Five Years Later: Achieving Professional Effectiveness to Move Neurorehabilitation Forward

Neurorehabilitation Research Published in 2012

Twenty-three publications on the topic of neurorehabilitation were identified. Of those, 10 (43%) were classified as intervention effectiveness studies (Finlayson, Preissner, & Cho, 2012; Glasgow, Fleming, Tooth, & Peters, 2012; Hayner, 2012; Martin, Johnston, & Sadowsky, 2012; Nilsen, Gillen, DiRusso, & Gordon, 2012; Polatajko, McEwen, Ryan, & Baum, 2012; Schepens, Braun, & Murphy, 2012; Skubik-Peplaski, Carrico, Nichols, Chelette, & Sawaki, 2012; Sledziewski, Schaaf, & Mount, 2012; Yang, Lin, Chen, Wu, & Chen, 2012); 6 (26%) discussed instrument development and testing (Engstrand, Krevers, & Kvist, 2012; Flinn, Pease, & Freimer, 2012; Katz, Bar-Haim Erez, Livni, & Averbuch, 2012; Mennem, Warren, & Yuen, 2012; Stefanovich, Williams, McKee, Hagemann & Carnahan, 2012; Tucker, Edwards, Mathews, Baum & Connor, 2012); 2 (8%) were basic research studies (Baker, Aufman, & Poole, 2012; Prager & Lang, 2012), 1 (4%) concerned a specific professional issue (Yuen, Brooks, Azuero, & Burik, 2012); 1 (4%) was centered on education (Frost & Barkley, 2012); and 3 (13%) involved issues of efficiency (Cimarolli, Morse, Horowitz, & Reinhardt, 2012; Craig, 2012; O’Brien, Bynon, Morarty, & Presnell, 2012). One article used qualitative analysis (Craig, 2012) and 1 used mixed methods (Finlayson et al., 2012); all other studies used quantitative methods. As in previous years, intervention effectiveness studies and instrument development and testing represented the largest percentage of publications in neurorehabilitation research this past year.

Within the effectiveness studies were 5 randomized controlled trials (RCTs; Glasgow et al., 2012; Nilsen et al., 2012; Polatajko et al., 2012; Schepens et al., 2012; Yang et al., 2012), which marks a notable increase in RCTs over previous years (2 in 2010, none in 2009). These effectiveness studies are classified as having Level I status—systematic reviews, meta-analyses, or RCTs (see the classification system outlined in Lieberman and Scheer, 2002). Five effectiveness studies were classified as Level III, one-group, nonrandomized studies (Finlayson et al., 2012; Hayner, 2012; Martin et al., 2012) or Level V, case reports (Skubik-Peplaski et al., 2012; Sledziewski et al., 2012). The diagnoses targeted for the interventions being assessed included stroke (n = 5), spinal cord injury (n = 2), joint stiffness (n = 2), and multiple sclerosis (n = 1).

Instrument development and testing was the next most common area of publication, with 6 articles published during 2012. Three studies examined instruments used with the stroke population: Katz et al. (2012) and Mennem et al. (2012) assessed the reliability and validity of the Dynamic Lowenstein Occupational Therapy Cognitive Assessment (DLOTCA) and the Self-Report Assessment of Functional Visual Performance (Gilbert & Baker, 2011), respectively. Tucker et al. (2012) reported the consistency and reliability of methods used to modify the administration and formatting of some commonly used assessments such as the SF–36 (Ware & Sherbourne, 1992), the Stroke Impact Scale (Duncan et al., 1999), and the Activity Card Sort (Baum & Edwards, 2001) when working with people with aphasia. The other three focused on orthopedic or peripheral hand conditions, with Engstrand et al. (2012) describing standard guidelines for finger goniometry measurement in people with Dupuytren’s contracture, Flinn et al. (2012) investigating the reliability of the Flinn Performance Screening Tool for grading the severity of carpal tunnel syndrome, and Stefanovich et al. (2012) assessing the effectiveness of a global rating scale and checklist to grade orthotic fabrication skills of occupational therapy students.

Summary of Research

This review examines 23 articles published in AJOT from January 2012 through November 2012 related to neurological rehabilitation. Of the 75 articles published in AJOT during this time period, those on this topic represented 30% of the total published studies.

Two intervention effectiveness studies over the past year focused on how specific factors interact with occupational therapy intervention and potentially affect patient outcomes. This theme was apparent in the Finlayson et al. (2012) article, which determined that age, level of impairment, and gender had a significant effect on outcomes of a fatigue management program for people with multiple sclerosis. In contrast, the Glasgow et al. (2012) article determined that the length of time a capener splint was worn (6–12 hr/day vs. 12–16 hr/day) to improve finger extension range of motion (ROM) after hand injury was not a significant factor in patient outcomes.

Three of the effectiveness studies and 1 efficiency study compared novel, specific approaches with general approaches or “standard” occupational therapy: Polatajko et al. (2012) found that people with stroke who engaged in a client-centered, cognitive-based goal achievement intervention performed better on functional tasks than those who engaged in traditional therapist-driven occupational therapy; Schepens et al. (2012) described that a “tailored” approach was better than a general occupational therapy approach when instructing people with osteoarthritis in activity pacing; the tailored approach group reported less joint stiffness over time. Likewise, Yang et al. (2012) found that two robot-assisted training regimens (unilateral and bilateral) improved upper-extremity movement in people with stroke differentially and better than standard occupational therapy intervention on selected measures. O’Brien et al. (2012) reported that a targeted occupational therapy intervention combined with a functional conditioning program reduced the length of stay for older people admitted to the hospital as a result of acute trauma when compared with length-of-stay data for people previously admitted receiving only standard occupational therapy treatment.

Another theme present in the effectiveness literature reviewed from the past year was the additive effect of specific interventions when used in conjunction with standard occupational therapy treatment: Using mental practice in addition to occupational therapy appeared to have beneficial effects in reducing impairments and improving perception of occupational performance after stroke when compared with relaxation imagery combined with occupational therapy (Nilsen et al., 2012); intense repetitive task training combined with neuromuscular electrical stimulation assisted in improving motor function of the hand and grip strength in people with tetraplegia (Martin et al., 2012). Last, occupational therapy combined with the use of the REO-Go™ (Motorika, Trussville, AL) upper-extremity robotic trainer increased active range of motion (AROM), strength, and independence during self-care tasks for people with incomplete spinal cord injury (Sledziewsi et al., 2012).

The final 2 effectiveness studies examined the effect of a novel or specific intervention that could be considered a subset of occupational therapy practice. Hayner (2012) assessed the use of a tri-pull method of taping for improving glenohumeral subluxation, ROM, and function in the upper extremities of people with chronic stroke. Skubik-Peplaski et al. (2012) examined how true occupation-based practice affected neuroplasticity and upper-extremity motor recovery after stroke.

The articles focusing on instrument development and testing were diverse, examining reliability and validity measures for new instruments such as the Flinn Performance Screening Tool for people with carpal tunnel syndrome (Flinn et al., 2012) and the Self-Report Assessment of Functional Visual Performance for people with homonymous hemianopia (Mennem et al., 2012), both of which revealed adequate score reliability. A novel global rating of change test and checklist was developed with input from several experienced occupational therapists and hand therapists to assess occupational therapy students’ skills in orthotic fabrication (Stefanovich et al., 2012). Tests more commonly seen in occupational therapy practice were also validated: The reliability of goniometry was measured in a population with Dupuytren’s disease; interrater reliability was high when standardized guidelines were followed (Engstrand et al., 2012). The Lowenstein Occupational Therapy Cognitive Assessment (LOTCA) was also found to have high correlations between raters when used with people with stroke (Katz et al., 2012).

Two studies examined the predictive value of initial occupational therapy measures of impairment: Vision impairment was found to be a strong predictor of decreased time spent in occupational therapy subacute rehabilitation sessions and a higher functional dependency level at discharge (Cimarolli et al., 2012). In contrast, Prager and Lang (2012) found that initial AROM measures at the wrist for people with acute stroke are weak predictors of upper-extremity function at 3 mo.

Two articles addressed specific occupational performance issues: Baker et al. (2012) identified computer equipment problems experienced by people with systemic sclerosis. This study determined that changing the seating, using foot and wrist rests, and adjusting computer components were the most frequent accommodation strategies used. Some of the most problematic driving scenarios were identified by certified driver rehabilitation specialists in the Yuen et al. (2012) study. Turning left into oncoming traffic, navigating four-way intersections, and reacting to unexpected events were acknowledged to be the most difficult when retraining people to drive after injury or illness.

Finally, 2 articles discussed occupational therapy practice, with the Craig (2012) review indicating that occupational therapy has a comprehensive role in home health services and that activities of daily living (ADLs), environmental modification, and caregiver training are foremost in typical home health occupational therapy interventions. Additionally, modification of standardized assessment protocols to accommodate people with aphasia was found to be effective; Tucker et al. (2012) described how these tools can be adapted to meet the needs of the patient and implemented in occupational therapy practice while still maintaining reliability.

A variety of instruments were used across the studies conducted. Common standardized assessments often seen in occupational therapy practice such as the SF–36, LOTCA, Jebsen–Taylor Test of Hand Function, Canadian Occupational Performance Measure, Box and Block Test, Fugl-Meyer Assessment, and upper-extremity motricity index were used in a majority of the articles reviewed (n = 14). Other, less commonly used instruments or tools developed for the specific research question posed were also present: the Computer Problems Survey, the Patient Transfer Curriculum Survey, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Self-Efficacy for Energy Conservation Questionnaire, and the Modified Telephone Interview for Cognitive Status. Impairment-level measures frequently used in occupational therapy practice, such as the Modified Ashworth Scale, manual muscle testing, goniometry, and ROM, were also present in the studies reviewed.

All 10 intervention effectiveness studies included impairment-level outcomes. Cimarolli et al. (2012) addressed vision impairment reduction in their efficiency study. The Prager and Lang (2012) basic research study likewise addressed whether initial upper-extremity AROM measurements would predict upper-extremity function 3 mo after stroke. As is evident in the reviewed articles, impairment-level measures that yield specific, objective data enable quantitative analysis and can be a starting point for scientific inquiry. Along with these measures, some of the studies also used instruments that yielded qualitative information such as the Self-Efficacy for Energy Conservation Questionnaire, the Self-Report Assessment of Functional Visual Performance, and a semistructured interview.

Five Years Later and Halfway to Our Centennial Vision: Are Neurorehabilitation Practice and Research Moving Forward?

As can be seen in the previous AJOT reviews, neurorehabilitation research articles continue to be generated at a rate of approximately 20 per year, which is relatively low. On a positive note, the quality of the studies appear to be improving: Five intervention studies from the past year are ranked as Level I (systematic reviews, meta-analyses, or randomized controlled trials). A PubMed search for research articles using the keywords occupational therapy and effectiveness yielded approximately 130 articles. However, when diagnosis-specific keywords such as stroke and spinal injury were added, the numbers were still surprisingly low (ns = 11 and 4). Although occupational therapy researchers may be publishing outside of AJOT, there remains a paucity of occupational therapy intervention effectiveness research in general.

Barriers outlined in the Centennial Vision (AOTA, 2007), such as “rigid adherence to the status quo” (p. 614) and “misalignment between the current occupational therapy priorities and the external environment” (p. 614), could certainly have an impact on the amount of research being published. The number of occupational therapy clinician–researchers is few despite initiatives by the association, educational programs, and professional leaders; clinicians are required to focus on service delivery, and many do not see research as clinically relevant (Cusick, 2001). A large disconnect still appears to exist between the academic and clinical environments in philosophy and priorities (Peloquin & Abreu, 1996), and even with the strong move toward evidence-based practice, use of research evidence by clinicians is suggested to be modest at best (Dysart & Tomlin, 2002). Effectiveness studies are the means by which we increase our value as a profession and impart to others the importance of our services. As we move forward, we will need to find the means to enable clinicians and researchers to engage in this type of inquiry and provide support for publication and dissemination of findings.

Instrument development continues and will be a critical element in occupational therapy’s achieving effectiveness as a profession. The use of standardized instruments that provide objective, measurable data can increase the value of a profession by validating the need for service provision, determining the appropriate health care services needed, addressing public policy issues, and assisting in the assessment of workforce requirements (Moore & Jull, 2009). At a minimum, it informs others of our ability to meet patient outcomes and determine the benefit of our interventions. The research reviewed in the past year is a movement in that direction; we can begin by measuring impairment-level outcomes, which lend themselves to easy, efficient measurement, to provide the data and pair these with activity or participation measures that will provide information, producing comprehensive assessments of patient function.

Our Next Steps: Moving Forward Toward Effectiveness as a Profession

As part of the Centennial Vision summary, eight elements were identified as being highly relevant to the vision both members and nonmembers wanted to emerge over the next 10 yr. In examining a few of these elements, we can see some of the challenges that lie ahead and the steps we will need to take to move closer toward our Centennial Vision.

Summary

As occupational therapists, we can increase our value to consumers, insurers, policymakers, and society simply by being more effective at what we do: Neurorehabilitation practice will be more effective if we step outside our comfort zone and are proactive in developing the clinical–academic alliances needed to improve patient care through rigorous scientific inquiry. We will be more effective if clinicians begin to engage in simple research designs that can answer the most basic clinical questions. We are effective if practicing therapists recognize the importance of standardized instruments and implement measures and interventions grounded in evidence. And we will become extremely effective if educators prepare future occupational therapy professionals for the realistic needs of the current and future health care systems in which they will be employed. Herein lies our value, our growth, and our future.