clinical improvement was seen in functional tasks and COPM scores at the end of the intervention period. The second investigation examined motor recovery and neuroplasticity effects seen when an occupation-based intervention was provided to a 55-yr-old man with chronic stroke (Skubik-Peplaski et al., 2012). Two studies (Henshaw et al., 2011; Polatajko et al., 2012) addressed occupational performance through cognitive means (discussed in the next paragraph). In all, 12 studies used the COPM as an assessment tool (Beckelhimer et al., 2011; Ciro et al., 2013; Hayner et al., 2010; Henshaw et al., 2011; Hermann et al., 2010; Jack & Estes, 2010; McCall et al., 2011; Nilsen et al., 2012; Polatajko et al., 2012; Skubik-Peplaski et al., 2012; Wu et al., 2011; Zlotnik et al., 2009).
Several research investigations conducted over the past 5 yr tested cognitive-based approaches. One strategy used for patients with TBI was a metacomponential intervention that included specific problem-solving skill training; this approach was compared with conventional cognitive training and resulted in greater gains for the metacomponential group (Fong & Howie, 2009). In an effort to improve memory, Goverover et al. (2009)  found that spaced learning was superior to massed learning techniques; similarly, Goverover et al. (2010)  compared self-generated strategies with provided strategies to improve cognitive recall, determining that the self-generated method resulted in better recall and learning of information.
The Cognitive Orientation to Occupational Performance (CO–OP) intervention approach was studied in the remaining 2 articles: The first used an occupational performance focus rather than an impairment focus to address functional deficits after stroke in two female patients (Henshaw et al., 2011); the second compared the CO–OP method with standard occupational therapy and determined that the CO–OP approach was superior for improving occupational performance and COPM scores (Polatajko et al., 2012).
The remaining neurorehabilitation-related articles spanned a diversity of topics. Three assessed the effectiveness of creative adaptive devices for improving function (Carver, 2009; Glasgow et al., 2012; Stapanian et al., 2010), and another examined the use of gel pads to prevent pressure sores (Thorne et al., 2009). Hall et al. (2013)  evaluated whether a conservative approach to treatment of carpal tunnel syndrome would reduce surgical intervention and found that patients in the conservative intervention group reported greater symptom relief. Similarly, a tailored approach to activity pacing was found to be superior to a general approach when used for people with osteoarthritic joint stiffness (Schepens et al., 2012), and Zlotnik et al. (2009)  reported that the Dynamic Interactional Model of intervention was effective in meeting the special needs of two teenagers with TBI.
Guidetti et al. (2009)  conducted a survey related to the role of context in regaining self-care skills after stroke or spinal injury, and Hand et al. (2011)  and Kim and Colantonio (2010)  produced two literature reviews on community-based intervention. The final literature review examined the effectiveness of mental practice used as part of occupational therapy with people with stroke (Nilsen et al., 2010).
Designs Used
The randomized controlled trial (RCT) has long been the standard for rigorous research designs; Nelson and Mathiowetz (2004)  advocated using this design to advance occupational therapy research and lead the way for developing a future evidence base for the profession. Quality investigations such as measurement studies, database research, intervention trials, qualitative research, and meta-analyses are also designs that will contribute substantially to a sound body of knowledge for occupational therapy (Kielhofner, Hammel, Finlayson, Helfrich, & Taylor, 2004).
Nine of the articles reviewed (21%) were Level I RCTs (Fong & Howie, 2009; Glasgow et al., 2012; Hall et al., 2013; McClure et al., 2010; Nilsen et al., 2012; Polatajko et al., 2012; Schepens et al., 2012; Wu et al., 2013; Yang et al., 2012). Another 2 (5%; Kim & Colantonio, 2010; Nilsen et al., 2010) were systematic reviews that also met Level I status, as defined by Lieberman and Scheer (2002; see note at end of Table 1). An additional scoping review (2%) was performed by Hand et al. (2011) . A total of 15 articles (36%) described single-subject or case designs that used 2 or fewer participants (Beckelhimer et al., 2011; Carver, 2009; Ciro et al., 2013; Earley et al., 2010; Hardy et al., 2010; Henshaw et al., 2011; Hermann et al., 2010; Jack & Estes, 2010; Preissner, 2010; Rowe et al., 2009; Skubik-Peplaski et al., 2012; Sledziewski et al., 2012; Stapanian et al., 2010; Wu et al., 2011; Zlotnik et al., 2009). See Table 3 for additional information regarding participant numbers for the studies reviewed.
Table 3.
Studies Categorized by Number of Participants
Studies Categorized by Number of Participants×
Single-Subject Case Designs, N = 1 or 22 < N ≤ 10N > 10Literature Reviews
(15 studies)(6 studies)(18 studies)(3 studies)
Table 3.
Studies Categorized by Number of Participants
Studies Categorized by Number of Participants×
Single-Subject Case Designs, N = 1 or 22 < N ≤ 10N > 10Literature Reviews
(15 studies)(6 studies)(18 studies)(3 studies)
×
Results and Limitations
Because many of the studies conducted had a small number of participants, in most cases the studies' authors acknowledged that translation or generalizability was limited. Single-subject and small case-series designs are convenient and can inform clinicians on the effect of a specified treatment with an individual, but these designs often do not have the rigor and fidelity of RCTs or studies with larger numbers of participants that can contribute to knowledge translation. Several researchers have recommended that substantive quantitative and graphical analyses should accompany single-subject designs to strengthen the data presented (Bengali & Ottenbacher, 1998; Ottenbacher, 1986; Wolery & Harris, 1982). Notable progress was evident, however, with a moderate number of RCTs published in rehabilitation research over the past 5 yr; however, randomization issues and the incorporation of valid and reliable instruments continue to make RCTs challenging for occupational therapy researchers (Nelson & Mathiowetz, 2004).
Conclusion and Future Directions
Halfway through the 10-yr journey toward the ambitious Centennial Vision put forth by leaders in the profession, rehabilitation researchers have responded by publishing 42 intervention effectiveness studies heavily focused on functional recovery of people with stroke and brain injury. Investigations included examinations of high-tech, low-tech, and established methods using single-subject or small case-series designs as well as descriptive, comparative, and quasi-experimental methodologies. Designs using a larger number of participants (≥11) were well represented, and the number of RCTs and systematic reviews conducted are trending upward.
Over the next 5 yr, occupational therapy can build on these notable accomplishments and continue to move rehabilitation research toward the Centennial Vision goals of 2017 in the following ways:
  1. Fostering knowledge translation. Occupational therapy can continue the positive research trend by increasing the volume of rigorous, quality research studies that produce meaningful effectiveness information. Research that affects practice by validating interventions and demonstrating that successful patient outcomes are the direct result of these evidence-based strategies will be most useful. Dissemination of findings to key stakeholders will be essential. Clinicians will need to become more familiar with standardized assessments and implement these tools in daily practice; this is a critical component of quality outcomes research. Scholars and academicians can assist in this effort.

  2. Expanding the number of participants. Studies incorporating larger numbers of participants not only provide more statistical power but also are more easily translated to patient populations to build a foundation of evidence for occupational therapy. Larger patient numbers can result when academics team with clinicians or align with health care organizations for ready access to patient populations. Scholars who diligently solicit outside funding from a variety of sources will have the means to build strong clinical–academic infrastructures that can increase the number of research participants and support intervention effectiveness research.

  3. Conducting research with a variety of populations. Although intervention effectiveness with the stroke population remains challenging and necessary, more work is needed to verify that occupational therapy intervention for patients with brain injury, spinal injury, dementia, and other neurological conditions results in improved health. Research that focuses on the needs and health concerns of the aging population will be required to meet the changing demographics of the United States in the upcoming years.

  4. Publishing a larger number of systematic reviews of the literature. Knowing what evidence currently exists and the meaning of that evidence will be the initial step in developing new and innovative research questions.

  5. Quantifying and centering on occupation-focused practice. Occupational therapy has a vast array of inventive, function-based tools designed to quantify activity, participation, and occupational performance. Payer sources such as the Centers for Medicare and Medicaid Services now have mandated reporting on functional abilities of clients through the recent G-code implementation (U.S. Department of Health and Human Services, 2012). Our profession is uniquely qualified to assess and explain to others the tremendous impact that meaningful activity exerts on health. We simply must capitalize on our own strengths, use these tools, and report outcomes. No other discipline is more qualified to provide this information. Using a combination of task-level and impairment-level assessments will provide comprehensive client information and data. These are the core tenets of occupational therapy and should therefore be the focus of research designs that demonstrate the importance and necessity of our services.

Through the diligent work of occupational therapy scholars, we have made significant progress toward our 2007 Centennial Vision goals. Occupational therapy practitioners have responded by producing a notable quantity of rehabilitation research studies that will be the foundation needed to develop an evidence base for occupational therapy.
In our effort to be the “widely recognized, science-driven, and evidence-based profession” of 2017 (AOTA, 2007, p. 613), we are ultimately the determining factor in how others define us. We are challenged over the next 5 yr to foster knowledge translation, expand research participant volume, study a broad array of neurological populations, conduct systematic reviews, and focus on the unique skills we possess to measure and report functional, occupation-centered patient outcomes. We can also build on our current successes by increasing the volume and quality of our research and disseminating our findings to other professionals and the public.
American Occupational Therapy Association. (2007). AOTA’s Centennial Vision and executive summary. American Journal of Occupational Therapy, 61, 613–614. http://dx.doi.org/10.5014/ajot.61.6.613 [Article]
American Occupational Therapy Association. (2007). AOTA’s Centennial Vision and executive summary. American Journal of Occupational Therapy, 61, 613–614. http://dx.doi.org/10.5014/ajot.61.6.613 [Article] ×
*Beckelhimer, S. C., Dalton, A. E., Richter, C. A., Hermann, V., & Page, S. J. (2011). Brief Report—Computer-based rhythm and timing training in severe, stroke-induced arm hemiparesis. American Journal of Occupational Therapy, 65, 96–100. http://dx.doi.org/10.5014/ajot.2011.09158 [Article] [PubMed]
*Beckelhimer, S. C., Dalton, A. E., Richter, C. A., Hermann, V., & Page, S. J. (2011). Brief Report—Computer-based rhythm and timing training in severe, stroke-induced arm hemiparesis. American Journal of Occupational Therapy, 65, 96–100. http://dx.doi.org/10.5014/ajot.2011.09158 [Article] [PubMed]×
Bengali, M. K., & Ottenbacher, K. J. (1998). The effect of autocorrelation on the results of visually analyzing data from single-subject designs. American Journal of Occupational Therapy, 52, 650–655. http://dx.doi.org/10.5014/ajot.52.8.650 [Article] [PubMed]
Bengali, M. K., & Ottenbacher, K. J. (1998). The effect of autocorrelation on the results of visually analyzing data from single-subject designs. American Journal of Occupational Therapy, 52, 650–655. http://dx.doi.org/10.5014/ajot.52.8.650 [Article] [PubMed]×
*Carver, M. D. (2009). Adaptive equipment to assist with one-handed intermittent self-catheterization: A case study of a patient with multiple brain injuries. American Journal of Occupational Therapy, 63, 333–336. http://dx.doi.org/10.5014/ajot.63.3.333 [Article] [PubMed]
*Carver, M. D. (2009). Adaptive equipment to assist with one-handed intermittent self-catheterization: A case study of a patient with multiple brain injuries. American Journal of Occupational Therapy, 63, 333–336. http://dx.doi.org/10.5014/ajot.63.3.333 [Article] [PubMed]×
*Ciro, C. A., Hershey, L. A., & Garrison, D. (2013). Enhanced task-oriented training in a person with dementia with Lewy bodies. American Journal of Occupational Therapy, 67, 556–563. http://dx.doi.org/10.5014/ajot.2013.008227 [Article] [PubMed]
*Ciro, C. A., Hershey, L. A., & Garrison, D. (2013). Enhanced task-oriented training in a person with dementia with Lewy bodies. American Journal of Occupational Therapy, 67, 556–563. http://dx.doi.org/10.5014/ajot.2013.008227 [Article] [PubMed]×
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U.S. Department of Health and Human Services. (2012). G. Therapy services. Federal Register, 77, 68958–68978.×
Winstein, C. J., Miller, J. P., Blanton, S., Taub, E., Uswatte, G., Morris, D., … Wolf, S. (2003). Methods for a multisite randomized trial to investigate the effect of constraint-induced movement therapy in improving upper extremity function among adults recovering from a cerebrovascular stroke. Neurorehabilitation and Neural Repair, 17, 137–152. http://dx.doi.org/10.1177/0888439003255511 [Article] [PubMed]
Winstein, C. J., Miller, J. P., Blanton, S., Taub, E., Uswatte, G., Morris, D., … Wolf, S. (2003). Methods for a multisite randomized trial to investigate the effect of constraint-induced movement therapy in improving upper extremity function among adults recovering from a cerebrovascular stroke. Neurorehabilitation and Neural Repair, 17, 137–152. http://dx.doi.org/10.1177/0888439003255511 [Article] [PubMed]×
Wolery, M., & Harris, S. R. (1982). Interpreting results of single-subject research designs. Physical Therapy, 62, 445–452. [PubMed]
Wolery, M., & Harris, S. R. (1982). Interpreting results of single-subject research designs. Physical Therapy, 62, 445–452. [PubMed]×
Wolf, T. J. (2011). Centennial Vision—Rehabilitation, disability, and participation research: Are occupational therapy researchers addressing cognitive rehabilitation after stroke? American Journal of Occupational Therapy, 65, e46–e59. http://dx.doi.org/10.5014/ajot.2011.002089 [Article]
Wolf, T. J. (2011). Centennial Vision—Rehabilitation, disability, and participation research: Are occupational therapy researchers addressing cognitive rehabilitation after stroke? American Journal of Occupational Therapy, 65, e46–e59. http://dx.doi.org/10.5014/ajot.2011.002089 [Article] ×
*Wu, A. J., Radel, J., & Hanna-Pladdy, B. (2011). Improved function after combined physical and mental practice after stroke: A case of hemiparesis and apraxia. American Journal of Occupational Therapy, 65, 161–168. http://dx.doi.org/10.5014/ajot.2011.000786 [Article] [PubMed]
*Wu, A. J., Radel, J., & Hanna-Pladdy, B. (2011). Improved function after combined physical and mental practice after stroke: A case of hemiparesis and apraxia. American Journal of Occupational Therapy, 65, 161–168. http://dx.doi.org/10.5014/ajot.2011.000786 [Article] [PubMed]×
*Wu, C. Y., Wang, T. N., Chen, Y. T., Lin, K. C., Chen, Y. A., Li, H. T., & Tsai, P. L. (2013). Effects of constraint-induced therapy combined with eye patching on functional outcomes and movement kinematics in poststroke neglect. American Journal of Occupational Therapy, 67, 236–245. http://dx.doi.org/10.5014/ajot.2013.006486 [Article] [PubMed]
*Wu, C. Y., Wang, T. N., Chen, Y. T., Lin, K. C., Chen, Y. A., Li, H. T., & Tsai, P. L. (2013). Effects of constraint-induced therapy combined with eye patching on functional outcomes and movement kinematics in poststroke neglect. American Journal of Occupational Therapy, 67, 236–245. http://dx.doi.org/10.5014/ajot.2013.006486 [Article] [PubMed]×
*Yang, C. L., Lin, K. C., Chen, H. C., Wu, C. Y., & Chen, C. L. (2012). Pilot comparative study of unilateral and bilateral robot-assisted training on upper-extremity performance in patients with stroke. American Journal of Occupational Therapy, 66, 198–206. http://dx.doi.org/10.5014/ajot.2012.003103 [Article] [PubMed]
*Yang, C. L., Lin, K. C., Chen, H. C., Wu, C. Y., & Chen, C. L. (2012). Pilot comparative study of unilateral and bilateral robot-assisted training on upper-extremity performance in patients with stroke. American Journal of Occupational Therapy, 66, 198–206. http://dx.doi.org/10.5014/ajot.2012.003103 [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. http://dx.doi.org/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. http://dx.doi.org/10.5014/ajot.63.5.549 [Article] [PubMed]×
*Indicates studies that were reviewed for this article.
Indicates studies that were reviewed for this article.×
Table 1.
Intervention Effectiveness Studies Published in the American Journal of Occupational Therapy, January 2009–June 2013
Intervention Effectiveness Studies Published in the American Journal of Occupational Therapy, January 2009–June 2013×
Author/YearStudy ObjectivesLevel/Design/ParticipantsIntervention and Outcome MeasuresStatistical MethodResultsStudy Limitations
Beckelhimer, Dalton, Richter, Hermann, & Page (2011) Would the use of an Interactive Metronome intervention improve the functionality of a hemiparetic arm in 2 stroke patients?
  • Level V
  • Pretest–postest design
  • N = 2 men (M age = 71.5 yr) with history of ischemic stroke (Participant 1, 25 yr poststroke, Participant 2, 2 yr 2 mo poststroke)
  • Intervention
  • 5 min of preparatory stretching exercises, 20 min of Interactive Metronome use and a combination of purposeful and occupation-based activities for 25 min
  • Outcome Measures
  • FMA Motor Activity Test, COPM, and SIS
Descriptive; pre- and posttestingStudy participants demonstrated a positive change from pre- to posttesting on all outcome measures.
  • Small sample size
  • Further research required to warrant study findings
Carver (2009) Would the use of a trough-shaped prop assist in the 1-handed self-catheterization of a TBI patient with a neurogenic bladder?
  • Level V
  • Single-subject case report
  • N = 1; 57-yr-old male with TBI
  • Intervention
  • Observation; successful insertion and use of catheter
  • Outcome Measures
  • Manual Muscle Testing, FIM™
DescriptiveAfter 3 treatment sessions using the novel M-shaped penile prop, the participant was able to successfully self-catheterize independently.Limited generalizability because of single-subject design
Ciro, Hershey, & Garrison (2013) What is the process and outcome of using the STOMP (Skill-building through Task-Oriented Motor Practice) intervention for a person with Lewy body dementia?
  • Level V
  • Case study
  • N = 1; 73-yr-old woman
  • Intervention
  • The STOMP intervention blended task-oriented training and motor learning principles. Intervention occurred 2–3 hr/day for 10 days.
  • Outcome Measures
  • MMSE, Cornell Scale for Depression, FIM, Caregiver Burden Scale, COPM, and goal attainment scaling
Descriptive; pre- and posttestingPatient demonstrated improvement in 2 of 3 goals that were created by patient’s spouse/caregiver. The STOMP intervention demonstrates some potential in evaluating and assisting with occupational performance deficits.
  • Limited generalizability and designation of causality because of study design
  • No follow-up conducted to determine long-term effects
Earley, Herlache, & Skelton (2010) Would using a meaningful occupation during mCIMT intervention lead to improved functionality of an involved UE?
  • Level V
  • Single-subject case report
  • N = 1; 52-yr-old female violinist, 4 yr poststroke
  • Intervention
  • Participant was involved in an mCIMT program consisting of preparatory methods, purposeful activities, and occupations custom designed to her therapeutic goals. Activities involved the repeated practice of specific skills and movements necessary to play the violin. Intervention occurred 3 hr/day for 20 days.
  • Outcome Measures
  • FMA, Sensorimotor Evaluation (modified version), Motor Functioning Assessment (MFA), Arm Improvement and Movement (AIM) checklist, and journaling
Descriptive; pre- and posttestingParticipant demonstrated improved scores on outcome measures and greater function in involved extremity after the mCIMT intervention.
  • Limited generalizability because of small sample size
  • Outcome measures used (FMA, MFA and AIM checklist) not standardized, no established reliability and validity
Finlayson, Preissner, & Cho (2012) Does age, gender, work status, or impairment level have an impact on fatigue management program outcomes for people with multiple sclerosis (MS)?
  • Level III
  • Secondary data analysis using mixed-effects model
  • N = 181 participants with MS (M age = 55 yr; 79% female)
  • Intervention
  • Participants engaged in a teleconference 1×/wk for 6 wk that emphasized rest, body mechanics, environmental modification, communication, activity analysis, and goal setting. Each session lasted 70 min and was facilitated by a licensed occupational therapist.
  • Outcome Measures
  • Fatigue Impact Scale, SF–36, Self-Efficacy for Energy Conservation Questionnaire
Descriptive, mixed-effects models with time trends and variance–covariance structures to determine best modelYounger participants experienced greater reductions in fatigue impact and greater improvements in self-efficacy. Participants with less impairment experienced greater mental health gains and were more likely to retain these gains. Women experienced greater fatigue impact benefits than men, but men experienced greater mental health benefits.
  • Cognitive issues of people with MS not considered
  • Work status not specifically defined
Fong & Howie (2009) Are there greater improvements in outpatients with acquired brain injury when problem-solving skills training includes metacomponential strategies rather than conventional cognitive methods?
  • Level I
  • RCT (matched pairs)
  • N = 33 who had sustained an acquired brain injury (M age = 33.4 yr; 18% female)
  • Intervention
  • The intervention group received functional skills training, conventional cognitive training, and explicit training in problem-solving skills with an emphasis on metacomponential strategies.
  • The control group received conventional cognitive training without the explicit problem-solving component. Training consisted of 2 sessions/wk for 22 sessions.
  • Outcome Measures
  • Behavioral Assessment of the Dysexecutive Syndrome, Social Problem Solving Video Measure, Means Ends Problem Solving Measure, Raven’s Progressive Matrices, Metacomponential Interview
Descriptive; nonparametric Mann–Whitney U test for comparison of change scoresThe intervention group showed significant advantages vs. the control group on the Metacomponential Interview, demonstrating an association with the metacomponential training method used; however, transferability of these skills to real-life problem-solving measures did not produce significant findings.
  • Small sample size and participant attrition
  • Lack of a culturally sensitive instrument to collect subjective data
  • Limited time of exposure to intervention
  • Limited extent of validation and adaptation of measures to Hong Kong Chinese population
Giuffrida, Demery, Reyes, Lebowitz, & Hanlon (2009) What are the significant differences in the acquisition, retention, and transfer of skills in participants with TBI who learned a task using random practice vs. blocked practice?
  • Level II
  • Comparative study
  • N = 6 men with TBI (M age = 28 yr)
  • Intervention
  • Random practice (30 min programmed instruction in touch typing, 10 min of learning a subway schedule, and 15 min of rapid numeric input)
  • Blocked practice (typing, subway stop, and numeric input)
  • Outcome Measures
  • WAIS–R, Wechsler Memory Scale–Revised, CVLT, Trail Making Test, Category Test, Finger Tapping Test, Grooved Pegboard Test, Wisconsin Card Sorting Test
Descriptive; ANOVAThe blocked practice and random practice groups both showed a significant increase in performance skill, acquisition, and retention; the random-practice group demonstrated greater transferability to another task.
  • Small sample size
  • Participants without TBI used as control group
  • Lack of functionally relevant tasks
Glasgow, Fleming, Tooth, & Peters (2012) Will participants who are using dynamic Capener splints 12–16 hr/day make greater progress in contracture resolution than those who use splints 6–12 hr/day over 8 wk of treatment?
  • Level I
  • RCT
  • N = 18 participants with extensor deficits of the proximal interphalangeal joint as a result of hand injury (for 6–12-hr group, M age = 41.0 yr; for 12–16-hr group, M age = 35.3 yr)
  • Intervention
  • Dynamic Capener splints were fabricated with mobilizing force set to 200–250 g; each participant was randomly allocated to either a 6–12-hr or a 12–16-hr wearing regimen. Participants were also required to attend therapy every 1–2 wk for 8 wk.
  • Outcome Measures Finger goniometry for ROM, tension gauge to measure torque
Descriptive; nonparametrics for group differences; linear regression analysisNo significant differences in extension ROM were noted between the 2 groups.
  • Small sample size
  • 78% of participants from the 12–16-hr group used their splints <12 hr/day.
  • Static extension splints were used in addition to Capener splint for participants with flexion and extension deficits.
Goverover, Arango-Lasprilla, Hillary, Chiaravalloti, & DeLuca (2009) Does spaced learning enhance the memory of functional tasks in people with TBI?
  • Level III
  • Within-subject
  • N = 25; 10 TBI patients (M age = 42.5 yr) and 15 healthy control participants (M age = 43.3 yr)
  • Intervention
  • Participants were required to complete paragraph learning and rote learning tasks. Trials were presented in massed and spaced conditions.
  • Outcome Measures
  • Digit Span subtest (WAIS–R), SDMT Oral version, CVLT, D–KEFS subtest
Descriptive; ANOVAsParticipants in the spaced learning condition were better able to recall material than those in the massed learning condition.
  • Small sample size
  • Severity of type of brain injury not accounted for
  • Only 2 functional activities assessed
  • Unclear whether this technique would work for more complex tasks
  • Not known whether effects of spaced learning would maintain over a longer follow-up period
Goverover, Chiaravalloti, & DeLuca (2010) Does using the self-generation method improve recall and performance of everyday functional tasks?
  • Level II
  • Within-group
  • N = 25; 10 TBI patients (M age = 42.5 yr) and 15 healthy control participants (M age = 43.3 yr)
  • Intervention
  • Participants were divided into 2 task-learning groups: generated and provided. Generated group generated the key word in each step of the task. Provided group members were provided directions for each task.
  • Outcome Measures
  • WAIS–R, SDMT, CVLT, D–KEFS
Descriptive; ANOVAsInformation learned using the generated procedure was recalled better than information learned using the provided procedure.
  • Small sample size
  • Severity of type of brain injury not accounted for
  • Only 2 functional activities assessed
  • Unclear whether this technique would work for more complex tasks
Guidetti, Asaba, & Tham (2009) What role does context play in recapturing self-care skills after a stroke or SCI?
  • Level III
  • Survey
  • N = 11; 5 participants with stroke and 6 participants with SCI (9 men, 2 women; M age = 52 yr)
  • Intervention
  • Participants were interviewed 1–3 mo after onset of the stroke or SCI to gather information regarding recapturing self-care skills.
  • Outcome Measure
  • Open-ended survey questions
Descriptive; empirical, phenomenological, and psychological method; qualitative analysisSix characteristics were identified that describe the role of context in recapturing self-care: (1) an air of expectation, (2) support from others, (3) new daily structure, (4) extended time, (5) gradual change in challenge, and (6) therapeutic relationship as enabling possibility.
  • Risk of bias in the analysis of interviews
  • Small sample size
  • Variability in self-care training among participants
Hall et al. (2013) Does a conservative treatment program for carpal tunnel syndrome improve symptoms and reduce the desire to seek surgical interventions?
  • Level I
  • RCT
  • N = 54 (50% men; intervention group, M age = 53.8 yr; control group, M age = 54.9 yr)
  • Intervention
  • Participants were separated into a conservative group or a control group. The conservative group received an 8-wk treatment program with a skilled occupational therapist that included wrist splint and education sessions.
  • The control group received no intervention and was only observed for the same period.
  • Outcome Measures
  • Boston Carpal Tunnel Questionnaire, VAS, dynamometer, Purdue Pegboard, Semmes-Weinstein monofilament testing, Phalen’s test, satisfaction questionnaire
Descriptive; paired and independent t tests, χ2 testsParticipants in the conservative group reported greater symptom relief and improved functional outcomes than the control group.
  • Electrodiagnostic testing not used as an outcome measure
  • Differing skill levels of therapists
  • Participant attrition
  • Interventionists not blinded to study purpose or group assignment
Hall, Lee, Page, Rosenwax, & Lee (2010) Do the 3 rehabilitation protocols to repair acute extensor tendon in Zones V and VI have differing treatment effects on patients?
  • Level III
  • Quasi-experimental
  • N = 27 (17 men, 10 women; M age = 30.4 yr)
  • Intervention
  • Participants were divided into 3 groups: IM (resting splint immobilized), EPM (dorsal dynamic extension splint), and EAM (palmar blocking splint). The IM group was immobilized for the 1st 3 wk and performed graded mobilization from Wk 3–6. EPM group began passive motion on Days 1–5 and exercised in the splint during Wk 1–3. EAM group had early active motion on Days 1–5 and exercised in the splint Wk 1–3. A graded mobilization program began in Wk 5–6 for both the EPM and the EAM groups.
  • Outcome Measures
  • ROM, dynamometer, VAS, goniometer, extension lag testing
Descriptive; ANOVAsAll patient groups showed improvement, but EAM group participants recovered ROM more rapidly.
  • Small sample size in the 3 groups
  • High attrition
  • Limited generalizability to other tendon zone injuries
Hand, Law, & McColl (2011) What is the effectiveness of community-based OT interventions for improving occupational outcomes in adults with chronic conditions?
  • Level IV
  • Literature review
  • N = 16 articles; scoping review methodology used. Conditions discussed include rheumatoid arthritis, chronic obstructive pulmonary disease, congestive heart failure, depression, and multiple conditions.
Studies were grouped by occupations: work, physical function, social function, psychological health, and overall health or quality of life.DescriptiveTen studies found significant differences between intervention group participants and control group in ≥1 outcome related to function in ADL, quality of life or health, self-efficacy, social or work function, and psychological health. OT interventions may improve occupational performance outcomes in adults with chronic conditions.
  • Search strategy may have excluded articles.
  • Scope of the articles was limited to select chronic conditions; other conditions may have benefited from OT interventions as well.
Hardy et al. (2010) Does the combined effect of functional training, UE bracing, and electrical stimulation reduce spasticity and improve functional ability in chronic stroke patients?
  • Level V
  • Case series
  • N = 2 women; M age = 72.5
  • Intervention
  • Participants received both clinic- and home-based treatment sessions over 5 wk that included wearing brace with stimulation followed by repetitive, task-specific purposeful activities.
  • Outcome Measures
  • Modified Ashworth Scale (MAS), MMSE, FMA, B&B, AMAT
Descriptive; pre- and posttest scoresAt the end of intervention, participants demonstrated a 1-point reduction in MAS scores, an increase in FMA scores, and an increase in the ability to perform AMAT activities.
  • Small sample size
  • Limited generalizability to other chronic stroke patients
  • In follow-up, no retesting on the outcome measures
Hayner (2012) Does the California Tri-Pull Taping (CTPT) method reduce shoulder pain and inferior glenohumeral subluxation, improve ADL function, and increase AROM?
  • Level III
  • Time series quasi-experimental single-subject ABA design
  • N = 10 participants ranging from 1 mo to 5 yr poststroke
  • Intervention
  • Participants’ affected UE was taped to prevent subluxation using the CTPT method. The tape was removed and replaced every Monday, Wednesday, and Friday for 3 consecutive weeks.
  • Outcome Measures
  • VAS for pain, Katz ADL Scale, goniometry
Descriptive; trend analysis, Wilcoxon matched pairs signed–rank testThe CTPT method showed significant decreases in inferior subluxation from baseline through intervention phase but not through postintervention phase. Significant increases in shoulder flexion and abduction AROM and improved ADLs were evident through both phases.
  • Limited generalizability because of small sample size
  • Interventionists not blinded
  • The primary researcher who created the method collected the data.
  • Varied time since onset of stroke
Hayner, Gibson, & Giles (2010) How does effectiveness of CIMT compare with bilateral treatment of equal intensity in improving UE function in people with chronic UE dysfunction after stroke?
  • Level I
  • Randomized 2-group intervention trial
  • N = 12 participants ≥6 mo since stroke onset; stratified as having more or less UE impairment (determined by WMFT score) and randomly assigned to either CIMT or bilateral treatment group
  • Intervention
  • CIMT group participants wore padded mitt on unimpaired hand; bilateral group participants were intrusively and repetitively cued to use both UEs during all activities; 6 hr/10 days plus additional home practice.
  • Outcome Measures
  • WMFT and COPM, administered before, after, and 6 mo after treatment
Descriptive statistics; mixed model (split-plot) ANOVAs
  • Significant improvements were found in WMFT and COPM scores across time in both groups. No significant between-group differences were found on WMFT. High-intensity OT using either approach can improve UE function in those with chronic poststroke UE impairment. Treatment intensity rather than restraint may be a critical therapeutic factor.
  • Generalizability limited because of small sample size
  • Behaviors learned by the bilateral group may have been more compatible with participants' routine activities than activities of CIMT group.
  • Study design prevents elimination of nonspecific factors accounting for observed improvements.
Henshaw, Polatajko, McEwen, Ryan, & Baum (2011) How can the CO-OP, a task-specific training program, help shift the focus of OT practice from addressing impairments to improving occupational performance in adults with stroke?
  • Level IV
  • 2 single-subject case reports
  • N = 2; 1 woman age 75 yr, 10 mo poststroke, and 1 woman age 65 yr, 13 mo poststroke
  • Intervention
  • Ten intervention sessions using CO-OP approach, a performance-based, problem-solving strategy of goal–plan–do–check
  • Outcome Measures
  • COPM and Performance Quality Rating Scale used to set goals in the areas of self-care, productivity, and leisure and evaluate goal performance
Descriptive; qualitative analysis
  • Improvements were seen in performance and performance satisfaction of selected goals.
  • Findings support continued research in this area.
  • Limited generalizability and designation of causality because of case study design
  • Some scores rated by treating therapist rather than objective party
  • Lack of long-term follow-up testing to determine maintenance of treatment
Hermann et al. (2010) Does a remotely based FES program administered via a neuroprosthesis and telerehabilitation decrease UE impairment in poststroke clients?
  • Level V
  • Single-subject case report
  • N = 1; 62-yr-old man 3 yr poststroke
  • Intervention
  • Participant was educated in use of FES orthosis and provided with computer camera and software for home use. Supervised by therapist over the Internet, participant engaged in occupation-based task-specific practice of ADL using involved UE 2×/wk for 3 wk; participant also performed unsupervised tasks for 2×/day for 3 days/wk.
  • Outcome Measures
  • FMA, ARAT, and COPM, administered before and after intervention
Descriptive; comparative analysis of pre- and postintervention results
  • Scores improved on FMA, ARAT, and COPM. Participant reported increased satisfaction with task performance for all 5 COPM tasks tested and increased bilateral UE use during ADLs. Results suggest feasibility and efficacy of remotely based FES for UE rehabilitation.
  • Limited generalizability to stroke population because of small sample size
  • Reduced neuroprosthesis compliance and probable decreased monitoring of neuroprosthesis use during functional activities
  • Variation in computer competency among potential participants; limits who may benefit from this intervention
Jack & Estes (2010) Does a shift from a biomechanical to an occupational adaptation (OA) hand therapy approach in an orthopedic outpatient clinic improve patient adaptation and motivation and result in clinically significant functional progress?
  • Level V
  • Single-subject case report
  • N = 1; 51-yr-old woman with chronic lupus-related arthritis 6 days postsurgery on left hand, wrist, and forearm
  • Intervention
  • Initial evaluation and treatment based on biomechanical approach aimed at gaining or maintaining AROM and PROM and reducing edema. Treatment included splinting, modalities, massage, and therapeutic exercise. Ten weeks postsurgery, authors decided to shift to a more client-centered, OA therapeutic focus.
  • Outcome Measures
  • COPM; participant seen for 6 additional sessions with emphasis on performance of valued functional activities including compensatory techniques and adaptive equipment
DescriptiveAfter 10 wk of biomechanical-focused therapy, minimal improvements were documented. At conclusion of OA intervention, clinically important improvements were documented in all functional tasks addressed in COPM. Authors recommend combining biomechanical approach with OA approach to facilitate client adaptation and functional progress.Limited generalizability because of small sample size and complexity of participant’s diagnosis
Kim & Colantonio (2010) How effective are postacute TBI rehabilitation intervention programs that include community integration (CI) as an outcome measure? What are characteristics of effective programs, and what is OT’s involvement?
  • Level I
  • Systematic review; included RCTs (2 single-blinded, 2 unblinded), 4 controlled trials (CTs), and 2 high-quality observational studies (1 prospective cohort study, 1 case-control study)
  • N = 10 studies, including a total of 771 participants, mean age 35.4 yr, male and female, TBI severity ranging from mild to severe. Cause of TBI, length of time since injury, duration of treatment periods, and length of follow-up varied across studies.
  • Interventions
  • Treatment interventions categorized into 4 general groups: multidisciplinary rehabilitation, intensive cognitive rehabilitation, comprehensive integrated rehabilitation, and telerehabilitation. Six of 10 studies involved OT.
  • Outcome Measures
  • Community Integration Questionnaire (CIQ) and Brain Injury Community Rehabilitation Outcome–39
  • PEDro used for quality assessment of RCTs; Downs and Black checklist used for CTs and observational study designs
Because each study had different research methods, populations, measurement tools, interventions, and goals, it was not possible to pool data and synthesize results (quantitative or meta-analysis).
  • No studies were of excellent methodological quality. Each research team provided evidence to support its study’s conclusions. Of the 10 studies, 7 found that postacute TBI rehabilitation benefits CI. All effective studies involved OT or interventions occupational therapists can do.
  • Variability in research methods, sample characteristics, measurements, and interventions made analysis of evidence difficult. Limited RCTs addressed CI interventions. Some studies used CI as global outcome rather than focus of intervention.
  • High probability of ceiling effect of CIQ
  • Nonrobust findings may be result of variability among clients with TBI.
Martin, Johnston, & Sadowsky (2012) Does repetitive neuromuscular electrical stimulation (NMES)–assisted training increase strength and efficiency of the hand of patients with chronic tetraplegia during grasp-and-release functional activities?
  • Level IV
  • Prospective case series
  • N = 3 (1 woman, 2 men, 6–21 mo post–cervical SCI; median age = 18.7 yr)
  • Intervention
  • Intervention consisted of grasp training with sequential application of NMES to wrist extensors, finger flexors, and finger extensors to assist grasp and release of balls. Eight 30-min sessions were conducted over 14 days.
  • Outcome Measures
  • JTTHF, B&B; measurements taken before intervention, after 1st training session, and after final session
Descriptive; Friedman repeated-measures ANOVA on ranks; χ2 and p values generated for each comparison; qualitative data analysis on information gained during semistructured interviews at conclusion of intervention period
  • Within-participant improvements in performance were observed in all outcome measures, particularly subtests of JTTHF requiring grasp. Subjectively, participants reported reduction of spasticity and more effective grasp.
  • Small sample size limits application and generalizability.
  • Because study was conducted during regular OT sessions, it is difficult to distinguish specific individual contribution of repetitive task training vs. NMES effects.
McCall, McEwen, Colantonio, Streiner, & Dawson (2011) What are the effects of a mCIMT protocol on participation, activity, and impairment in a population of older adults with subacute stroke?
  • Level III
  • Interrupted time series
  • N = 4 (2 men, 2 women; M age = 82 yr), M time from stroke onset to start of study = 61 days
  • Intervention
  • An mCIMT protocol was individually customized to each participant on the basis of functional goals; treatment mainly shaping during functional activity with mitt worn on nonaffected UE.
  • Sessions were 2 hr/day, 5 days/wk.
  • Outcome Measures
  • COPM, FIM, Chedoke Arm and Hand Activity Inventory (CAHAI), ARAT
Descriptive analysis of mean differences and trend line analysis
  • Improvement was seen in COPM and CAHAI scores in 4 of 4 participants; improvement was seen in FIM self-report in 3 of 4 participants. Improvement was seen only on Pinch subtest of ARAT. Results suggest positive effects on participation and activity levels, with a small positive effect on impairment.
  • Small sample size
  • Nonblinded assessment of outcome measures
  • Difficult to separate treatment effects from naturally occurring recovery or placebo effect
McClure, McClure, Day, & Brufsky (2010) Does participation of clients with breast cancer–related lymphedema (BCRL) in the Breast Cancer Recovery Program (BCRP), a program of exercise and relaxation, improve physical and emotional BCRL symptoms compared with clients following standard professional recommendations?
  • Level I
  • RCT
  • N = 32 (treatment group, n = 16; control group, n = 16). Participants were female outpatients ages 21–80 yr who demonstrated Stage I or II unilateral BCRL.
  • Intervention
  • Treatment group attended 10 biweekly 1-hr sessions followed by 3 mo self-monitored home program sessions focused on relaxation techniques and low- to moderate-intensity exercise. Control group instructed to continue with lymphedema instructions from their medical team.
  • Outcome Measures
  • Lymphedema swelling (bioelectric impedence analysis and truncated cone girth measurements); patient weight (medical scale); goniometry for shoulder AROM, Beck Depression Inventory–II; SF–36 Health Survey II for quality of life; exercise adherence using self-report tool. Participants tested at entry, 2.5 wk, 5 wk, and 3 mo.
Repeated-measures mixed-model analysisTreatment group participants demonstrated significant treatment effects for improved bioimpedence, arm flexibility, quality of life, mood at 3 mo, and weight loss compared with control group. Adherence to home program was high. Results support use of BCRP as a standardized program for clients with BCRL to improve physical and emotional symptoms.
  • Small sample size
  • High percentage of participants with chronic BCRL vs. those newly diagnosed
  • Lack of experimental control of daily exercise and relaxation routine for control group participants
Nilsen, Gillen, DiRusso, & Gordon (2012) Will OT paired with mental practice (MP) reduce impairments and improve function? Would using MP as an internal (first-person) view or external (third-person) view be more effective in reducing impairment and increasing self-perception of occupational performance?
  • Level I
  • Single-blind RCT
  • N = 19 (9 men, 10 women) with unilateral subacute stroke assigned to one of three groups: control group (n = 6; M age = 66.2 yr), internal MP group (n = 6; M age = 46.6 yr), and external MP group (n = 7, M age = 62.0 yr)
  • Intervention
  • Groups received skilled OT training in functional tasks using mental imagery with either internal or external perspective, 30 min 2×/wk for 6 wk; for control group, relaxation imagery training for same duration
  • Outcome Measures
  • Vividness of Movement Imagery Questionnaire–2 to determine imagery ability and FMA, JTTHF, and COPM to assess change
Descriptive; ANOVAsBoth experimental MP groups (internal and external perspective) showed statistically similar improvements on the JTTHF and FMA at posttest. All 3 groups demonstrated improvements on the COPM. OT and MP combined may prove beneficial for UE recovery after a stroke; self-perception does not appear to be enhanced by MP.
  • Limited generalizability because of small sample size and specific population
  • Lack of blinding of interventionist
  • Randomization not stratified by side of stroke or other potential confounding variables
Nilsen, Gillen, & Gordon (2010) Does mental practice remediate impairments and improve function of the upper limb after stroke?
  • Level I
  • Systematic literature review
  • N = 15 studies; total of 140 participants with unilateral stroke, male and female, M age = 51.66. Stroke onset varied widely from acute to chronic phase. Study levels of evidence: 4 Level I, 2 Level II, 1 Level III, 6 Level IV, and 2 Level V
  • Intervention
  • Most studies combined mental and physical practice with substantial differences in protocol, intensity, and duration.
  • Outcome Measures
  • Most common outcome measures included FMA, Motricity Index, JTTHF, and ARAT.
PEDro scale used for quality assessment of internal validity of Level I and Level II studies
  • Most studies showed that mental practice, when combined with physical practice, reduces impairments and improves functional recovery of the affected upper limb.
  • Results were unclear on appropriate dosing, whether benefits are retained over time, and effect of mental practice on occupational performance.
  • Generalizations on effects difficult because of heterogeneity of studies
  • Search limited to journals published in English
  • No differentiation between large and small RCTs labeled Level I
Page, Murray, & Hermann (2011) Do people with stroke participating in mCIT retain motor benefits in the affected UE 3 mo after intervention?
  • Level III
  • Nonrandomized cohort study
  • N = 13 (9 men, 4 women; M age = 63.4 yr; M time since stroke onset = 29.5 mo)
  • Intervention
  • mCIT protocol for 30-min sessions 3×/wk for 10 wk.
  • Treatment included shaping during functional activity and restraint of unaffected arm in sling. No rehabilitative intervention was provided during 3-mo period after mCIT completion.
  • Outcome Measures
  • ARAT and FMA administered directly after mCIT intervention and 3 mo postintervention
Descriptive; t tests3 mo after intervention, 25 of 26 scores on ARAT and FMA showed nominal increases from scores taken directly after intervention. Changes during this period were not significant but indicate that participants retained previous functional level.
  • Small sample size
  • No comparison with participants not receiving mCIT
  • Only impairment level addressed by outcome measures
  • No information on activities of participants during 3-mo postintervention period
Polatajko, McEwen, Ryan, & Baum (2012) Is there a difference in performance on self-selected goals when comparing CO–OP intervention with standard occupational therapy (SOT) in adults poststroke?
  • Level I
  • RCT (pilot study)
  • N = 8 community-dwelling participants ≥ 6 mo after stroke onset with National Institutes of Health Stroke Scale score <13, IQ ≥ 80, and minimal aphasia (M age = 60.4 yr; 57.9% female); randomly assigned to receive CO-OP (n = 4) or SOT (n = 4)
  • Intervention
  • CO-OP, a 10-session, cognitive-oriented approach using client-driven, performance-based, problem-solving strategies. SOT interventions were therapist driven and combined task-specific and component-based training.
  • Outcome Measures
  • Performance Quality Rating Scale and COPM
Descriptive; Mann–Whitney U; linear regressionParticipants in the CO-OP group showed greater improvements in performance than participants receiving SOT.
  • Small sample size
  • Nonblinding of assessment administration
  • Significant withdrawal rates
  • High recruitment-to-enrollment ratio
Preissner (2010) Can the OT task-oriented approach be used to evaluate and treat a client with severe cognitive limitations poststroke? What are the benefits of this approach with this population?
  • Level V
  • Single-subject case report
  • N = 1; 83-yr-old woman with history of dementia and diagnosis of stroke seen in an inpatient rehabilitation setting
  • Intervention
  • 90 min of OT treatment 6 days/wk for 4 wk, applying selected treatment principles of OT task-oriented approach and using both compensatory and remediative strategies
  • Outcome Measures
  • Five-step evaluation framework for OT task-oriented approach, FIM, Assessment of Motor and Process Skills
Descriptive
  • FIM scores improved on all self-care items at time of discharge. Client met 7 of 9 long-term OT goals and was able to improve participation in meaningful occupations and transition to desired postdischarge setting.
Findings not generalizable to general stroke or dementia population because of small sample size
Rand, Weiss, & Katz (2009) Will clients with multitasking deficits after stroke benefit from training with a virtual supermarket running on a video-capture virtual reality system?
  • Level III
  • Pretest–posttest design
  • N = 4 community-dwelling adults poststroke (3 men, 1 woman; ages 53–70 yr; time since stroke ranged from 5 to 27 mo)
  • Intervention
  • Ten 60-min sessions over 3 wk using VMall, a virtual supermarket
  • Outcome Measures
  • Multiple Errands Test (MET)–Hospital Version, Virtual MET, IADL questionnaire
Descriptive; calculation of percentage of improvementParticipants showed improvements ranging from 20.5% to 51.2% in most mistake categories of MET in both a real shopping mall and the VMall. No significant improvement was seen in IADL scores.
  • Small sample size
  • Participants not balanced for gender or time since stroke onset
  • Stroke severity not considered
  • Limited repertoire of tasks addressed by VMall intervention
Rowe, Blanton, & Wolf (2009) Can UE gains achieved with CIT in a person with chronic stroke be maintained several years after intervention?
  • Level V
  • Case report
  • N = 1 woman (age 36 yr) enrolled in CIT training 19 mo poststroke
  • Intervention
  • CIT included mitt-wearing for 90% of waking hours over 14 days; specialized CIT sessions were provided 5.5 hr/weekday.
  • Outcome Measures
  • WMFT, Motor Activity Log (MAL), and Health-Related Quality of Life levels with Stroke Impact Scale used preintervention and immediately postintervention; 4- and 5-yr follow-up retention measures also were collected.
Descriptive analysis of results, change scores from preintervention, postintervention, and follow-upAfter intervention, participant increased speed on tasks on the WMFT; speed continued to increase at 4- and 5-yr follow-up when compared with preintervention measures. MAL amount of use score improved 2.7 points, quality of use improved 2.2 points. Overall improved quality of life was apparent on SIS.Single-subject study
Schepens, Braun, & Murphy (2012) Does a tailored approach to activity pacing improve self-perceived osteoarthritis joint stiffness to a greater degree than a general approach?
  • Level I
  • Secondary analysis of an RCT
  • N = 32 participants with symptomatic knee or hip osteoarthritis (M age = 59.5 yr for general activity-pacing group, 63.9 yr for tailored activity-pacing group)
  • Intervention
  • General approach group received generic activity-pacing educational module; tailored group received patient-specific pacing information. Both groups addressed progress and barriers in implementing pacing strategies.
  • Outcome Measures
  • Baseline data measures, Western Ontario and McMaster Universities Osteoarthritis Index, wrist accelerometer
Descriptive; ANOVA and linear mixed regression model; covariate analysisParticipants in the tailored activity-pacing group significantly improved self-perception of joint stiffness compared with the general group. The tailored activity-pacing group also demonstrated decreasing self-perceived joint stiffness over time.
  • Limited generalizability because of small sample size
  • Only a limited number of occupational therapists trained in the interventions, resulting in possible bias
Skubik-Peplaski, Carrico, Nichols, Chelette, & Sawaki (2012) Do UE motor recovery, neuroplasticity, and occupational performance change with the use of occupation-based interventions provided to a patient with chronic stroke?
  • Level V
  • Single-subject case report
  • N = 1 man (age = 55 yr) with chronic stroke (15 mo postinfarct)
  • Intervention
  • Client-centered OT provided on the basis of COPM goals and interests (meal preparation, home management tasks, playing guitar, object manipulation)
  • Outcome Measures
  • COPM, FMA, SIS, transcranial magnetic stimulation (TMS)
Descriptive; comparative analysis at baseline and postinterventionContralesional and ipsilesional cortical reorganization and expansion of motor maps were seen through TMS. Improved occupational performance and functional use of UE were also present as supported by changes on COPM.
  • Limited generalizability to stroke population because of small sample size
  • Possible confounding from ancillary techniques such as purposeful activities and preparatory methods
Sledziewski, Schaaf, & Mount (2012) Does traditional OT combined with use of the ReoGo® UE robotic trainer increase UE function after incomplete SCI?
  • Level V
  • Single-subject case report
  • N = 1 man (age 51 yr) with incomplete SCI
  • Intervention
  • Intervention combined traditional OT with ReoGo, a robotic device providing high repetitions of functionally relevant UE exercises.
  • Outcome Measures
  • Manual muscle testing, AROM and sensory testing; functional testing including FIM and Capabilities of Upper Extremity (CUE) instrument
Descriptive measures onlyParticipant demonstrated increases in AROM, independence during self-care tasks, strength, and perceived right UE function.
  • Findings not generalizable to SCI population
  • CUE completed retrospectively
  • Lack of established exercise protocols for the ReoGo
  • Goniometer measurements highly variable
Stapanian, Stapanian, & Staley (2010) Can a patient with bilateral amputations of fingers regain functional independence with creative OT interventions, adaptations, and active patient involvement?
  • Level V
  • Case report
  • N = 1 man (age 40 yr) with bilateral amputation of all 5 fingers of both hands through proximal phalanges; skin grafts and “on-top plasty” surgery performed to expand web space and extend thumb lever arm for functional pinch
Intensive OT included sensory stimulation, scar massage, stretching, exercising joints, splint construction, and functional task performance to improve dexterity. AROM measures were taken. Adaptations to clothes, automobile, home and kitchen, and exercise equipment were made to facilitate independence.DescriptiveAROM increased after OT intervention and surgeries; creative adaptations for power and woodworking tools, exercise equipment, and leisure activities were fabricated to maximize independence. An additional universal hand splint was designed to improve prehension.Single-subject study
Thorne, Sauvé, Yacoub, & Guitard (2009) Can gel pads typically used in wheelchairs be used in supine for pressure-relieving purposes and pressure ulcer management?
  • Level III
  • One-group, nonrandomized crossover design
  • N = 60 patients from acute medical floor of metropolitan hospital at low to moderate risk of skin breakdown
  • Intervention
  • Skin integrity of patient was initially assessed, followed by pressure measurement of coccygeal area in supine using a pressure-mapping system inserted between the patient’s buttocks and mattress for 20 min while measures were taken every 5 min; process was repeated after 2 hr with gel pad inserted under pressure-mapping system.
  • Outcome Measures
  • Medical history and demographics, Braden Scale score, Force Sensitive Applications pressure-mapping system
Wilcoxon signed ranks test and post hoc testing to calculate pressure differences; Spearman’s rank-order correlation to test gender, height, weight, and body mass index (BMI) relationshipsOverall, addition of gel pad did not significantly change pressure or pressure ulcer management. Pressure increased with increased weight and BMI of participants.Difficulty determining accurate height, weight, and BMI because of patients’ varied attire
Tsai et al. (2013) Does listening to classical music reduce unilateral neglect (UN) in stroke patients?
  • Level III
  • One-group, nonrandomized, within-subject, repeated-measures design
  • N = 16; convenience sample of patients with right hemisphere stroke and UN from a local medical center and 3 rehabilitation clinics
Participants sat in a quiet room and rated mood states with before and after audio exposure. Classical music, white noise, or silence was used while patients completed the Behavioral Inattention Test subtests of Star Cancellation, Line Bisection (LBT), and Picture Scanning (PST).Repeated-measures ANOVA with post hoc Bonferroni tests for pairwise comparisonsPatients performed better on LBT and PST when listening to classical music; no significant mood change occurred between conditions. Trend showed positive results for using classical music over white noise or silence to improve UN.
  • Subjectively reported mood assessments
  • Physiological responses not measured
  • Only 2 classical music excerpts used
  • Studies with larger populations needed
Unsworth, Bearup, & Rickard (2009) Can previous Upper Limb Use Scale outcomes and intervention data from the Australian Therapy Outcome Measures (AusTOMs) assessment be used as a benchmark for current OT intervention practices and AusTOMs outcomes?
  • Level II
  • Two-group nonrandomized study
  • N = 40; 20 people with stroke admitted to local subacute rehabilitation unit 4 yr earlier (benchmark sample) and 20 people with stroke currently admitted to subacute rehabilitation units (treatment sample)
Retrospective analysis of benchmark data collecting information on interventions used and outcomes on the AusTOMs Upper Limb Use Scale; these were compared with current interventions used and AusTOMs outcomes.Two-way ANOVA with post hoc testing to compare AusTOMs outcomes dataOT intervention practices were used with treatment sample similar to those used with benchmark sample; participants in both samples showed significant improvement in UE function from pre- to postintervention. No significant differences were found when benchmark scores were compared with treatment scores. AusTOMs outcomes can be used as benchmark.
  • Gains achieved may not be solely result of OT intervention
  • Samples drawn from facilities within same metropolitan area
  • Global upper-limb use outcomes assessed; more information may be needed regarding specific skills gained
Wu, Radel, & Hanna-Pladdy (2011) Can physical practice combined with mental practice improve functional performance and self-perception in a person with stroke and ideomotor apraxia (IMA)?
  • Level V
  • Case report
  • N = 1 man (age 44 yr) 7 mo post–ischemic infarct; immediately after stroke, he had received 30 days of inpatient rehabilitation including physical therapy, OT, and speech pathology
  • Intervention
  • Physical practice focused on reaching for cup and turning book pages, which were practiced for first 30 min of session, followed by 30 min of mental practice with audiotape
  • Outcome Measures
  • AMAT, COPM, and abbreviated Florida Apraxia Battery
  • Measures taken preintervention, postintervention, and 4 wk after intervention
Descriptive data and change scoresDespite persisting IMA, functional performance scores on AMAT improved; self-perception also increased as evidenced by COPM scores after intervention.
  • Single-subject study
  • Same investigator performed assessments and interventions
Wu et al. (2013) Can CIT and eye patching (EP) improve functional performance, eye movement, and trunk–arm kinematics in people with stroke and left neglect syndrome?
  • Level I
  • Single-blinded, randomized pretest–posttest control-group design
  • N = 24 patients with right-sided infarct and left neglect syndrome recruited from 8 medical centers and clinics; randomly assigned to 1 of 3 groups: CIT+EP, CIT only, or conventional therapy
  • Intervention
  • CIT+EP group wore mitt on unaffected UE for 6 hr/day for 3 wk while performing functional tasks; also wore glasses with right patch; CIT-only group received same intervention without glasses; conventional group received traditional OT matched in intensity and duration.
  • Outcome Measures
  • Catherine Bergego checklist of neglect (CBCN); kinematic data
ANCOVA to determine differences in performance between groups with Fisher’s post hoc tests; effect size calculationParticipants in the CIT+EP and CIT-only groups improved daily function as evidenced by scores on CBCN; CIT-only group showed greatest eye fixation improvement, and CIT+EP participants improved trunk–arm kinematics more than other groups.Further study needed with varying types of neglect
Yang, Lin, Chen, Wu, & Chen (2012) Will unilateral and bilateral robot-assisted training for recovery of UE movement after stroke elicit better performance than standard OT treatment? Will the 2 training methods have differential effects in outcome measures?
  • Level I
  • RCT
  • N = 21 people with stroke ≥ 6 mo but < 5 yr postonset (14 men, 7 women; M age= 51.29 yr), divided into unilateral robot-assisted training protocol (URTP), bilateral assisted robot training protocol (BRTP), and standard rehabilitation groups
  • Interview
  • Patients received 90–105 min of therapy 5 days/wk for 4 wk. Participants in the URTP and BRTP groups practiced forearm and wrist movements in a simultaneous manner with the Bi-Manu-Track robotic device. The control group received standard rehabilitation.
  • Outcome Measures
  • FMA, Medical Research Council instrument, grip strength, Modified Ashworth Scale, and Bi-Manu-Track robotic device
Descriptive; χ2 test for categorical data; ANCOVA for pre–post and group differencesURTP and BRTP showed different types of benefits for improvement in movement. URTP may be most beneficial for those needing to improve muscle power, strength at distal joints, and upper limb motor impairment, whereas BRTP might be more beneficial for those needing to improve proximal muscle power.
  • Limited generalizability and power because of small sample size
  • Motor control strategy used postintervention not assessed
  • No follow-up time point
  • Occupation-based outcome measures not included
Zlotnik, Sachs, Rosenblum, Shpasser, & Josman (2009) Can the Dynamic Interactional Model of intervention promote changes in the self-care and motor skills of adolescents with TBI?
  • Level V
  • Case studies of 2 adolescents with TBI
  • Case 1: 16-yr-old boy who sustained traumatic TBI and C7 spinal injury with right hemiparesis and Glasgow Coma Scale (GCS) score of 6–7 on admission to intensive care unit; transferred to rehabilitation 2 wk later
  • Case 2: 17-yr-old girl who sustained traumatic TBI, multiple fractures, and subarachnoid hemorrhage with speech and sensory deficits and GCS score of 14–15 on admission; transferred to rehabilitation 10 days later
  • Intervention
  • Case 1 received OT for 32 sessions (1-hr sessions 5 days/wk); Case 2 received 30 OT sessions (0.5- to 1-hr sessions 5 days/wk).
  • Outcome Measures
  • FIM, COPM, Computerized Penmanship Object Evaluation Tool, and Awareness of Mobility Deficits Questionnaire
Outcomes before, during, and after intervention were compared using visual analysis of graphic data, and qualitative results were described.Use of the Dynamic Interactional Model combined with the Extended Awareness Model was effective in meeting the special needs of the 2 adolescents with TBI. Both clients improved from partial awareness of limitations to full awareness after intervention, and both achieved desired improvement in mobility, self-care, and graphomotor functioning.
  • Research conducted in 2 separate rehabilitation settings under varying conditions
  • Treatment and assessment performed by same clinician on 1 case
Table Footer NoteNote. Effectiveness studies are classified using the system described in Lieberman and Scheer (2002) : Level I = systematic reviews, meta-analyses, and RCTs; Level II = two-group, nonrandomized studies; Level III = one-group, nonrandomized studies; Level IV = descriptive studies; and Level V = case reports and expert opinion. ADL = activities of daily living; AMAT = Arm Motor Ability Test; ANCOVA = analysis of covariance; ANOVA = analysis of variance; ARAT = Action Research Arm Test; AROM = active range of motion; B&B = Box and Block Test; CIMT = constraint-induced movement therapy; CIT = constraint-induced therapy; CO-OP = Cognitive Orientation to Daily Occupational Performance; COPM = Canadian Occupational Performance Measure; CVLT = California Verbal Learning Test; D–KEFS = Delis–Kaplan Executive Function System; FES = functional electrical stimulation; FMA = Fugl-Meyer Assessment; IADL = instrumental activities of daily living; JTTHF = Jebsen–Taylor Test of Hand Function; M = mean; mCIMT = modified constraint-induced movement therapy; mCIT = modified constraint-induced therapy; MMSE = Mini-Mental State Examination; OT = occupational therapy; PEDro = Physiotherapy Evidence Database rating scale; PROM = passive range of motion; RCT = randomized controlled trial; ROM = range of motion; SCI = spinal cord injury; SDMT = Symbol Digit Modalities Test; SF–36 = 36-Item Short Form Health Survey; SIS = Stroke Impact Scale; TBI = traumatic brain injury; UE = upper extremity; VAS = visual analog scale; WAIS–R = Wechsler Adult Intelligence Scale–Revised; WMFT = Wolf Motor Function Test.
Note. Effectiveness studies are classified using the system described in Lieberman and Scheer (2002) : Level I = systematic reviews, meta-analyses, and RCTs; Level II = two-group, nonrandomized studies; Level III = one-group, nonrandomized studies; Level IV = descriptive studies; and Level V = case reports and expert opinion. ADL = activities of daily living; AMAT = Arm Motor Ability Test; ANCOVA = analysis of covariance; ANOVA = analysis of variance; ARAT = Action Research Arm Test; AROM = active range of motion; B&B = Box and Block Test; CIMT = constraint-induced movement therapy; CIT = constraint-induced therapy; CO-OP = Cognitive Orientation to Daily Occupational Performance; COPM = Canadian Occupational Performance Measure; CVLT = California Verbal Learning Test; D–KEFS = Delis–Kaplan Executive Function System; FES = functional electrical stimulation; FMA = Fugl-Meyer Assessment; IADL = instrumental activities of daily living; JTTHF = Jebsen–Taylor Test of Hand Function; M = mean; mCIMT = modified constraint-induced movement therapy; mCIT = modified constraint-induced therapy; MMSE = Mini-Mental State Examination; OT = occupational therapy; PEDro = Physiotherapy Evidence Database rating scale; PROM = passive range of motion; RCT = randomized controlled trial; ROM = range of motion; SCI = spinal cord injury; SDMT = Symbol Digit Modalities Test; SF–36 = 36-Item Short Form Health Survey; SIS = Stroke Impact Scale; TBI = traumatic brain injury; UE = upper extremity; VAS = visual analog scale; WAIS–R = Wechsler Adult Intelligence Scale–Revised; WMFT = Wolf Motor Function Test.×
Table 1.
Intervention Effectiveness Studies Published in the American Journal of Occupational Therapy, January 2009–June 2013
Intervention Effectiveness Studies Published in the American Journal of Occupational Therapy, January 2009–June 2013×
Author/YearStudy ObjectivesLevel/Design/ParticipantsIntervention and Outcome MeasuresStatistical MethodResultsStudy Limitations
Beckelhimer, Dalton, Richter, Hermann, & Page (2011) Would the use of an Interactive Metronome intervention improve the functionality of a hemiparetic arm in 2 stroke patients?
  • Level V
  • Pretest–postest design
  • N = 2 men (M age = 71.5 yr) with history of ischemic stroke (Participant 1, 25 yr poststroke, Participant 2, 2 yr 2 mo poststroke)
  • Intervention
  • 5 min of preparatory stretching exercises, 20 min of Interactive Metronome use and a combination of purposeful and occupation-based activities for 25 min
  • Outcome Measures
  • FMA Motor Activity Test, COPM, and SIS
Descriptive; pre- and posttestingStudy participants demonstrated a positive change from pre- to posttesting on all outcome measures.
  • Small sample size
  • Further research required to warrant study findings
Carver (2009) Would the use of a trough-shaped prop assist in the 1-handed self-catheterization of a TBI patient with a neurogenic bladder?
  • Level V
  • Single-subject case report
  • N = 1; 57-yr-old male with TBI
  • Intervention
  • Observation; successful insertion and use of catheter
  • Outcome Measures
  • Manual Muscle Testing, FIM™
DescriptiveAfter 3 treatment sessions using the novel M-shaped penile prop, the participant was able to successfully self-catheterize independently.Limited generalizability because of single-subject design
Ciro, Hershey, & Garrison (2013) What is the process and outcome of using the STOMP (Skill-building through Task-Oriented Motor Practice) intervention for a person with Lewy body dementia?
  • Level V
  • Case study
  • N = 1; 73-yr-old woman
  • Intervention
  • The STOMP intervention blended task-oriented training and motor learning principles. Intervention occurred 2–3 hr/day for 10 days.
  • Outcome Measures
  • MMSE, Cornell Scale for Depression, FIM, Caregiver Burden Scale, COPM, and goal attainment scaling
Descriptive; pre- and posttestingPatient demonstrated improvement in 2 of 3 goals that were created by patient’s spouse/caregiver. The STOMP intervention demonstrates some potential in evaluating and assisting with occupational performance deficits.
  • Limited generalizability and designation of causality because of study design
  • No follow-up conducted to determine long-term effects
Earley, Herlache, & Skelton (2010) Would using a meaningful occupation during mCIMT intervention lead to improved functionality of an involved UE?
  • Level V
  • Single-subject case report
  • N = 1; 52-yr-old female violinist, 4 yr poststroke
  • Intervention
  • Participant was involved in an mCIMT program consisting of preparatory methods, purposeful activities, and occupations custom designed to her therapeutic goals. Activities involved the repeated practice of specific skills and movements necessary to play the violin. Intervention occurred 3 hr/day for 20 days.
  • Outcome Measures
  • FMA, Sensorimotor Evaluation (modified version), Motor Functioning Assessment (MFA), Arm Improvement and Movement (AIM) checklist, and journaling
Descriptive; pre- and posttestingParticipant demonstrated improved scores on outcome measures and greater function in involved extremity after the mCIMT intervention.
  • Limited generalizability because of small sample size
  • Outcome measures used (FMA, MFA and AIM checklist) not standardized, no established reliability and validity
Finlayson, Preissner, & Cho (2012) Does age, gender, work status, or impairment level have an impact on fatigue management program outcomes for people with multiple sclerosis (MS)?
  • Level III
  • Secondary data analysis using mixed-effects model
  • N = 181 participants with MS (M age = 55 yr; 79% female)
  • Intervention
  • Participants engaged in a teleconference 1×/wk for 6 wk that emphasized rest, body mechanics, environmental modification, communication, activity analysis, and goal setting. Each session lasted 70 min and was facilitated by a licensed occupational therapist.
  • Outcome Measures
  • Fatigue Impact Scale, SF–36, Self-Efficacy for Energy Conservation Questionnaire
Descriptive, mixed-effects models with time trends and variance–covariance structures to determine best modelYounger participants experienced greater reductions in fatigue impact and greater improvements in self-efficacy. Participants with less impairment experienced greater mental health gains and were more likely to retain these gains. Women experienced greater fatigue impact benefits than men, but men experienced greater mental health benefits.
  • Cognitive issues of people with MS not considered
  • Work status not specifically defined
Fong & Howie (2009) Are there greater improvements in outpatients with acquired brain injury when problem-solving skills training includes metacomponential strategies rather than conventional cognitive methods?
  • Level I
  • RCT (matched pairs)
  • N = 33 who had sustained an acquired brain injury (M age = 33.4 yr; 18% female)
  • Intervention
  • The intervention group received functional skills training, conventional cognitive training, and explicit training in problem-solving skills with an emphasis on metacomponential strategies.
  • The control group received conventional cognitive training without the explicit problem-solving component. Training consisted of 2 sessions/wk for 22 sessions.
  • Outcome Measures
  • Behavioral Assessment of the Dysexecutive Syndrome, Social Problem Solving Video Measure, Means Ends Problem Solving Measure, Raven’s Progressive Matrices, Metacomponential Interview
Descriptive; nonparametric Mann–Whitney U test for comparison of change scoresThe intervention group showed significant advantages vs. the control group on the Metacomponential Interview, demonstrating an association with the metacomponential training method used; however, transferability of these skills to real-life problem-solving measures did not produce significant findings.
  • Small sample size and participant attrition
  • Lack of a culturally sensitive instrument to collect subjective data
  • Limited time of exposure to intervention
  • Limited extent of validation and adaptation of measures to Hong Kong Chinese population
Giuffrida, Demery, Reyes, Lebowitz, & Hanlon (2009) What are the significant differences in the acquisition, retention, and transfer of skills in participants with TBI who learned a task using random practice vs. blocked practice?
  • Level II
  • Comparative study
  • N = 6 men with TBI (M age = 28 yr)
  • Intervention
  • Random practice (30 min programmed instruction in touch typing, 10 min of learning a subway schedule, and 15 min of rapid numeric input)
  • Blocked practice (typing, subway stop, and numeric input)
  • Outcome Measures
  • WAIS–R, Wechsler Memory Scale–Revised, CVLT, Trail Making Test, Category Test, Finger Tapping Test, Grooved Pegboard Test, Wisconsin Card Sorting Test
Descriptive; ANOVAThe blocked practice and random practice groups both showed a significant increase in performance skill, acquisition, and retention; the random-practice group demonstrated greater transferability to another task.
  • Small sample size
  • Participants without TBI used as control group
  • Lack of functionally relevant tasks
Glasgow, Fleming, Tooth, & Peters (2012) Will participants who are using dynamic Capener splints 12–16 hr/day make greater progress in contracture resolution than those who use splints 6–12 hr/day over 8 wk of treatment?
  • Level I
  • RCT
  • N = 18 participants with extensor deficits of the proximal interphalangeal joint as a result of hand injury (for 6–12-hr group, M age = 41.0 yr; for 12–16-hr group, M age = 35.3 yr)
  • Intervention
  • Dynamic Capener splints were fabricated with mobilizing force set to 200–250 g; each participant was randomly allocated to either a 6–12-hr or a 12–16-hr wearing regimen. Participants were also required to attend therapy every 1–2 wk for 8 wk.
  • Outcome Measures Finger goniometry for ROM, tension gauge to measure torque
Descriptive; nonparametrics for group differences; linear regression analysisNo significant differences in extension ROM were noted between the 2 groups.
  • Small sample size
  • 78% of participants from the 12–16-hr group used their splints <12 hr/day.
  • Static extension splints were used in addition to Capener splint for participants with flexion and extension deficits.
Goverover, Arango-Lasprilla, Hillary, Chiaravalloti, & DeLuca (2009) Does spaced learning enhance the memory of functional tasks in people with TBI?
  • Level III
  • Within-subject
  • N = 25; 10 TBI patients (M age = 42.5 yr) and 15 healthy control participants (M age = 43.3 yr)
  • Intervention
  • Participants were required to complete paragraph learning and rote learning tasks. Trials were presented in massed and spaced conditions.
  • Outcome Measures
  • Digit Span subtest (WAIS–R), SDMT Oral version, CVLT, D–KEFS subtest
Descriptive; ANOVAsParticipants in the spaced learning condition were better able to recall material than those in the massed learning condition.
  • Small sample size
  • Severity of type of brain injury not accounted for
  • Only 2 functional activities assessed
  • Unclear whether this technique would work for more complex tasks
  • Not known whether effects of spaced learning would maintain over a longer follow-up period
Goverover, Chiaravalloti, & DeLuca (2010) Does using the self-generation method improve recall and performance of everyday functional tasks?
  • Level II
  • Within-group
  • N = 25; 10 TBI patients (M age = 42.5 yr) and 15 healthy control participants (M age = 43.3 yr)
  • Intervention
  • Participants were divided into 2 task-learning groups: generated and provided. Generated group generated the key word in each step of the task. Provided group members were provided directions for each task.
  • Outcome Measures
  • WAIS–R, SDMT, CVLT, D–KEFS
Descriptive; ANOVAsInformation learned using the generated procedure was recalled better than information learned using the provided procedure.
  • Small sample size
  • Severity of type of brain injury not accounted for
  • Only 2 functional activities assessed
  • Unclear whether this technique would work for more complex tasks
Guidetti, Asaba, & Tham (2009) What role does context play in recapturing self-care skills after a stroke or SCI?
  • Level III
  • Survey
  • N = 11; 5 participants with stroke and 6 participants with SCI (9 men, 2 women; M age = 52 yr)
  • Intervention
  • Participants were interviewed 1–3 mo after onset of the stroke or SCI to gather information regarding recapturing self-care skills.
  • Outcome Measure
  • Open-ended survey questions
Descriptive; empirical, phenomenological, and psychological method; qualitative analysisSix characteristics were identified that describe the role of context in recapturing self-care: (1) an air of expectation, (2) support from others, (3) new daily structure, (4) extended time, (5) gradual change in challenge, and (6) therapeutic relationship as enabling possibility.
  • Risk of bias in the analysis of interviews
  • Small sample size
  • Variability in self-care training among participants
Hall et al. (2013) Does a conservative treatment program for carpal tunnel syndrome improve symptoms and reduce the desire to seek surgical interventions?
  • Level I
  • RCT
  • N = 54 (50% men; intervention group, M age = 53.8 yr; control group, M age = 54.9 yr)
  • Intervention
  • Participants were separated into a conservative group or a control group. The conservative group received an 8-wk treatment program with a skilled occupational therapist that included wrist splint and education sessions.
  • The control group received no intervention and was only observed for the same period.
  • Outcome Measures
  • Boston Carpal Tunnel Questionnaire, VAS, dynamometer, Purdue Pegboard, Semmes-Weinstein monofilament testing, Phalen’s test, satisfaction questionnaire
Descriptive; paired and independent t tests, χ2 testsParticipants in the conservative group reported greater symptom relief and improved functional outcomes than the control group.
  • Electrodiagnostic testing not used as an outcome measure
  • Differing skill levels of therapists
  • Participant attrition
  • Interventionists not blinded to study purpose or group assignment
Hall, Lee, Page, Rosenwax, & Lee (2010) Do the 3 rehabilitation protocols to repair acute extensor tendon in Zones V and VI have differing treatment effects on patients?
  • Level III
  • Quasi-experimental
  • N = 27 (17 men, 10 women; M age = 30.4 yr)
  • Intervention
  • Participants were divided into 3 groups: IM (resting splint immobilized), EPM (dorsal dynamic extension splint), and EAM (palmar blocking splint). The IM group was immobilized for the 1st 3 wk and performed graded mobilization from Wk 3–6. EPM group began passive motion on Days 1–5 and exercised in the splint during Wk 1–3. EAM group had early active motion on Days 1–5 and exercised in the splint Wk 1–3. A graded mobilization program began in Wk 5–6 for both the EPM and the EAM groups.
  • Outcome Measures
  • ROM, dynamometer, VAS, goniometer, extension lag testing
Descriptive; ANOVAsAll patient groups showed improvement, but EAM group participants recovered ROM more rapidly.
  • Small sample size in the 3 groups
  • High attrition
  • Limited generalizability to other tendon zone injuries
Hand, Law, & McColl (2011) What is the effectiveness of community-based OT interventions for improving occupational outcomes in adults with chronic conditions?
  • Level IV
  • Literature review
  • N = 16 articles; scoping review methodology used. Conditions discussed include rheumatoid arthritis, chronic obstructive pulmonary disease, congestive heart failure, depression, and multiple conditions.
Studies were grouped by occupations: work, physical function, social function, psychological health, and overall health or quality of life.DescriptiveTen studies found significant differences between intervention group participants and control group in ≥1 outcome related to function in ADL, quality of life or health, self-efficacy, social or work function, and psychological health. OT interventions may improve occupational performance outcomes in adults with chronic conditions.
  • Search strategy may have excluded articles.
  • Scope of the articles was limited to select chronic conditions; other conditions may have benefited from OT interventions as well.
Hardy et al. (2010) Does the combined effect of functional training, UE bracing, and electrical stimulation reduce spasticity and improve functional ability in chronic stroke patients?
  • Level V
  • Case series
  • N = 2 women; M age = 72.5
  • Intervention
  • Participants received both clinic- and home-based treatment sessions over 5 wk that included wearing brace with stimulation followed by repetitive, task-specific purposeful activities.
  • Outcome Measures
  • Modified Ashworth Scale (MAS), MMSE, FMA, B&B, AMAT
Descriptive; pre- and posttest scoresAt the end of intervention, participants demonstrated a 1-point reduction in MAS scores, an increase in FMA scores, and an increase in the ability to perform AMAT activities.
  • Small sample size
  • Limited generalizability to other chronic stroke patients
  • In follow-up, no retesting on the outcome measures
Hayner (2012) Does the California Tri-Pull Taping (CTPT) method reduce shoulder pain and inferior glenohumeral subluxation, improve ADL function, and increase AROM?
  • Level III
  • Time series quasi-experimental single-subject ABA design
  • N = 10 participants ranging from 1 mo to 5 yr poststroke
  • Intervention
  • Participants’ affected UE was taped to prevent subluxation using the CTPT method. The tape was removed and replaced every Monday, Wednesday, and Friday for 3 consecutive weeks.
  • Outcome Measures
  • VAS for pain, Katz ADL Scale, goniometry
Descriptive; trend analysis, Wilcoxon matched pairs signed–rank testThe CTPT method showed significant decreases in inferior subluxation from baseline through intervention phase but not through postintervention phase. Significant increases in shoulder flexion and abduction AROM and improved ADLs were evident through both phases.
  • Limited generalizability because of small sample size
  • Interventionists not blinded
  • The primary researcher who created the method collected the data.
  • Varied time since onset of stroke
Hayner, Gibson, & Giles (2010) How does effectiveness of CIMT compare with bilateral treatment of equal intensity in improving UE function in people with chronic UE dysfunction after stroke?
  • Level I
  • Randomized 2-group intervention trial
  • N = 12 participants ≥6 mo since stroke onset; stratified as having more or less UE impairment (determined by WMFT score) and randomly assigned to either CIMT or bilateral treatment group
  • Intervention
  • CIMT group participants wore padded mitt on unimpaired hand; bilateral group participants were intrusively and repetitively cued to use both UEs during all activities; 6 hr/10 days plus additional home practice.
  • Outcome Measures
  • WMFT and COPM, administered before, after, and 6 mo after treatment
Descriptive statistics; mixed model (split-plot) ANOVAs
  • Significant improvements were found in WMFT and COPM scores across time in both groups. No significant between-group differences were found on WMFT. High-intensity OT using either approach can improve UE function in those with chronic poststroke UE impairment. Treatment intensity rather than restraint may be a critical therapeutic factor.
  • Generalizability limited because of small sample size
  • Behaviors learned by the bilateral group may have been more compatible with participants' routine activities than activities of CIMT group.
  • Study design prevents elimination of nonspecific factors accounting for observed improvements.
Henshaw, Polatajko, McEwen, Ryan, & Baum (2011) How can the CO-OP, a task-specific training program, help shift the focus of OT practice from addressing impairments to improving occupational performance in adults with stroke?
  • Level IV
  • 2 single-subject case reports
  • N = 2; 1 woman age 75 yr, 10 mo poststroke, and 1 woman age 65 yr, 13 mo poststroke
  • Intervention
  • Ten intervention sessions using CO-OP approach, a performance-based, problem-solving strategy of goal–plan–do–check
  • Outcome Measures
  • COPM and Performance Quality Rating Scale used to set goals in the areas of self-care, productivity, and leisure and evaluate goal performance
Descriptive; qualitative analysis
  • Improvements were seen in performance and performance satisfaction of selected goals.
  • Findings support continued research in this area.
  • Limited generalizability and designation of causality because of case study design
  • Some scores rated by treating therapist rather than objective party
  • Lack of long-term follow-up testing to determine maintenance of treatment
Hermann et al. (2010) Does a remotely based FES program administered via a neuroprosthesis and telerehabilitation decrease UE impairment in poststroke clients?
  • Level V
  • Single-subject case report
  • N = 1; 62-yr-old man 3 yr poststroke
  • Intervention
  • Participant was educated in use of FES orthosis and provided with computer camera and software for home use. Supervised by therapist over the Internet, participant engaged in occupation-based task-specific practice of ADL using involved UE 2×/wk for 3 wk; participant also performed unsupervised tasks for 2×/day for 3 days/wk.
  • Outcome Measures
  • FMA, ARAT, and COPM, administered before and after intervention
Descriptive; comparative analysis of pre- and postintervention results
  • Scores improved on FMA, ARAT, and COPM. Participant reported increased satisfaction with task performance for all 5 COPM tasks tested and increased bilateral UE use during ADLs. Results suggest feasibility and efficacy of remotely based FES for UE rehabilitation.
  • Limited generalizability to stroke population because of small sample size
  • Reduced neuroprosthesis compliance and probable decreased monitoring of neuroprosthesis use during functional activities
  • Variation in computer competency among potential participants; limits who may benefit from this intervention
Jack & Estes (2010) Does a shift from a biomechanical to an occupational adaptation (OA) hand therapy approach in an orthopedic outpatient clinic improve patient adaptation and motivation and result in clinically significant functional progress?
  • Level V
  • Single-subject case report
  • N = 1; 51-yr-old woman with chronic lupus-related arthritis 6 days postsurgery on left hand, wrist, and forearm
  • Intervention
  • Initial evaluation and treatment based on biomechanical approach aimed at gaining or maintaining AROM and PROM and reducing edema. Treatment included splinting, modalities, massage, and therapeutic exercise. Ten weeks postsurgery, authors decided to shift to a more client-centered, OA therapeutic focus.
  • Outcome Measures
  • COPM; participant seen for 6 additional sessions with emphasis on performance of valued functional activities including compensatory techniques and adaptive equipment
DescriptiveAfter 10 wk of biomechanical-focused therapy, minimal improvements were documented. At conclusion of OA intervention, clinically important improvements were documented in all functional tasks addressed in COPM. Authors recommend combining biomechanical approach with OA approach to facilitate client adaptation and functional progress.Limited generalizability because of small sample size and complexity of participant’s diagnosis
Kim & Colantonio (2010) How effective are postacute TBI rehabilitation intervention programs that include community integration (CI) as an outcome measure? What are characteristics of effective programs, and what is OT’s involvement?
  • Level I
  • Systematic review; included RCTs (2 single-blinded, 2 unblinded), 4 controlled trials (CTs), and 2 high-quality observational studies (1 prospective cohort study, 1 case-control study)
  • N = 10 studies, including a total of 771 participants, mean age 35.4 yr, male and female, TBI severity ranging from mild to severe. Cause of TBI, length of time since injury, duration of treatment periods, and length of follow-up varied across studies.
  • Interventions
  • Treatment interventions categorized into 4 general groups: multidisciplinary rehabilitation, intensive cognitive rehabilitation, comprehensive integrated rehabilitation, and telerehabilitation. Six of 10 studies involved OT.
  • Outcome Measures
  • Community Integration Questionnaire (CIQ) and Brain Injury Community Rehabilitation Outcome–39
  • PEDro used for quality assessment of RCTs; Downs and Black checklist used for CTs and observational study designs
Because each study had different research methods, populations, measurement tools, interventions, and goals, it was not possible to pool data and synthesize results (quantitative or meta-analysis).
  • No studies were of excellent methodological quality. Each research team provided evidence to support its study’s conclusions. Of the 10 studies, 7 found that postacute TBI rehabilitation benefits CI. All effective studies involved OT or interventions occupational therapists can do.
  • Variability in research methods, sample characteristics, measurements, and interventions made analysis of evidence difficult. Limited RCTs addressed CI interventions. Some studies used CI as global outcome rather than focus of intervention.
  • High probability of ceiling effect of CIQ
  • Nonrobust findings may be result of variability among clients with TBI.
Martin, Johnston, & Sadowsky (2012) Does repetitive neuromuscular electrical stimulation (NMES)–assisted training increase strength and efficiency of the hand of patients with chronic tetraplegia during grasp-and-release functional activities?
  • Level IV
  • Prospective case series
  • N = 3 (1 woman, 2 men, 6–21 mo post–cervical SCI; median age = 18.7 yr)
  • Intervention
  • Intervention consisted of grasp training with sequential application of NMES to wrist extensors, finger flexors, and finger extensors to assist grasp and release of balls. Eight 30-min sessions were conducted over 14 days.
  • Outcome Measures
  • JTTHF, B&B; measurements taken before intervention, after 1st training session, and after final session
Descriptive; Friedman repeated-measures ANOVA on ranks; χ2 and p values generated for each comparison; qualitative data analysis on information gained during semistructured interviews at conclusion of intervention period
  • Within-participant improvements in performance were observed in all outcome measures, particularly subtests of JTTHF requiring grasp. Subjectively, participants reported reduction of spasticity and more effective grasp.
  • Small sample size limits application and generalizability.
  • Because study was conducted during regular OT sessions, it is difficult to distinguish specific individual contribution of repetitive task training vs. NMES effects.
McCall, McEwen, Colantonio, Streiner, & Dawson (2011) What are the effects of a mCIMT protocol on participation, activity, and impairment in a population of older adults with subacute stroke?
  • Level III
  • Interrupted time series
  • N = 4 (2 men, 2 women; M age = 82 yr), M time from stroke onset to start of study = 61 days
  • Intervention
  • An mCIMT protocol was individually customized to each participant on the basis of functional goals; treatment mainly shaping during functional activity with mitt worn on nonaffected UE.
  • Sessions were 2 hr/day, 5 days/wk.
  • Outcome Measures
  • COPM, FIM, Chedoke Arm and Hand Activity Inventory (CAHAI), ARAT
Descriptive analysis of mean differences and trend line analysis
  • Improvement was seen in COPM and CAHAI scores in 4 of 4 participants; improvement was seen in FIM self-report in 3 of 4 participants. Improvement was seen only on Pinch subtest of ARAT. Results suggest positive effects on participation and activity levels, with a small positive effect on impairment.
  • Small sample size
  • Nonblinded assessment of outcome measures
  • Difficult to separate treatment effects from naturally occurring recovery or placebo effect
McClure, McClure, Day, & Brufsky (2010) Does participation of clients with breast cancer–related lymphedema (BCRL) in the Breast Cancer Recovery Program (BCRP), a program of exercise and relaxation, improve physical and emotional BCRL symptoms compared with clients following standard professional recommendations?
  • Level I
  • RCT
  • N = 32 (treatment group, n = 16; control group, n = 16). Participants were female outpatients ages 21–80 yr who demonstrated Stage I or II unilateral BCRL.
  • Intervention
  • Treatment group attended 10 biweekly 1-hr sessions followed by 3 mo self-monitored home program sessions focused on relaxation techniques and low- to moderate-intensity exercise. Control group instructed to continue with lymphedema instructions from their medical team.
  • Outcome Measures
  • Lymphedema swelling (bioelectric impedence analysis and truncated cone girth measurements); patient weight (medical scale); goniometry for shoulder AROM, Beck Depression Inventory–II; SF–36 Health Survey II for quality of life; exercise adherence using self-report tool. Participants tested at entry, 2.5 wk, 5 wk, and 3 mo.
Repeated-measures mixed-model analysisTreatment group participants demonstrated significant treatment effects for improved bioimpedence, arm flexibility, quality of life, mood at 3 mo, and weight loss compared with control group. Adherence to home program was high. Results support use of BCRP as a standardized program for clients with BCRL to improve physical and emotional symptoms.
  • Small sample size
  • High percentage of participants with chronic BCRL vs. those newly diagnosed
  • Lack of experimental control of daily exercise and relaxation routine for control group participants
Nilsen, Gillen, DiRusso, & Gordon (2012) Will OT paired with mental practice (MP) reduce impairments and improve function? Would using MP as an internal (first-person) view or external (third-person) view be more effective in reducing impairment and increasing self-perception of occupational performance?
  • Level I
  • Single-blind RCT
  • N = 19 (9 men, 10 women) with unilateral subacute stroke assigned to one of three groups: control group (n = 6; M age = 66.2 yr), internal MP group (n = 6; M age = 46.6 yr), and external MP group (n = 7, M age = 62.0 yr)
  • Intervention
  • Groups received skilled OT training in functional tasks using mental imagery with either internal or external perspective, 30 min 2×/wk for 6 wk; for control group, relaxation imagery training for same duration
  • Outcome Measures
  • Vividness of Movement Imagery Questionnaire–2 to determine imagery ability and FMA, JTTHF, and COPM to assess change
Descriptive; ANOVAsBoth experimental MP groups (internal and external perspective) showed statistically similar improvements on the JTTHF and FMA at posttest. All 3 groups demonstrated improvements on the COPM. OT and MP combined may prove beneficial for UE recovery after a stroke; self-perception does not appear to be enhanced by MP.
  • Limited generalizability because of small sample size and specific population
  • Lack of blinding of interventionist
  • Randomization not stratified by side of stroke or other potential confounding variables
Nilsen, Gillen, & Gordon (2010) Does mental practice remediate impairments and improve function of the upper limb after stroke?
  • Level I
  • Systematic literature review
  • N = 15 studies; total of 140 participants with unilateral stroke, male and female, M age = 51.66. Stroke onset varied widely from acute to chronic phase. Study levels of evidence: 4 Level I, 2 Level II, 1 Level III, 6 Level IV, and 2 Level V
  • Intervention
  • Most studies combined mental and physical practice with substantial differences in protocol, intensity, and duration.
  • Outcome Measures
  • Most common outcome measures included FMA, Motricity Index, JTTHF, and ARAT.
PEDro scale used for quality assessment of internal validity of Level I and Level II studies
  • Most studies showed that mental practice, when combined with physical practice, reduces impairments and improves functional recovery of the affected upper limb.
  • Results were unclear on appropriate dosing, whether benefits are retained over time, and effect of mental practice on occupational performance.
  • Generalizations on effects difficult because of heterogeneity of studies
  • Search limited to journals published in English
  • No differentiation between large and small RCTs labeled Level I
Page, Murray, & Hermann (2011) Do people with stroke participating in mCIT retain motor benefits in the affected UE 3 mo after intervention?
  • Level III
  • Nonrandomized cohort study
  • N = 13 (9 men, 4 women; M age = 63.4 yr; M time since stroke onset = 29.5 mo)
  • Intervention
  • mCIT protocol for 30-min sessions 3×/wk for 10 wk.
  • Treatment included shaping during functional activity and restraint of unaffected arm in sling. No rehabilitative intervention was provided during 3-mo period after mCIT completion.
  • Outcome Measures
  • ARAT and FMA administered directly after mCIT intervention and 3 mo postintervention
Descriptive; t tests3 mo after intervention, 25 of 26 scores on ARAT and FMA showed nominal increases from scores taken directly after intervention. Changes during this period were not significant but indicate that participants retained previous functional level.
  • Small sample size
  • No comparison with participants not receiving mCIT
  • Only impairment level addressed by outcome measures
  • No information on activities of participants during 3-mo postintervention period
Polatajko, McEwen, Ryan, & Baum (2012) Is there a difference in performance on self-selected goals when comparing CO–OP intervention with standard occupational therapy (SOT) in adults poststroke?
  • Level I
  • RCT (pilot study)
  • N = 8 community-dwelling participants ≥ 6 mo after stroke onset with National Institutes of Health Stroke Scale score <13, IQ ≥ 80, and minimal aphasia (M age = 60.4 yr; 57.9% female); randomly assigned to receive CO-OP (n = 4) or SOT (n = 4)
  • Intervention
  • CO-OP, a 10-session, cognitive-oriented approach using client-driven, performance-based, problem-solving strategies. SOT interventions were therapist driven and combined task-specific and component-based training.
  • Outcome Measures
  • Performance Quality Rating Scale and COPM
Descriptive; Mann–Whitney U; linear regressionParticipants in the CO-OP group showed greater improvements in performance than participants receiving SOT.
  • Small sample size
  • Nonblinding of assessment administration
  • Significant withdrawal rates
  • High recruitment-to-enrollment ratio
Preissner (2010) Can the OT task-oriented approach be used to evaluate and treat a client with severe cognitive limitations poststroke? What are the benefits of this approach with this population?
  • Level V
  • Single-subject case report
  • N = 1; 83-yr-old woman with history of dementia and diagnosis of stroke seen in an inpatient rehabilitation setting
  • Intervention
  • 90 min of OT treatment 6 days/wk for 4 wk, applying selected treatment principles of OT task-oriented approach and using both compensatory and remediative strategies
  • Outcome Measures
  • Five-step evaluation framework for OT task-oriented approach, FIM, Assessment of Motor and Process Skills
Descriptive
  • FIM scores improved on all self-care items at time of discharge. Client met 7 of 9 long-term OT goals and was able to improve participation in meaningful occupations and transition to desired postdischarge setting.
Findings not generalizable to general stroke or dementia population because of small sample size
Rand, Weiss, & Katz (2009) Will clients with multitasking deficits after stroke benefit from training with a virtual supermarket running on a video-capture virtual reality system?
  • Level III
  • Pretest–posttest design
  • N = 4 community-dwelling adults poststroke (3 men, 1 woman; ages 53–70 yr; time since stroke ranged from 5 to 27 mo)
  • Intervention
  • Ten 60-min sessions over 3 wk using VMall, a virtual supermarket
  • Outcome Measures
  • Multiple Errands Test (MET)–Hospital Version, Virtual MET, IADL questionnaire
Descriptive; calculation of percentage of improvementParticipants showed improvements ranging from 20.5% to 51.2% in most mistake categories of MET in both a real shopping mall and the VMall. No significant improvement was seen in IADL scores.
  • Small sample size
  • Participants not balanced for gender or time since stroke onset
  • Stroke severity not considered
  • Limited repertoire of tasks addressed by VMall intervention
Rowe, Blanton, & Wolf (2009) Can UE gains achieved with CIT in a person with chronic stroke be maintained several years after intervention?
  • Level V
  • Case report
  • N = 1 woman (age 36 yr) enrolled in CIT training 19 mo poststroke
  • Intervention
  • CIT included mitt-wearing for 90% of waking hours over 14 days; specialized CIT sessions were provided 5.5 hr/weekday.
  • Outcome Measures
  • WMFT, Motor Activity Log (MAL), and Health-Related Quality of Life levels with Stroke Impact Scale used preintervention and immediately postintervention; 4- and 5-yr follow-up retention measures also were collected.
Descriptive analysis of results, change scores from preintervention, postintervention, and follow-upAfter intervention, participant increased speed on tasks on the WMFT; speed continued to increase at 4- and 5-yr follow-up when compared with preintervention measures. MAL amount of use score improved 2.7 points, quality of use improved 2.2 points. Overall improved quality of life was apparent on SIS.Single-subject study
Schepens, Braun, & Murphy (2012) Does a tailored approach to activity pacing improve self-perceived osteoarthritis joint stiffness to a greater degree than a general approach?
  • Level I
  • Secondary analysis of an RCT
  • N = 32 participants with symptomatic knee or hip osteoarthritis (M age = 59.5 yr for general activity-pacing group, 63.9 yr for tailored activity-pacing group)
  • Intervention
  • General approach group received generic activity-pacing educational module; tailored group received patient-specific pacing information. Both groups addressed progress and barriers in implementing pacing strategies.
  • Outcome Measures
  • Baseline data measures, Western Ontario and McMaster Universities Osteoarthritis Index, wrist accelerometer
Descriptive; ANOVA and linear mixed regression model; covariate analysisParticipants in the tailored activity-pacing group significantly improved self-perception of joint stiffness compared with the general group. The tailored activity-pacing group also demonstrated decreasing self-perceived joint stiffness over time.
  • Limited generalizability because of small sample size
  • Only a limited number of occupational therapists trained in the interventions, resulting in possible bias
Skubik-Peplaski, Carrico, Nichols, Chelette, & Sawaki (2012) Do UE motor recovery, neuroplasticity, and occupational performance change with the use of occupation-based interventions provided to a patient with chronic stroke?
  • Level V
  • Single-subject case report
  • N = 1 man (age = 55 yr) with chronic stroke (15 mo postinfarct)
  • Intervention
  • Client-centered OT provided on the basis of COPM goals and interests (meal preparation, home management tasks, playing guitar, object manipulation)
  • Outcome Measures
  • COPM, FMA, SIS, transcranial magnetic stimulation (TMS)
Descriptive; comparative analysis at baseline and postinterventionContralesional and ipsilesional cortical reorganization and expansion of motor maps were seen through TMS. Improved occupational performance and functional use of UE were also present as supported by changes on COPM.
  • Limited generalizability to stroke population because of small sample size
  • Possible confounding from ancillary techniques such as purposeful activities and preparatory methods
Sledziewski, Schaaf, & Mount (2012) Does traditional OT combined with use of the ReoGo® UE robotic trainer increase UE function after incomplete SCI?
  • Level V
  • Single-subject case report
  • N = 1 man (age 51 yr) with incomplete SCI
  • Intervention
  • Intervention combined traditional OT with ReoGo, a robotic device providing high repetitions of functionally relevant UE exercises.
  • Outcome Measures
  • Manual muscle testing, AROM and sensory testing; functional testing including FIM and Capabilities of Upper Extremity (CUE) instrument
Descriptive measures onlyParticipant demonstrated increases in AROM, independence during self-care tasks, strength, and perceived right UE function.
  • Findings not generalizable to SCI population
  • CUE completed retrospectively
  • Lack of established exercise protocols for the ReoGo
  • Goniometer measurements highly variable
Stapanian, Stapanian, & Staley (2010) Can a patient with bilateral amputations of fingers regain functional independence with creative OT interventions, adaptations, and active patient involvement?
  • Level V
  • Case report
  • N = 1 man (age 40 yr) with bilateral amputation of all 5 fingers of both hands through proximal phalanges; skin grafts and “on-top plasty” surgery performed to expand web space and extend thumb lever arm for functional pinch
Intensive OT included sensory stimulation, scar massage, stretching, exercising joints, splint construction, and functional task performance to improve dexterity. AROM measures were taken. Adaptations to clothes, automobile, home and kitchen, and exercise equipment were made to facilitate independence.DescriptiveAROM increased after OT intervention and surgeries; creative adaptations for power and woodworking tools, exercise equipment, and leisure activities were fabricated to maximize independence. An additional universal hand splint was designed to improve prehension.Single-subject study
Thorne, Sauvé, Yacoub, & Guitard (2009) Can gel pads typically used in wheelchairs be used in supine for pressure-relieving purposes and pressure ulcer management?
  • Level III
  • One-group, nonrandomized crossover design
  • N = 60 patients from acute medical floor of metropolitan hospital at low to moderate risk of skin breakdown
  • Intervention
  • Skin integrity of patient was initially assessed, followed by pressure measurement of coccygeal area in supine using a pressure-mapping system inserted between the patient’s buttocks and mattress for 20 min while measures were taken every 5 min; process was repeated after 2 hr with gel pad inserted under pressure-mapping system.
  • Outcome Measures
  • Medical history and demographics, Braden Scale score, Force Sensitive Applications pressure-mapping system
Wilcoxon signed ranks test and post hoc testing to calculate pressure differences; Spearman’s rank-order correlation to test gender, height, weight, and body mass index (BMI) relationshipsOverall, addition of gel pad did not significantly change pressure or pressure ulcer management. Pressure increased with increased weight and BMI of participants.Difficulty determining accurate height, weight, and BMI because of patients’ varied attire
Tsai et al. (2013) Does listening to classical music reduce unilateral neglect (UN) in stroke patients?
  • Level III
  • One-group, nonrandomized, within-subject, repeated-measures design
  • N = 16; convenience sample of patients with right hemisphere stroke and UN from a local medical center and 3 rehabilitation clinics
Participants sat in a quiet room and rated mood states with before and after audio exposure. Classical music, white noise, or silence was used while patients completed the Behavioral Inattention Test subtests of Star Cancellation, Line Bisection (LBT), and Picture Scanning (PST).Repeated-measures ANOVA with post hoc Bonferroni tests for pairwise comparisonsPatients performed better on LBT and PST when listening to classical music; no significant mood change occurred between conditions. Trend showed positive results for using classical music over white noise or silence to improve UN.
  • Subjectively reported mood assessments
  • Physiological responses not measured
  • Only 2 classical music excerpts used
  • Studies with larger populations needed
Unsworth, Bearup, & Rickard (2009) Can previous Upper Limb Use Scale outcomes and intervention data from the Australian Therapy Outcome Measures (AusTOMs) assessment be used as a benchmark for current OT intervention practices and AusTOMs outcomes?
  • Level II
  • Two-group nonrandomized study
  • N = 40; 20 people with stroke admitted to local subacute rehabilitation unit 4 yr earlier (benchmark sample) and 20 people with stroke currently admitted to subacute rehabilitation units (treatment sample)
Retrospective analysis of benchmark data collecting information on interventions used and outcomes on the AusTOMs Upper Limb Use Scale; these were compared with current interventions used and AusTOMs outcomes.Two-way ANOVA with post hoc testing to compare AusTOMs outcomes dataOT intervention practices were used with treatment sample similar to those used with benchmark sample; participants in both samples showed significant improvement in UE function from pre- to postintervention. No significant differences were found when benchmark scores were compared with treatment scores. AusTOMs outcomes can be used as benchmark.
  • Gains achieved may not be solely result of OT intervention
  • Samples drawn from facilities within same metropolitan area
  • Global upper-limb use outcomes assessed; more information may be needed regarding specific skills gained
Wu, Radel, & Hanna-Pladdy (2011) Can physical practice combined with mental practice improve functional performance and self-perception in a person with stroke and ideomotor apraxia (IMA)?
  • Level V
  • Case report
  • N = 1 man (age 44 yr) 7 mo post–ischemic infarct; immediately after stroke, he had received 30 days of inpatient rehabilitation including physical therapy, OT, and speech pathology
  • Intervention
  • Physical practice focused on reaching for cup and turning book pages, which were practiced for first 30 min of session, followed by 30 min of mental practice with audiotape
  • Outcome Measures
  • AMAT, COPM, and abbreviated Florida Apraxia Battery
  • Measures taken preintervention, postintervention, and 4 wk after intervention
Descriptive data and change scoresDespite persisting IMA, functional performance scores on AMAT improved; self-perception also increased as evidenced by COPM scores after intervention.
  • Single-subject study
  • Same investigator performed assessments and interventions
Wu et al. (2013) Can CIT and eye patching (EP) improve functional performance, eye movement, and trunk–arm kinematics in people with stroke and left neglect syndrome?
  • Level I
  • Single-blinded, randomized pretest–posttest control-group design
  • N = 24 patients with right-sided infarct and left neglect syndrome recruited from 8 medical centers and clinics; randomly assigned to 1 of 3 groups: CIT+EP, CIT only, or conventional therapy
  • Intervention
  • CIT+EP group wore mitt on unaffected UE for 6 hr/day for 3 wk while performing functional tasks; also wore glasses with right patch; CIT-only group received same intervention without glasses; conventional group received traditional OT matched in intensity and duration.
  • Outcome Measures
  • Catherine Bergego checklist of neglect (CBCN); kinematic data
ANCOVA to determine differences in performance between groups with Fisher’s post hoc tests; effect size calculationParticipants in the CIT+EP and CIT-only groups improved daily function as evidenced by scores on CBCN; CIT-only group showed greatest eye fixation improvement, and CIT+EP participants improved trunk–arm kinematics more than other groups.Further study needed with varying types of neglect
Yang, Lin, Chen, Wu, & Chen (2012) Will unilateral and bilateral robot-assisted training for recovery of UE movement after stroke elicit better performance than standard OT treatment? Will the 2 training methods have differential effects in outcome measures?
  • Level I
  • RCT
  • N = 21 people with stroke ≥ 6 mo but < 5 yr postonset (14 men, 7 women; M age= 51.29 yr), divided into unilateral robot-assisted training protocol (URTP), bilateral assisted robot training protocol (BRTP), and standard rehabilitation groups
  • Interview
  • Patients received 90–105 min of therapy 5 days/wk for 4 wk. Participants in the URTP and BRTP groups practiced forearm and wrist movements in a simultaneous manner with the Bi-Manu-Track robotic device. The control group received standard rehabilitation.
  • Outcome Measures
  • FMA, Medical Research Council instrument, grip strength, Modified Ashworth Scale, and Bi-Manu-Track robotic device
Descriptive; χ2 test for categorical data; ANCOVA for pre–post and group differencesURTP and BRTP showed different types of benefits for improvement in movement. URTP may be most beneficial for those needing to improve muscle power, strength at distal joints, and upper limb motor impairment, whereas BRTP might be more beneficial for those needing to improve proximal muscle power.
  • Limited generalizability and power because of small sample size
  • Motor control strategy used postintervention not assessed
  • No follow-up time point
  • Occupation-based outcome measures not included
Zlotnik, Sachs, Rosenblum, Shpasser, & Josman (2009) Can the Dynamic Interactional Model of intervention promote changes in the self-care and motor skills of adolescents with TBI?
  • Level V
  • Case studies of 2 adolescents with TBI
  • Case 1: 16-yr-old boy who sustained traumatic TBI and C7 spinal injury with right hemiparesis and Glasgow Coma Scale (GCS) score of 6–7 on admission to intensive care unit; transferred to rehabilitation 2 wk later
  • Case 2: 17-yr-old girl who sustained traumatic TBI, multiple fractures, and subarachnoid hemorrhage with speech and sensory deficits and GCS score of 14–15 on admission; transferred to rehabilitation 10 days later
  • Intervention
  • Case 1 received OT for 32 sessions (1-hr sessions 5 days/wk); Case 2 received 30 OT sessions (0.5- to 1-hr sessions 5 days/wk).
  • Outcome Measures
  • FIM, COPM, Computerized Penmanship Object Evaluation Tool, and Awareness of Mobility Deficits Questionnaire
Outcomes before, during, and after intervention were compared using visual analysis of graphic data, and qualitative results were described.Use of the Dynamic Interactional Model combined with the Extended Awareness Model was effective in meeting the special needs of the 2 adolescents with TBI. Both clients improved from partial awareness of limitations to full awareness after intervention, and both achieved desired improvement in mobility, self-care, and graphomotor functioning.
  • Research conducted in 2 separate rehabilitation settings under varying conditions
  • Treatment and assessment performed by same clinician on 1 case
Table Footer NoteNote. Effectiveness studies are classified using the system described in Lieberman and Scheer (2002) : Level I = systematic reviews, meta-analyses, and RCTs; Level II = two-group, nonrandomized studies; Level III = one-group, nonrandomized studies; Level IV = descriptive studies; and Level V = case reports and expert opinion. ADL = activities of daily living; AMAT = Arm Motor Ability Test; ANCOVA = analysis of covariance; ANOVA = analysis of variance; ARAT = Action Research Arm Test; AROM = active range of motion; B&B = Box and Block Test; CIMT = constraint-induced movement therapy; CIT = constraint-induced therapy; CO-OP = Cognitive Orientation to Daily Occupational Performance; COPM = Canadian Occupational Performance Measure; CVLT = California Verbal Learning Test; D–KEFS = Delis–Kaplan Executive Function System; FES = functional electrical stimulation; FMA = Fugl-Meyer Assessment; IADL = instrumental activities of daily living; JTTHF = Jebsen–Taylor Test of Hand Function; M = mean; mCIMT = modified constraint-induced movement therapy; mCIT = modified constraint-induced therapy; MMSE = Mini-Mental State Examination; OT = occupational therapy; PEDro = Physiotherapy Evidence Database rating scale; PROM = passive range of motion; RCT = randomized controlled trial; ROM = range of motion; SCI = spinal cord injury; SDMT = Symbol Digit Modalities Test; SF–36 = 36-Item Short Form Health Survey; SIS = Stroke Impact Scale; TBI = traumatic brain injury; UE = upper extremity; VAS = visual analog scale; WAIS–R = Wechsler Adult Intelligence Scale–Revised; WMFT = Wolf Motor Function Test.
Note. Effectiveness studies are classified using the system described in Lieberman and Scheer (2002) : Level I = systematic reviews, meta-analyses, and RCTs; Level II = two-group, nonrandomized studies; Level III = one-group, nonrandomized studies; Level IV = descriptive studies; and Level V = case reports and expert opinion. ADL = activities of daily living; AMAT = Arm Motor Ability Test; ANCOVA = analysis of covariance; ANOVA = analysis of variance; ARAT = Action Research Arm Test; AROM = active range of motion; B&B = Box and Block Test; CIMT = constraint-induced movement therapy; CIT = constraint-induced therapy; CO-OP = Cognitive Orientation to Daily Occupational Performance; COPM = Canadian Occupational Performance Measure; CVLT = California Verbal Learning Test; D–KEFS = Delis–Kaplan Executive Function System; FES = functional electrical stimulation; FMA = Fugl-Meyer Assessment; IADL = instrumental activities of daily living; JTTHF = Jebsen–Taylor Test of Hand Function; M = mean; mCIMT = modified constraint-induced movement therapy; mCIT = modified constraint-induced therapy; MMSE = Mini-Mental State Examination; OT = occupational therapy; PEDro = Physiotherapy Evidence Database rating scale; PROM = passive range of motion; RCT = randomized controlled trial; ROM = range of motion; SCI = spinal cord injury; SDMT = Symbol Digit Modalities Test; SF–36 = 36-Item Short Form Health Survey; SIS = Stroke Impact Scale; TBI = traumatic brain injury; UE = upper extremity; VAS = visual analog scale; WAIS–R = Wechsler Adult Intelligence Scale–Revised; WMFT = Wolf Motor Function Test.×
×
Table 2.
Interventions Studied
Interventions Studied×
Interventions for Stroke
Problem Area Addressed or InvestigatedIntervention
Overall functionInteractive MetronomePhysical and mental practice
Self-care skillsContext survey
Upper-extremity spasticityFunctional training, bracing, and electrical stimulation
Glenohumeral subluxationCalifornia Tri-Pull Taping
Upper-extremity function
  • Modified CIMT
  • CIMT vs. bilateral training
  • Remote functional electrical stimulation and neuroprosthetic
  • Occupational therapy and mental practice
  • Mental practice
  • Modified CIMT
  • CIMT
  • Occupation-based intervention
  • CIMT and eye patching
  • Robot training
Occupational performanceCO-OP training method
ParticipationModified CIMT
CognitionOccupational therapy task-oriented approach
MultitaskingVirtual reality training
Unilateral neglectClassical music
Self-selected goalsCO–OP training method
Benchmarking occupational therapy practiceAusTOMs
Interventions for Traumatic Brain Injury
Problem Area Addressed or InvestigatedIntervention
Self-catheterizationPenile trough
Cognition
  • Metacomponential strategies
  • Spaced learning
  • Self-generation method
FunctionRandom vs. blocked practice
Self-care skillsContext survey
Outcomes
  • Traumatic brain injury rehabilitation programs incorporating community integration
  • Dynamic Interaction Model
Interventions for Hand Injuries
Problem Area Addressed or InvestigatedIntervention
Contracture managementDynamic Capener splint
Reduction in need for surgeryConservative treatment approach for carpal tunnel syndrome
Treatment effectsAcute extensor tendon repair in Zones V and VI
FunctionCreative intervention and adaptations for bilateral finger amputations
Interventions for Other Conditions
ConditionProblem Addressed or InvestigatedIntervention
Spinal injury
  • Hand strength and efficiency
  • UE function
Repetitive electrical stimulation to UE Reo-Go robotic training
DementiaSTOMP method
LymphedemaEmotional symptomsRelaxation and exercise
Multiple sclerosisFatigue management
OsteoarthritisDecreased joint stiffnessActivity pacing
General medicalCoccygeal pressure in supineGel pads
Chronic conditions
  • Occupational outcomes
  • Function
  • Community-based occupational therapy for adults with rheumatoid arthritis, chronic obstructive pulmonary disease, and congestive heart failure
  • Biomechanical vs. occupational adaptation approach for lupus
Table Footer NoteNote. AusTOMs = Australian Therapy Outcome Measures; CIMT = constraint-induced movement therapy; CO–OP = Cognitive Orientation to Daily Occupational Performance; STOMP = Skill-building through Task-Oriented Motor Practice; UE = upper extremity.
Note. AusTOMs = Australian Therapy Outcome Measures; CIMT = constraint-induced movement therapy; CO–OP = Cognitive Orientation to Daily Occupational Performance; STOMP = Skill-building through Task-Oriented Motor Practice; UE = upper extremity.×
Table 2.
Interventions Studied
Interventions Studied×
Interventions for Stroke
Problem Area Addressed or InvestigatedIntervention
Overall functionInteractive MetronomePhysical and mental practice
Self-care skillsContext survey
Upper-extremity spasticityFunctional training, bracing, and electrical stimulation
Glenohumeral subluxationCalifornia Tri-Pull Taping
Upper-extremity function
  • Modified CIMT
  • CIMT vs. bilateral training
  • Remote functional electrical stimulation and neuroprosthetic
  • Occupational therapy and mental practice
  • Mental practice
  • Modified CIMT
  • CIMT
  • Occupation-based intervention
  • CIMT and eye patching
  • Robot training
Occupational performanceCO-OP training method
ParticipationModified CIMT
CognitionOccupational therapy task-oriented approach
MultitaskingVirtual reality training
Unilateral neglectClassical music
Self-selected goalsCO–OP training method
Benchmarking occupational therapy practiceAusTOMs
Interventions for Traumatic Brain Injury
Problem Area Addressed or InvestigatedIntervention
Self-catheterizationPenile trough
Cognition
  • Metacomponential strategies
  • Spaced learning
  • Self-generation method
FunctionRandom vs. blocked practice
Self-care skillsContext survey
Outcomes
  • Traumatic brain injury rehabilitation programs incorporating community integration
  • Dynamic Interaction Model
Interventions for Hand Injuries
Problem Area Addressed or InvestigatedIntervention
Contracture managementDynamic Capener splint
Reduction in need for surgeryConservative treatment approach for carpal tunnel syndrome
Treatment effectsAcute extensor tendon repair in Zones V and VI
FunctionCreative intervention and adaptations for bilateral finger amputations
Interventions for Other Conditions
ConditionProblem Addressed or InvestigatedIntervention
Spinal injury
  • Hand strength and efficiency
  • UE function
Repetitive electrical stimulation to UE Reo-Go robotic training
DementiaSTOMP method
LymphedemaEmotional symptomsRelaxation and exercise
Multiple sclerosisFatigue management
OsteoarthritisDecreased joint stiffnessActivity pacing
General medicalCoccygeal pressure in supineGel pads
Chronic conditions
  • Occupational outcomes
  • Function
  • Community-based occupational therapy for adults with rheumatoid arthritis, chronic obstructive pulmonary disease, and congestive heart failure
  • Biomechanical vs. occupational adaptation approach for lupus
Table Footer NoteNote. AusTOMs = Australian Therapy Outcome Measures; CIMT = constraint-induced movement therapy; CO–OP = Cognitive Orientation to Daily Occupational Performance; STOMP = Skill-building through Task-Oriented Motor Practice; UE = upper extremity.
Note. AusTOMs = Australian Therapy Outcome Measures; CIMT = constraint-induced movement therapy; CO–OP = Cognitive Orientation to Daily Occupational Performance; STOMP = Skill-building through Task-Oriented Motor Practice; UE = upper extremity.×
×
Table 3.
Studies Categorized by Number of Participants
Studies Categorized by Number of Participants×
Single-Subject Case Designs, N = 1 or 22 < N ≤ 10N > 10Literature Reviews
(15 studies)(6 studies)(18 studies)(3 studies)
Table 3.
Studies Categorized by Number of Participants
Studies Categorized by Number of Participants×
Single-Subject Case Designs, N = 1 or 22 < N ≤ 10N > 10Literature Reviews
(15 studies)(6 studies)(18 studies)(3 studies)
×