Rehabilitation,Disability,and Participation Research: Are Occupational Therapy Researchers Addressing Cognitive Rehabilitation After Stroke?

Research That Does Not Produce Evidence for the Profession

Most of the research related to rehabilitation, disability, and participation did not produce evidence for the profession. Of the 58 rehabilitation, disability, and participation studies published in AJOT in 2009 and 2010, 38 were efficiency studies, basic research studies, instrument development and testing studies, or studies that explored the link between occupational engagement and health. All four of these areas serve a key role in the continuum of research and are ultimately necessary for the development of evidence to support the profession. For example, efficiency studies are necessary to determine whether a certain intervention can affect an outcome. It is crucial to conduct a study of this nature to determine whether an effectiveness study is warranted. For example, Walker and colleagues (2010) developed a community mobility skills course for people using mobility devices. The authors were able to determine that some skills gained through a community mobility skills course can transfer to use in a real-world environment; this finding can now be translated into clinical guidelines that can be evaluated in effectiveness studies.

The review of the AJOT literature reported in this article highlights the fact that most research in this area of practice is in an early phase of development (e.g., basic science and efficiency studies) and has not progressed to the level of effectiveness studies. This concern is notable for the profession because effectiveness studies are the only studies that truly produce evidence. If the occupational therapy profession is to meet the goal of being evidence based in this practice area, the research community must give special consideration to developing lines of research inquiry along the research continuum, culminating in effectiveness studies.

Poor Representation of Several Populations

Several populations may be poorly represented in the work being produced in rehabilitation, disability, and participation. Stroke and TBI were overrepresented in the effectiveness studies reviewed for this article; however, several considerations must be noted. First, the results are skewed by the fact that many of the studies were published in a 2009 special issue of AJOT focused on stroke and TBI. Second, although stroke and TBI affect two of the largest populations with which occupational therapists work, thereby warranting a special issue to highlight related work being produced, in the past 2 years the focus on stroke and TBI created a void that left several other major populations underrepresented in AJOT. For example, spinal cord injury (SCI) affects a large population with which occupational therapy practitioners work in a variety of rehabilitation settings. AJOT published no effectiveness studies in 2009 and 2010 related to the SCI population. AJOT should give special consideration to the production of special issues highlighting research related to other populations with whom practitioners work in rehabilitation, disability, and participation.

Preponderance of Case Studies and Studies With Small Sample Sizes

Most effectiveness studies related to rehabilitation, disability, and participation are case studies or have a small sample size, which limits the generalizability of the findings. Of the 20 effectiveness studies published by AJOT in 2009 and 2010 related to rehabilitation, disability, and participation, nearly half (n = 9) were case studies (Carver, 2009; Earley et al., 2010; Hardy et al., 2010; Hermann et al., 2010; Jack & Estes, 2010; Preissner, 2010; Rowe et al., 2009; Stapanian et al., 2010; Zlotnik et al., 2009). Moreover, 4 studies had <10 participants per intervention group evaluated (Giuffrida et al., 2009; Hall et al., 2010; Hayner et al., 2010; Rand et al., 2009). This review suggests that the evidence being published is not at the strongest levels to support practice. This finding speaks to a larger issue in occupational therapy research: Sufficiently powered randomized controlled studies (Level 1 evidence) require many resources to conduct, and few occupational therapy scientists have the research infrastructure and resources necessary to conduct such trials. In addition, the trials that are being conducted are being reported in venues other than AJOT. For these reasons, it is critical that the Level I evidence being produced make its way back to the occupational therapy community. AJOT should make the Level I evidence in this practice area accessible to the occupational therapy community through systematic reviews or other avenues such as the AOTA Evidence-Based Practice and Research resources.

Outcome Measures at the Impairment Level

More than half of the rehabilitation, disability, and participation effectiveness studies reported in AJOT in 2009 and 2010 (n = 11) used impairment-level measures as their primary outcome measures (Earley et al., 2010; Fong & Howie, 2009; Giuffrida et al., 2009; Goverover et al., 2009, 2010; Hall et al., 2010; McClure et al., 2010; Nilsen et al., 2010; Rand et al., 2009; Stapanian et al., 2010; Thorne et al., 2009). Impairment associated with any disorder, disease, or condition must be addressed in some capacity during rehabilitation to improve participation; however, the unique contribution of occupational therapy practitioners to the health care community is their focus on everyday life participation. Occupational therapy researchers must highlight this unique contribution to the health care community by including measures of participation in studies that demonstrate occupational therapy’s effectiveness.

Need to Address Poststroke Cognitive Dysfunction

A significant need exists for occupational therapy practitioners in rehabilitation, disability, and participation to expand their focus to address poststroke cognitive dysfunction. Among the many areas that arguably need to be addressed in producing evidence to support occupational therapy practice in this area, one of the most critical is cognitive dysfunction after a stroke. The AOTA Research Advisory Panel (2009) identified people with cognitive impairments, specifically after stroke, as a priority population in the Occupational Therapy Research Agenda. The review undertaken for this article highlighted that although evidence is being produced related to stroke, most of this work is focused on motor recovery and self-care. The remainder of this article addresses the unique needs of people with cognitive dysfunction poststroke, the reasons poststroke cognitive rehabilitation should be a priority for occupational therapy practitioners, and the evidence being produced to support practice in this area.

Existing Knowledge of Cognitive Rehabilitation After Stroke

The second purpose of this review was to synthesize and review the evidence produced in an underdeveloped subcategory of rehabilitation, disability, and participation practice: poststroke cognitive rehabilitation. Two of the leading publicly available repositories of evidence-based reviews are the Cochrane Reviews (www2.cochrane.org/reviews) and the Evidence-Based Review of Stroke Rehabilitation (EBRSR; www.ebrsr.com). The EBRSR is an excellent resource for evidence to support stroke rehabilitation, but a major limitation exists in its clinical utility related to addressing cognitive dysfunction poststroke: Most of the evidence reported in the EBRSR comes from studies of TBI, not stroke. Although the clinical presentation of cognitive dysfunction can sometimes be similar, the populations are sufficiently different to warrant further study using the methodologies reported in the EBRSR to confirm whether findings can be replicated with a stroke population. For this reason, I did not review the EBRSR information related to cognitive dysfunction. To examine available evidence to support cognitive rehabilitation poststroke, I examined the information reported in the Cochrane Reviews.

Cochrane Reviews

The Cochrane Collaboration is a network of scholars focused on helping stakeholders in health care (e.g., policymakers, health care providers, consumers, caregivers) make well-informed health care decisions (Mavergames et al., 2010) by systematically reviewing and assessing all available evidence for specific interventions and populations. Cochrane Reviews are continuously updated to ensure that reviews provide the most current information. Three Cochrane Reviews addressed poststroke cognitive rehabilitation for (1) attention deficits (Lincoln, Majid, & Weyman, 2000), (2) memory deficits (das Nair & Lincoln, 2007), and (3) spatial neglect (Bowen & Lincoln, 2007). Each group completed a comprehensive review of electronic databases and hand searches of journals related to the specific topic. All three coordinated with the Cochrane Stroke Group, and details of their search criteria can be found in their references or on the Stroke Group’s Web page (Editorial Team, Cochrane Stroke Group, 2010). Of particular note, the Stroke Group used strict inclusion criteria, and only controlled trials and systematic reviews were included (AJOT Level I only). Table 2 summarizes the studies identified by the Cochrane Reviews to support cognitive rehabilitation for attention, memory, and spatial neglect poststroke.

In the Cochrane Review that examined cognitive rehabilitation for attention deficits after stroke, two trials were identified (Schöttke, 1997; Sturm & Willmes, 1991). The authors of the review concluded that evidence supports the use of cognitive training to improve alertness and sustained attention; however, no evidence has indicated that such improvements translate to improvement in everyday life activities (Lincoln et al., 2000).

In the review that examined memory deficits, two studies were also identified (see Table 2; Doornhein & deHaan, 1998; Kaschel et al., 2002). Neither study demonstrated any significant effect of memory rehabilitation on impairment-level assessments, and the review group therefore concluded that no evidence either supports or refutes the effectiveness of memory rehabilitation on functional outcomes (das Nair & Lincoln, 2007).

Finally, the group that examined spatial neglect identified 11 studies that evaluated the effectiveness of various interventions (see Table 2; Cherney, Halper, & Papachronis, 2003; Edmans, Webster, & Lincoln, 2000; Fanthome, Lincoln, Drummond, & Walker, 1995; Kalra, Perez, Gupta, & Wittink, 1997; Robertson, Gray, Pentland, & Waite, 1990; Robertson, McMillan, MacLeod, Edgeworth, & Brock, 2002; Rossi, Kheyfets, & Reding, 1990; Rusconi, Meinecke, Sbrissa, & Bernardini, 2002; Weinberg et al., 1977; Wiart et al., 1997; Zeloni, Farne, & Baccini, 2002). Again, the group concluded that although some evidence has supported the effectiveness of the interventions in improving performance on impairment-level testing, insufficient evidence exists to support or refute the effectiveness of any of the intervention approaches in reducing disability and improving independence in everyday life activities (Bowen & Lincoln, 2007).

The available data from the Cochrane Reviews clearly indicate that insufficient knowledge and evidence are being produced by occupational therapy—or any other health care profession—to support or refute the effectiveness of cognitive rehabilitation approaches poststroke. Moreover, none of the studies in the three reviews demonstrated that any of the intervention approaches translated to improvement in everyday life activities—a clinical objective within occupational therapy’s domain. Note that a Cochrane Review protocol was published indicating intent to produce a review related to occupational therapy’s effectiveness in improving function in people with cognitive impairment poststroke (Hoffmann, Bennett, Koh, & McKenna, 2007).

The Cochrane Reviews demonstrate that limited evidence is being produced anywhere by any health care profession to support specific cognitive intervention approaches that can improve everyday life performance after a stroke. This situation is disconcerting for clients but presents a unique opportunity for occupational therapy to contribute to this body of knowledge. Cognitive rehabilitation approaches are largely impairment focused and often give little consideration to the environmental context in which clients with cognitive dysfunction have difficulty (Bowen & Lincoln, 2007; das Nair & Lincoln, 2007; Lincoln et al., 2000). Although transferability and generalization are critical to every intervention approach used in rehabilitation, it can be argued that they are most important in the area of cognitive rehabilitation. Occupational therapists are trained to collectively evaluate the person, the environment, and the occupation to improve client participation in everyday life (Christiansen, Baum, & Bass Haugen, 2005). Intervention approaches for cognitive rehabilitation that independently address the person, the environment, or the occupation have been shown not to lead to improvement in participation. All three contexts must be taken into account, and occupational therapists have established intervention approaches that do just that. For example, the Cognitive Orientation to daily Occupational Performance model (CO–OP; McEwen, Polatajko, Huijbregts, & Ryan, 2009, 2010; Polatajko, McEwen, Ryan, & Baum, 2009) was originally designed for children but has recently been adapted for use with people with poststroke cognitive dysfunction. The CO–OP model uses cognitive strategy training to help people compensate for cognitive loss, and in preliminary studies it has been shown to improve participation even in untrained tasks. However, researchers have not conducted the studies necessary to demonstrate that intervention approaches such as CO–OP are effective in helping people with cognitive dysfunction participate in their daily life activities. Conducting effectiveness studies needs to be at the forefront of occupational therapy’s research agenda to enable the profession to achieve the goal of being evidence based.