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.
Keywords
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.
Intervention Effectiveness Studies Published in the American Journal of Occupational Therapy, January 2009–June 2013
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.
Interventions Studied
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.
Studies Categorized by Number of Participants
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:
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.
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.
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.
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.
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.
Footnotes
*
Indicates studies that were reviewed for this article.