Characterizing Occupational Therapy Practice in Stroke Rehabilitation

Article Outline

• Abstract
• Methods
  • Patients in the OT Subset
  • Instrumentation
  • Data Analysis
• Results
  • Relation of Activities to Outcome
• Discussion
  • Do Occupational Therapists Use a Strategy of Task Training or Restoration of Body Structure and Function?
  • Do Occupational Therapists Address Activities Across Life Roles?
  • Do Occupational Therapists Tailor Therapy Based on Patient Disability?
  • Is the Amount of Time in OT Activities Related to Functional Outcome?
• Conclusions
• Acknowledgments
• Appendix 1. OT intervention documentation form
• Appendix 2. Component of dressing, upper body
• References
• Copyright

Abstract 

Richards LG, Latham NK, Jette DU, Rosenberg L, Smout RJ, DeJong G. Characterizing occupational therapy practice in stroke rehabilitation.

Objectives

To describe how occupational therapy (OT) activities during stroke inpatient rehabilitation vary by admission functional status and over time and how time spent in these various activities relates to functional status at discharge.

Design

Observational cohort study.

Setting

Six inpatient rehabilitation hospitals in the United States.

Participants

People (N=713) receiving 4 to 19 hours of poststroke OT.

Interventions

Not applicable.

Main Outcome Measures

Patients were categorized by number of 4-hour blocks of OT received and by admission upper-extremity (UE) dressing score on the FIM instrument. In each group, the percentage of time spent in 16 activities and the percentage of patients who received each activity were calculated. The amount of time in activities was compared for those patients scoring 1 or 2 at admission who achieved at least a level of supervision for UE dressing (a score of ≥5) using Wilcoxon 2-sample tests.

Results

The majority of OT time was spent in impairment-focused activities (37.5%) or training basic activities of daily living (31.9%). Treatment progressed to more advanced activities over time (eg, less bed mobility, more home management), yet little time was spent on community integration or leisure activities and with very few patients. Successful patients received more higher-level activities, whereas unsuccessful patients received larger amounts of basic-level activities.

Conclusions

OT activities focused on a combination of remediating impairments and retraining specific functional tasks, at the ability level of each individual patient, and provided higher-level activities as patients improved their function. More time in higher-level activities was related to greater success in rehabilitation. However, higher-level activities remain the least common activities provided during inpatient rehabilitation.

Key Words:  Activities of daily living , Clinical practice patterns , Cerebrovascular accident , Occupational therapy , Rehabilitation

A DETAILED LITERATURE REVIEW substantiating the need to examine multidimensional rehabilitation processes to improve outcomes for specific types of patients is presented elsewhere.¹ Also described elsewhere is an introduction on where this study’s research methodology fits into the pantheon of biomedical and clinical research methodology.²

Occupational therapists play a key role in poststroke rehabilitation. People with stroke make up the most common diagnostic group served by occupational therapists.³, ⁴, ⁵ However, precise descriptions of activities occupational therapists provide to patients undergoing inpatient stroke rehabilitation are lacking. The Occupational Therapy Practice Framework⁶ asserts that occupational therapists should address ability to participate in activities in a variety of life roles. The process for facilitating participation in stroke rehabilitation can include a mixture of remediation, compensatory techniques, and preventative intervention. Knowledge of which occupational therapy (OT) process combinations are best for facilitating successful rehabilitation outcomes is not known.

Several recent systematic reviews suggest that OT improves the performance of some functional tasks and reduces impairments after a stroke.⁷, ⁸, ⁹ A few observational studies describe the nature of OT interventions currently being used for stroke rehabilitation. For the most part, such studies have been conducted in countries outside the United States,¹⁰, ¹¹, ¹² have described treatment only in terms of duration or frequency,¹⁰, ¹³, ¹⁴ or have involved a limited number of patients.¹¹, ¹² Keren et al¹⁵ found that OT provided more intensely was associated with more cognitive improvement and higher scores on the cognitive domains of the FIM but did not describe the actual activities provided by these occupational therapists. The National Board for Certification in Occupational Therapy Practice Analysis reported the frequency with which entry-level practitioners used specific interventions but did not break these down by patient condition and only surveyed occupational therapists within the first 3 years of their practices.⁵

Recently, only 2 studies have examined in detail the content of OT in inpatient stroke rehabilitation. Bode et al¹⁶ surveyed the content of therapy for 177 patients with stroke undergoing 2 to 5 weeks of inpatient stroke rehabilitation across 8 acute and 5 subacute settings in the United States between 1993 and 2000. Health care providers in these settings recorded time spent across 5 activity categories (evaluation and screening, activities of daily living [ADLs] and instrumental activities of daily living [IADLs], interventions for performance skills or body structure and function impairments, discharge planning, or case management) in 15-minute increments. They found that occupational therapists spent most of their time providing interventions that addressed performance skills or body structure and function impairments, such as motor rehabilitation, cognitive retraining, or therapeutic equipment.

As part of the Post-Stroke Rehabilitation Outcomes Project (PSROP), members of our group created a taxonomy of activities used in OT.¹⁷ This taxonomy provides details about treatments and therapeutic activities that therapists used throughout the rehabilitation stay. We recently reported on the percentage of time in OT that 954 patients spent in the 16 OT activities during inpatient poststroke rehabilitation.¹⁸ Although we organized our activities somewhat differently from Bode et al,¹⁶ we also found that occupational therapists spent almost half of the therapy time using activities that directly targeted remediating performance skills or body structure and function impairments (ie, upper-extremity [UE] control, sitting balance, bed mobility, wheelchair, prefunctional, transfers). The second most common set of activities provided was the practice of basic ADLs (BADLs). A variety of intervention techniques were associated with each activity.

Our previous report described OT activities provided for patients undergoing inpatient stroke rehabilitation without concern for the functional levels of patients. However, occupational therapists most likely base intervention selections on the impairment and activity limitations of each patient, as well as the amount of therapy time that will be tolerated by each patient. In addition, it is likely that the types of activities and interventions that are provided vary across a patient’s rehabilitation stay. These ideas receive support from the Bode¹⁶ study, in which the amount of time spent in ADLs and IADLs versus impairment-focused activities varied somewhat with length of stay and whether a patient was more or less impaired. Therefore, in this report, we provide a more detailed description of OT for people undergoing stroke rehabilitation by classifying patients on the basis of amount of OT received and amount of limitation exhibited in ADL performance at admission. We then describe OT activities that therapists provided as interventions across the rehabilitation episode.

Back to Article Outline

Methods 

The methodology governing the full PSROP, provided in this supplement by Gassaway et al,¹⁹ presents a detailed description of the larger study’s participating facilities, patient selection criteria, data collection instruments including their validity and reliability, and a detailed description of the project’s final study group. The methodology is summarized in Maulden et al.²⁰ The institutional review boards at Boston University and at each participating inpatient rehabilitation facility (IRF) approved the study.

Patients in the OT Subset 

We examined a subset of the PSROP U.S. database that received at least 1 OT session during rehabilitation as documented on project point-of-care OT intervention documentation forms. OT sessions were documented for 1096 U.S. patients (94% of the 1161-subject U.S. sample).

The next step was to identify the amount of OT services that patients received. The amount of OT received was divided into 4-hour blocks. Those 713 patients who had at least 1 four-hour block and less than 5 four-hour blocks of therapy were selected for analysis in this report. We chose this group of patients because our data showed that patients with less or more time in rehabilitation may have had important differences in illness severity and function from the group receiving 3 to 19 hours of therapy.

Instrumentation 

The OT intervention documentation form (appendix 1) developed for the PSROP included a taxonomy of information such as targeted activity area, interventions used by the clinician within each activity, and duration of each activity, measured in 5-minute increments. Activity categories included prefunctional, bed mobility, sitting balance, UE control, transfers, wheelchair management, bathing, grooming, dressing, toileting, feeding, functional mobility, home management, community integration, and leisure. Definitions for the activities and interventions contained on the OT intervention documentation form were provided to practicing clinicians and are available on request. Additional information, such as whether the session was individual or group, time spent in evaluation and planning, and potentially influential professional discussion of the patient among colleagues, was also obtained. One OT intervention documentation form was completed for each OT session a patient received during his/her inpatient rehabilitation stay.

A lead occupational therapist from each IRF participated in a train-the-trainer teleconference to learn how to use and teach others to use the OT intervention documentation form. After the teleconference, the lead occupational therapists trained colleagues in their respective IRFs.

Each site incorporated auditing of intervention documentation form use into routine site practices. Typically, the lead occupational therapists observed a patient session and completed a separate intervention documentation form based on what was observed. The therapist providing the session completed a form as per protocol. The lead therapist reviewed and discussed differences in completion with the practicing therapist.

Face validity was built into the intervention documentation forms as they were developed and used by IRF therapists as described above. Predictive validity was assessed by showing significant effects of OT interventions (and other therapy interventions) on outcomes.²¹, ²², ²³ For example, the amount of variation explained in discharge FIM score, controlling for patient characteristics (including admission FIM score, severity of illness, and demographic factors), was 40% for moderate strokes and 45% for severe strokes. When total time per day spent on physical therapy (PT), OT, and speech-language pathology (SLP) was added, there was no increase in variation explained for discharge FIM score, consistent with previous findings by Bode¹⁶ However, when time per day spent in specific PT, OT, and SLP activities was added, the amount of variation explained increased to 52% for moderate strokes and 68% for severe strokes, adding 12% to 23% explanation of variation, respectively, in discharge FIM scores.

Functional performance for each study patient at admission to and discharge from inpatient rehabilitation was obtained via retrospective chart review using the study site’s reporting of the FIM.²⁴, ²⁵ We assumed all clinicians providing FIM data within IRFs as part of standard practice were FIM credentialed; no additional documentation of FIM elements was performed for project purposes. We categorized our sample by a representative admission functional status score on the FIM. The UE dressing score was selected as our categorizing variable because dressing practice was one of the most frequently reported activities provided to this group of patients,¹⁸ and because only 3 patients were more independent in lower extremity than UE dressing at baseline. Appendix 2 provides a description of FIM levels for the UE dressing component.

Data Analysis 

Patients were divided into those who received 1, 2, 3, or 4 four-hour blocks of OT. Because data concerning activities were collected across an entire session and because OT sessions differed in length, each 4-hour block of therapy could contain a variable number of sessions. Therefore, we classified patients using the number of full sessions that would bring the therapy hours the closest to 4, 8, 12, and 16 hours of OT without including the next time block. For example, patients classified as having 1 four-hour block of therapy received between 3 and 4.75 hours of OT during their rehabilitation stay. For each group, descriptive statistics were derived to examine patients’ demographics and processes of care. Then, because we believed that the content of therapy is driven by the severity of patients’ deficits and activity limitations, we grouped patients by FIM UE dressing scores: 1 or 2, 3 or 4, or 5 or more.

For each OT duration (eg, number of 4-h blocks) and UE dressing FIM score group, we first determined the percentage of time spent in assessment and then determined the percentage of all nonassessment OT time across blocks and for each block of therapy spent directed to each OT activity. In addition, we examined the amount of time spent in home assessment. Second, we wanted to determine whether the amount of time spent in any of these activities was associated with better outcomes. To do this, we examined the group of patients who required the most assistance in UE dressing at the start of rehabilitation (those scoring 1 or 2 on the FIM UE dressing item). We defined attaining a level of supervision or better for UE dressing (a score of ≥5 on the FIM UE dressing item) at discharge as successful rehabilitation. We ran Wilcoxon nonparametric 2-sample tests comparing mean percentage time spent in each activity between those who achieved a 5 or greater on the FIM UE dressing item and those who failed to achieve such a result. Because this analysis was considered exploratory in nature, we did not control for simultaneous error rates.

Back to Article Outline

Results 

Table 1 gives the demographic, process, and outcome variables for patients in this analysis. Generally, patients with longer durations of OT had a longer time period from onset of stroke to rehabilitation admission, a lower admission motor FIM score, and slightly lower admission cognitive FIM scores. Thus, patients with more functional deficits received more OT. Approximately the same percentage of patients in each group returned home. Patients’ time in OT was divided into 4-hour blocks of therapy. Each block ranged, on average, from 223.6 to 242.1 minutes and consisted of between 5.2 and 6.8 sessions across 4 to 8 days. It appeared that occupational therapists designed therapy based more on the level of dysfunction of each patient and changed therapy across the rehabilitation episode rather than the amount of time the patient was in rehabilitation. However, in general, occupational therapists provided each activity to a larger percentage of patients as the number of OT blocks provided increased. To understand patterns in the data, we divided activities into 4 categories: BADL training, IADL training, impairment-focused activities (those targeting performance skill or body structure and function impairments—eg, UE control or prefunctional activities), and mobility activities. Fig 1, Fig 2, Fig 3, Fig 4 show the pattern of time spent in each therapy across admission FIM UE dressing levels.

Table 1. Characteristics of Patient, Process, and Outcome Variables by Amount of OT Received

	No. of 4-Hour Blocks of OT
PSROP Variable	1 (n=188)	2 (n=209)	3 (n=175)	4 (n=141)
Patient characteristics
Mean age (y)	67.1	68.2	66.2	66.4
Race (%)
White	53.2	58.4	58.3	63.1
Black	26.1	25.4	24.6	20.6
Other, including Hispanic	20.7	16.2	17.1	16.3
Sex (% men)	48.4	51.2	49.7	49.7
Type of stroke (%)
Hemorrhagic	25.5	25.8	27.4	22.0
Ischemic	74.5	74.2	72.6	78.0
Side of stroke (%)
Left	40.4	38.8	45.1	41.8
Right	46.8	46.4	41.7	51.1
Bilateral	10.1	12.9	10.9	5.0
Unknown	2.1	2.3	1.9	2.7
Mean admission motor FIM score	45.2	40.6	38.5	36.0
Mean admission cognitive FIM score	21.7	21.5	21.3	20.2
Mean days from symptom onset to rehab admission	10.3	12.5	14.7	16.6
Process variables
Mean length of stay	10.7	14.8	19.0	23.1
Mean total minutes of OT	291	523	759	996
Mean total no. of OT sessions	7.2	13.1	19.2	26.9
Outcome variables
Discharge disposition (%)
Home	79.8	80.9	75.4	80.1
Board and care (assisted living)	0.5	1.9	2.9	5.5
Skilled nursing facility	8.5	12.4	18.3	12.8
Acute care hospital (own or other facility)	9.0	2.9	0.6	0.7
Other rehabilitation facility	2.1	2.4	2.9	0.7
Mean discharge motor FIM score	63.0	63.8	61.8	60.6
Mean discharge cognitive FIM score	25.3	25.5	25.1	25.3

Abbreviation: rehab, rehabilitation.

• 
  • View Large Image
  • Download to PowerPoint

• Fig 1. 

  Amount of time spent in activity categories for patients with 1 four-hour block of therapy across admission FIM UE dressing scores.

• 
  • View Large Image
  • Download to PowerPoint

• Fig 2. 

  Amount of time spent in activity categories for patients with 2 four-hour blocks of therapy across admission FIM UE dressing scores.

• 
  • View Large Image
  • Download to PowerPoint

• Fig 3. 

  Amount of time spent in activity categories for patients with 3 four-hour blocks of therapy across admission FIM UE dressing scores.

• 
  • View Large Image
  • Download to PowerPoint

• Fig 4. 

  Amount of time spent in activity categories for patients with 4 four-hour blocks of therapy across admission FIM UE dressing scores.

Occupational therapists provided both basic impairment-focused activities and BADLs to a majority (n=672) of patients. In general, impairment-focused activities were the most, and BADLs the second most, frequently provided activities (37.5% and 31.9% of therapy, respectively). Of the impairment-focused activities, the least amount of time was spent working on activities to improve sitting balance and the most time was spent providing UE control activities. In fact, UE control was the most frequently provided activity across activities (except for the 2-block, FIM 1 or 2 group). The most frequently provided BADL activity was dressing training; the least amount of time was spent in feeding.

Therapists tailored therapy to patients’ levels of dysfunction in these activities. Typically, the amount of time occupational therapists spent in impairment-focused and BADL activities decreased as admission FIM UE dressing level increased, regardless of how many blocks of OT patients received.

Occupational therapists provided IADL training to 75.5% of patients. For all patient groups, the percentage of patients given IADL training and the amount of time spent in IADL training increased as FIM UE dressing level increased. Home management activities were the most frequent activities provided, but occupational therapists devoted little time to either community integration or leisure activities (<10% of time to community integration, <5% to leisure) for any of the patient groups. Occupational therapists performed few home evaluations (0%–7.9% of patients received a home evaluation, with no more than 1.8% of time spent on home evaluation), despite a large percentage of patients returning home. Sixty-nine percent of patients who were discharged home received recommendations for follow-up therapy (home health or outpatient).

Mobility training was provided to 88.4% of patients. In general, occupational therapists spent more time working on mobility skills with patients with higher FIM UE dressing scores. The pattern of time spent in each activity varied. Although transfer training was the most frequent mobility training provided for those patients with admission FIM UE dressing scores of 1 or 2, functional mobility training was the most frequently provided mobility training for most patients who had FIM UE dressing scores of 3 to 5.

We were also interested to know whether the amount of time spent in more basic activities decreased and that spent in more complex activities increased across the rehabilitation episode as patients presumably improved in function. Indeed, this was generally the case. The amount of time in the following basic activities typically decreased the longer a patient was in therapy: dressing, grooming, feeding, bed mobility, and sitting balance. More complex activities of home management, functional mobility, community integration, and leisure tended to increase the longer patients were in rehabilitation.

Relation of Activities to Outcome 

One hundred fifty-two patients started rehabilitation at a dependent or maximum-assist level of UE dressing. Forty-seven achieved at least a supervised level of independence in UE dressing by discharge, and 105 did not. Table 2 describes the mean percentage of time spent in each activity for those patients with and without a successful UE dressing outcome. First, it is important to notice that although we defined success based on the UE dressing item of the FIM, all FIM item scores are lower for the nonsuccessful group than for the successful group. Those who were successful at obtaining a FIM UE dressing score of at least 5 were provided with a greater amount of time in higher-level activities such as community integration, functional mobility, home management, and leisure activities. In contrast, patients who failed to obtain a score of 5 or greater on the FIM UE dressing item received more OT directed toward the lower-level activities of wheelchair management, sitting balance, grooming, and feeding. The percentage of time spent on toileting, transfers, UE control, bathing, bed mobility, and dressing did not differentiate those who succeeded from those who failed to obtain at least a supervised level in UE dressing activities.

Table 2. Mean Percentage of Time Spent on Therapeutic Activities by UE Dressing Outcome

NOTE. Patients at a dependent (FIM score, 1) or maximum-assistance (FIM score, 2) level in UE dressing at admission. Outcome: attain at least a supervised level of function in UE dressing at discharge.

Back to Article Outline

Discussion 

According to the Occupational Therapy Practice Framework,⁶ occupational therapists should assist patients in regaining the ability to complete activities across multiple life roles. These activities include BADLs, home management, work or school activities, and leisure or recreation. Facilitating increased independence and participation can be achieved either by modifying tasks and adapting environments, by decreasing impairment in body structures and functions, or a combination of approaches. Therapists are encouraged to tailor therapy to the needs of patients and the likelihood of goal attainment within the amount of therapy time available. Therefore, to expand our original report in which we catalogued time spent in OT activities across all PSROP patients with stroke, in this report we analyzed time spent in these activities based on the amount of disability exhibited by each patient (represented by the FIM UE dressing item score) and the amount of OT the patient received. In addition, it is expected that therapy should change as patients gain in skill. Hence, we also analyzed how the amount of time spent in OT activities changed across the rehabilitation episode.

Do Occupational Therapists Use a Strategy of Task Training or Restoration of Body Structure and Function? 

Our data show that occupational therapists frequently use a combination of approaches. For all but 1 patient group, the most common group of activities provided to these patients undergoing inpatient stroke rehabilitation was impairment-focused activities, followed by BADL training. This finding is similar to that of Bode et al,¹⁶ who reported that occupational therapists spent more time providing impairment-focused than functional activities to most of their patients. The 2 activities that occupational therapists spent the most time delivering were UE control and dressing activities. Thus, it appears that occupational therapists value the practice of actual daily tasks but also view the motor impairments caused by stroke to be a significant problem that needs to be addressed in therapy.

Do Occupational Therapists Address Activities Across Life Roles? 

Our data indicate that the kinds of activities addressed in OT during inpatient stroke rehabilitation were restricted. Basic self-care activities were provided to nearly all patients, with a large percentage of time spent in these activities. IADLs involved in home management, however, were primarily provided to those patients with greater function at admission, probably because therapy time for patients at a lower functional level was spent on more basic activities. In addition, very little time was spent providing leisure activities to a very small number of patients. What is more disconcerting is how little attention is paid to community integration activities, which in our study was defined with a heavy emphasis on community mobility. Difficulty being mobile in the community (getting into and out of a car, driving, using public transportation) severely restricts participation in activities outside the home and precludes many recreation and social activities. These data underscore the need for adequate community-based therapy services to facilitate independence in community participation—unfortunately at a time when the amount of therapy patients receive from outpatient or home health services has decreased dramatically.²⁶

The lack of attention to these higher-level activities may stem from several sources. One possibility is short rehabilitation stays combined with the view that the ability to perform more basic activities is a precursor to training higher-level activities. Such a view may not be unfounded. The belief that improving basic motor skills will lead to increased function is inherent to motor rehabilitation, and several studies have shown that improvements in motor skills is associated with increases in functional ability.²⁷, ²⁸ In addition, inability to complete basic self-care activities independently or at least with minimal assistance often determines whether patients are discharged to the community, where they have the opportunity to engage in higher-level activities. It is possible that were rehabilitation stays longer, therapists would provide more advanced activities later on in the rehabilitation episode. This idea receives some support from our data, which show that more patients were provided with and increased time was spent in these activities as the rehabilitation episode progressed. Another possible contributor to the focus on more basic activities could be the use of the FIM instrument itself. Rehabilitation hospitals use changes in FIM scores as quality indicators of success in rehabilitation. However, the FIM was designed only to measure BADLs and, as such, does not capture patients’ performances in more advanced participation activities.

The small amount of leisure training provided by the occupational therapists in our study may reflect the fact that the therapists worked on health care teams that also included recreation therapists. Therefore, despite the OT profession endorsing leisure activities as falling within the domain of OT, leisure training and counseling on these teams may have been the province of recreation therapists.

Do Occupational Therapists Tailor Therapy Based on Patient Disability? 

We found partial evidence to suggest that occupational therapists tailored therapy based on patient functional level, both at admission and as patients recovered. For example, less time was spent in low-level activities (eg, grooming, sitting balance, bed mobility) with those patients scoring at a FIM UE dressing level 5 or above compared with those scoring at levels 1 or 2, whereas the amount of time spent in the higher activities of functional mobility and home management was greater for the former group of patients. A larger amount of time was spent on higher-level activities, such as functional mobility and home management and less time on more basic activities (eg, sitting balance) later in the rehabilitation episode. Bode et al¹⁶ also found that for some groups of patients, occupational therapists tailored their activities based on patient disability. For example, for patients with 2-week rehabilitation durations, occupational therapists provided more functional activities to those with less disability compared with more impairment in the last week of rehabilitation, whereas the reverse was seen for those with 5-week stays. However, because they did not break down their functional category into BADLs, IADLs, and mobility, nor into higher- or lower-level activities within those categories, direct comparisons between their study and ours is not possible.

However, the amount of time spent in dressing and UE control activities remained substantial. This may reflect the breadth of those categories. Dressing tasks, for example, range from the simple—putting on a T-shirt—to the complicated—donning of a brassiere or tying shoelaces. UE control ranges from simple 1-joint proximal movements to tasks such as piano playing, which requires exquisite fine motor control. In addition, the affected UE poststroke has been particularly resistant to recovery to a functional capacity, most likely because of the level of coordination required to have a functional hand.²⁹ As UE function improved, BADL training may have progressed from compensatory training to a more remedial approach in which emerging UE motor skills were incorporated into BADLs. Therefore, it is likely that patients experienced a continued need for UE training and BADL training throughout the rehabilitation episode. Because we did not collect data about subactivities within each BADL category (ie, putting on a T-shirt and fastening a hook closure; both were categorized as dressing yet require very differing motor skills), actual therapy differences between patients of different functional levels could not be detected by these categories.

Although we found that occupational therapists customized therapy based on patient disability, we found little evidence to suggest that therapy was tailored based on the amount of OT provided. Because most patients eventually were referred to outpatient or home health therapy, therapists in the inpatient rehabilitation setting may believe that their therapy only begins the process of facilitating independence. Therapy does not need to be limited if there is a belief that continued training will be available once a patient leaves the facility. However, this belief may be erroneous given the decreased amount of therapy time that patients receive from outpatient or home health services.²⁶ Although occupational therapists did not seem to alter activities provided based on amount of time available in rehabilitation, they might have altered specific methods used for training within these activities. For example, they may have provided more compensatory than remedial training when rehabilitation stays were shorter. The current data do not speak to whether such alterations in OT intervention techniques occur.

Is the Amount of Time in OT Activities Related to Functional Outcome? 

The intent of rehabilitation is to promote independence in functional activities. There has been little evidence to date to guide therapists in treatment planning. However, there have been studies finding that OT can improve task performance and reduce impairments after stroke.⁷, ⁸, ⁹ There is a great need to examine which aspects of OT practice are and are not effective. In this study, we examined the relation between amount of time spent in various OT activities with outcomes in UE dressing skill for those patients who were admitted to rehabilitation at a dependent or maximum-assist level of independence in UE dressing. Those patients who successfully achieved at least a supervised level of UE dressing had been provided with larger amounts of therapy directed at higher-level activities than those who were unsuccessful in achieving this level of independence. This result is similar to that found in the study by Latham et al,²¹ in which more PT time in advanced gait activities was found for those patients with greater success in rehabilitation. It may be that practicing the types of motor and cognitive processing required of these higher-level activities facilitates gains in independence in other areas of daily functioning. Alternatively, it may be that those patients who were successful in rehabilitation received greater amounts of higher-level activities because they experienced more recovery and were better able to engage in such activity practice.

We were surprised that amount of time spent in dressing activities did not delineate those who were successful in UE dressing recovery from those who were not. We would have expected an increased amount of time spent in dressing activities to be associated with an item on the FIM measuring dressing ability. One possible reason that this was not so is that the activity category of dressing covers a wide range of activities, from putting on a shirt or pants to tying shoelaces. It may be that both groups received a similar amount of dressing training but that this training emphasized different dressing activities.

We also were surprised that the most frequently provided activity was not associated with successful outcome. On average, occupational therapists spent nearly a third of their time providing UE control activities, yet this training was not associated with success in UE dressing. There are several possible reasons for this. First, it must be emphasized that our definition of success was limited solely to reaching a supervised or higher level of independence in UE dressing, rather than independence across multiple meaningful daily activities. It may be that UE training better facilitates independence in other activities.

Second, BADL training in stroke rehabilitation consists largely of teaching compensatory techniques for completing activities, such as 1-handed dressing techniques and prescribing adapted equipment to make 1-handed dressing activities easier (eg, providing a button hook). These techniques train a patient not to use his/her affected UE. Thus, increasing motor skills may indeed be unrelated to improvements in UE dressing because the patient is attempting to complete UE dressing tasks without using the affected UE. In addition, compensatory training in BADLs and IADLs may actually contradict the UE control training by encouraging learned nonuse of the affected UE.

A third reason for the lack of impact of UE control training on UE dressing ability is that, although occupational therapists spent a large percentage of their time on UE motor rehabilitation, in actual minutes this only averaged 10 to 12 minutes of direct UE motor control practice per session (although motor practice may have occurred during activities targeting other skills as well). This paucity of time devoted to motor practice contradicts an accepted principle of movement therapy: that intensity of practice is important.³⁰ Such a modest amount of time spent in training a motor skill is unlikely to facilitate enough motor recovery to affect dressing ability. Intensive therapy is an accepted principle of movement therapy.

In contrast, those patients who were unsuccessful at achieving a supervision level of independence in FIM UE dressing at discharge spent larger amounts of time in several lower-level activities than patients who were successful. These activities included wheelchair management, sitting balance, grooming, and feeding. Because these are more basic, it is likely that the amount of time spent in these activities reflects patient abilities. However, these data suggest that, at least for UE dressing, spending more time in these basic activities is not facilitating increased independence in this population. Obviously, this type of analysis will need to be repeated with outcomes in other patient-relevant activities and with other groups of patients with stroke to determine whether or not increased time on basic activities fails to promote improvements in function. Nonetheless, these data argue that it is important to understand the limits of our therapies in reaching certain functional outcomes.

Several limitations of this study warrant caution during interpretation of the results. The data about time in therapy activities and the percentage of patients who received each activity were gathered by therapists’ reports. The therapy staff of each participating facility was highly engaged in the project. However, self-reports are open to several biases, such as social desirability. Although therapists were trained and given explicit definitions of activity categories, validation of how therapists classified the activities that they were providing was performed at the site level and may have been inconsistent among sites. Also, not all activity categories were mutually exclusive, either in definition or in clinical practice, which might have made it difficult for therapists to document which activity they were providing. For example, some mobility tasks could have fit in either bed mobility or functional mobility based on the definition, and a therapist could have been working on UE motor control simultaneously with dressing or grooming; however, there was no way to categorize more than 1 activity per 5-minute period. Another limitation is that we had only FIM scores available rather than impairment-level information for categorizing patient groups and outcomes. Occupational therapists most likely base treatment decisions on both client disability and impairments. Because patients can be heterogeneous in impairments and be in the same functional level, it is likely that different therapy treatments would be used with these patients. Also, we had no information about functional abilities in activities other than BADLs. Although independence in BADLs is important, it is far from a sufficient condition for full community participation and a satisfying quality of life. Rehabilitation should improve patients’ quality of life.

Nonetheless, the aim of this study was to explore functional changes that take place within inpatient rehabilitation, and this study has numerous strengths in this area. It included a large number of geographically diverse patients in the United States, increasing the generalizability of these findings. The study used a detailed taxonomy of activities that was created by a team of both study personnel and practicing occupational therapists in the participating facilities, which resulted in data collection that was meaningful to practicing clinicians.

Back to Article Outline

Conclusions 

In this study, we examined types of activities that occupational therapists provided to patients during inpatient stroke rehabilitation. We discovered that occupational therapists provided a mixture of task training and restorative activities and that they tailored their therapy programs based on patient disability but did not seem to tailor therapy based on amount of OT. In patients who were admitted requiring at least maximum assistance in UE dressing, more time spent in higher-level activities (eg, community integration, functional mobility) was associated with a greater likelihood of reaching at least a supervised level of independence in FIM UE dressing.

Back to Article Outline

Acknowledgments 

We acknowledge the role and contributions of our collaborators at each of the clinical sites represented in the Post-Stroke Rehabilitation Outcomes Project: Brendan Conroy, MD (Stroke Recovery Program, National Rehabilitation Hospital, Washington, DC); Richard Zorowitz, MD (Department of Rehabilitation Medicine, University of Pennsylvania Medical Center, Philadelphia, PA); David Ryser, MD (Neuro Specialty Rehabilitation Unit, LDS Hospital, Salt Lake City, UT); Jeffrey Teraoka, MD (Division of Physical Medicine and Rehabilitation, Stanford University, Palo Alto, CA); Frank Wong, MD, and LeeAnn Sims, RN (Rehabilitation Institute of Oregon, Legacy Health Systems, Portland, OR); Murray Brandstater, MD (Loma Linda University Medical Center, Loma Linda, CA); and Harry McNaughton, MD (Wellington and Kenepuru Hospitals, Wellington, NZ). We also acknowledge the role of Alan Jette, PhD (Rehabilitation Research and Training Center on Medical Rehabilitation Outcomes, Boston University, Boston, MA).

Back to Article Outline

Appendix 1. OT intervention documentation form 

©ISIS, 2003. Reprinted with permission.

Abbreviations: FWW, front-wheel walker; KAFO, knee-ankle-foot orthosis; NDT, neurodevelopmental technique; PNF, proprioceptive neuromuscular fasciculation; PROM, passive range of motion.

Back to Article Outline

Appendix 2. Component of dressing, upper body 

Dressing, Upper body: Includes dressing and undressing above the waist, as well as applying and removing a prosthesis or orthosis when applicable. Performs safely.

Back to Article Outline

References 

1. DeJong G , Horn SD , Conroy B , Nichols D , Healton EB . Opening the black box of poststroke rehabilitation (stroke rehabilitation patients, processes, and outcomes) . Arch Phys Med Rehabil . 2005;86(12 Suppl 2):S1–S7
   • View In Article
   • MEDLINE
2. Horn SD , DeJong G , Ryser DK , Veazie PJ , Teraoka J . Another look at observational studies in rehabilitation research (going beyond the holy grail of the randomized controlled trial) . Arch Phys Med Rehabil . 2005;86(12 Suppl 2):S8–S15
   • View In Article
   • MEDLINE
3. Rijken PM , Dekker J . Clinical experience of rehabilitation therapists with chronic diseases (a quantitative approach) . Clin Rehabil . 1998;12:143–150
   • View In Article
   • MEDLINE
   • CrossRef
4. Liu K , Gage B , Kramer A . Medicare post-acute care (quality measurement final report) . Appendix A. 1998 reports . Washington (DC): U.S. Department of Health and Human Services; 1998; Contract No. HHS-100-97-0010
   • View In Article
5. National Board for Certification in Occupational Therapy Inc . A practice analysis study of entry-level occupational therapists registered and certified occupational therapy assistant practice . Occup Ther J Res . 2004;24(Suppl 1):7–31
   • View In Article
6. American Occupational Therapy Association . Occupational therapy practice framework (domain and process) . Am J Occup Ther . 2002;56:609–639
   • View In Article
   • MEDLINE
   • CrossRef
7. Ma HI , Trombly CA . A synthesis of the effects of occupational therapy for persons with stroke. Part II: Remediation of impairments . Am J Occup Ther . 2002;56:260–274
   • View In Article
   • MEDLINE
   • CrossRef
8. Steultjens EM , Dekker J , Bouter LM , van de Nes JC , Cup EH , van den Ende CH . Occupational therapy for stroke patients (a systematic review) . Stroke . 2003;34:676–687
   • View In Article
   • CrossRef
9. Trombly CA , Ma HI . A synthesis of the effects of occupational therapy for persons with stroke. Part I: Restoration of roles, tasks and activities . Am J Occup Ther . 2002;56:250–259
   • View In Article
   • MEDLINE
   • CrossRef
10. Alexander H , Bugge C , Hagen S . What is the association between the different components of stroke rehabilitation and health outcomes? . Clin Rehabil . 2001;15:207–215
    • View In Article
    • MEDLINE
    • CrossRef
11. Ballinger C , Ashburn A , Low J , Roderick P . Unpacking the black box of therapy—a pilot study to describe occupational and physiotherapy interventions for people with stroke . Clin Rehabil . 1999;13:301–309
    • View In Article
    • MEDLINE
    • CrossRef
12. deWeerdt W , Selz B , Nuyens G , et al.   Time use of stroke patients in an intensive rehabilitation unit (a comparison between a Belgian and Swiss setting) . Disabil Rehabil . 2000;22:181–186
    • View In Article
    • MEDLINE
    • CrossRef
13. Bernhardt J , Dewey H , Thrift A , Donnan G . Inactive and alone (physical activity within the first 14 days of acute stroke unit care) . Stroke . 2004;35:1005–1009
    • View In Article
    • CrossRef
14. Sulch D , Perez I , Melbourn A , Karla L . Randomized controlled trial of integrated (managed) care pathway for stroke rehabilitation . Stroke . 2000;31:1929–1934
    • View In Article
    • MEDLINE
    • CrossRef
15. Keren O , Motin M , Heinemann AW , et al.   Relationship between rehabilitation therapies and outcome of stroke patients in Israel (a preliminary study) . Isr Med Assoc J . 2004;6:736–741
    • View In Article
    • MEDLINE
16. Bode RK , Heinemann AW , Semik P , Mallinson T . Patterns of therapy activities across length of stay and impairment levels (peering inside the “black box” of inpatient stroke rehabilitation) . Arch Phys Med Rehabil . 2004;85:1901–1908
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (426 KB)
    • CrossRef
17. DeJong G , Horn SD , Gassaway JA , Slavin MD , Dijkers MP . Toward a taxonomy of rehabilitation interventions (using an inductive approach to examine the “black box” of rehabilitation) . Arch Phys Med Rehabil . 2004;85:678–686
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (305 KB)
    • CrossRef
18. Latham N, Jette D, Coster W, et al. Occupational therapy activities and intervention techniques for clients with stroke in six rehabilitation hospitals. Am J Occup Ther. In press.
    • View In Article
19. Gassaway J , Horn SD , DeJong G , Smout RJ , Clark C , James R . Applying the clinical practice improvement approach to stroke rehabilitation (methods used and baseline results) . Arch Phys Med Rehabil . 2005;86(12 Suppl 2):S16–S33
    • View In Article
    • MEDLINE
20. Maulden SA , Gassaway J , Horn SD , Smout RJ , DeJong G . Timing of initiation of rehabilitation after stroke . Arch Phys Med Rehabil . 2005;86(12 Suppl 2):S34–S40
    • View In Article
    • MEDLINE
21. Latham NK , Jette DU , Slavin M , et al.   Physical therapy during stroke rehabilitation for people with different walking abilities . Arch Phys Med Rehabil . 2005;86(12 Suppl 2):S41–S50
    • View In Article
    • MEDLINE
22. Hatfield B , Millet D , Coles J , Gassaway J , Conroy B , Smout RJ . Characterizing speech and language pathology outcomes in stroke rehabilitation . Arch Phys Med Rehabil . 2005;86(12 Suppl 2):S61–S72
    • View In Article
    • MEDLINE
23. Horn SD , DeJong G , Smout RJ , Gassaway J , James R , Conroy B . Stroke rehabilitation patients, practice, and outcomes (is earlier and more aggressive therapy better?) . Arch Phys Med Rehabil . 2005;86(12 Suppl 2):S101–S114
    • View In Article
    • MEDLINE
24. Laughlin JA , Granger CV , Hamilton BB . Outcomes measurement in medical rehabilitation . Rehab Manage . 1992;5:57–58
    • View In Article
25. Hamilton BB , Laughlin JA , Fiedler RC , Granger CV . Interrater reliability of the 7-level Functional Independence Measure (FIM) . Scand J Rehabil Med . 1994;26:115–119
    • View In Article
    • MEDLINE
26. Murkofsky RL , Phillips RS , McCarthy EP , Davis RB , Hamel MB . Length of stay in home care before and after the 1997 Balanced Budget Act . JAMA . 2003;289:2841–2848
    • View In Article
    • MEDLINE
    • CrossRef
27. Taub E , Uswatte G , Pidikiti R . Constraint-Induced Movement Therapy (a new family of techniques with a broad application to physical rehabilitation—a clinical review) . J Rehabil Res Dev . 1999;36:237–251
    • View In Article
    • MEDLINE
28. Whitall J , McComb Waller S , Silver K , Macko R . Repetitive bilateral arm training with rhythmic auditory cueing improves motor function in chronic hemiparetic stroke . Stroke . 2000;31:2390–2395
    • View In Article
    • CrossRef
29. Woldag H , Waldmann G , Heuschkel G , Hummelsheim H . Is the repetitive training of complex hand and arm movements beneficial for motor recovery in stroke patients? . Clin Rehabil . 2003;17:723–730
    • View In Article
    • MEDLINE
    • CrossRef
30. Hesse S , Schulte-Tigges G , Konrad M , Bardeleben A , Werner C . Robot-assisted arm trainer for the passive and active practice of bilateral forearm and wrist movements in hemiparetic subjects . Arch Phys Med Rehabil . 2003;84:915–920
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (127 KB)
    • CrossRef